Journal of the Korean Orthopaedic Association (대한정형외과학회지)

Korean Orthopaedic Association (대한정형외과학회)
권호 표지
DOI QR코드

DOI QR Code

Treatment of Distal Tibial Spiral Fractures Combined with Posterior Malleolar Fractures

후과 골절이 동반된 경골 원위부 나선상 골절의 치료

  • Kim, Young Sung (Department of Orthopedic Surgery, Dongguk University College of Medicine) ;
  • Lee, Ho Min (Department of Orthopedic Surgery, Dongguk University College of Medicine) ;
  • Kim, Jong Pil (Department of Orthopedic Surgery, Dongguk University College of Medicine) ;
  • Chung, Phil Hyun (Department of Orthopedic Surgery, Dongguk University College of Medicine) ;
  • Park, Soon Young (Department of Orthopedic Surgery, Dongguk University College of Medicine)
  • 김영성 (동국대학교 의과대학 정형외과학교실) ;
  • 이호민 (동국대학교 의과대학 정형외과학교실) ;
  • 김종필 (동국대학교 의과대학 정형외과학교실) ;
  • 정필현 (동국대학교 의과대학 정형외과학교실) ;
  • 박순영 (동국대학교 의과대학 정형외과학교실)
  • Received : 2020.09.21
  • Accepted : 2020.12.29
  • Published : 2021.08.30
⟨ Previous Next ⟩

Abstract

Purpose: This study compared the functional and radiologic outcomes of intramedullary nailing (IMN) and minimally invasive plate osteosynthesis (MIPO) for tibia fractures in distal tibial spiral fractures combined with posterior malleolar fractures, as well as the functional and radiologic outcomes with and without fixation for posterior malleolar fractures. Materials and Methods: From January 2010 to December 2018 the radiological and clinical outcomes of 30 skeletally mature patients with tibial spiral fractures (AO Foundation/Orthopaedic Trauma Association classification 42-A1, B1, C1) combined with posterior malleolar fractures were analyzed. Sixteen patients were treated with IMN, and 14 patients were treated with MIPO. Depending on the surgical methods, the radiologic and clinical outcomes were compared by evaluating the bone union time, postoperative alignment, postoperative displacement of the posterior malleolar fragment, and American Orthopaedic Foot and Ankle Society (AOFAS) score. Moreover, the functional and clinical outcomes with and without fixation for posterior malleolar fractures were compared. Results: The mean bone union time was 21.8 weeks in the IMN group and 23.1 weeks in the MIPO group (p=0.500). At the final follow up, the mean alignment was coronal angulation of 1.8°, sagittal angulation of 1.6° in the IMN group and coronal angulation of 1.2° and sagittal angulation of 1.7° in the MIPO group (conoral angulation: p=0.131, sagittal angulation: p=0.850). The postoperative and final radiologic evaluation showed no displacement of the posterior malleolar fragment and excellent joint congruity in all cases. At the final follow-up, the mean AOFAS score was 88.0 on average in the IMN group and 87.6 on average in the MIPO group (p=0.905). The ankle range of motion and AOFAS score were similar in the fixation group and no fixation group for posterior malleolar fractures. Conclusion: Both IMN and MIPO for tibial spiral fractures combined with posterior malleolar fractures result in satisfactory radiological and clinical outcomes.

목적: 본 연구는 족관절 후과 골절을 동반한 경골 원위부 나선상 골절에서 경골에 대한 고정술로 골수강 내 금속정 고정술과 최소 침습적 금속판 고정술의 기능적, 방사선학적 결과 및 후과 골절에 대한 고정술 유무에 따른 기능적, 방사선학적 결과를 비교하였다. 대상 및 방법: 2010년 1월부터 2018년 12월까지 본원에서 족관절 후과 골절을 동반한 경골 원위부 나선상 골절(AO Foundation/Orthopaedic Trauma Association 분류 42-A1, B1, C1) 30명의 환자를 대상으로 연구하였다. 골수강 내 금속정 고정술을 시행한 16명을 intramedullary nailing (IMN)군으로, 최소 침습적 금속판 고정술을 시행한 14명을 minimally invasive plate osteosynthesis (MIPO)군으로 분류하여 양 군의 골유합 시기, 술 후 각 정렬, 족관절 후과 골편의 전위 정도 및 American Orthopaedic Foot and Ankle Society (AOFAS) 점수를 비교, 분석하였다. 또한 각 군에서 후과 골절에 대한 고정술 유무에 따른 족관절 관절 운동 범위 및 AOFAS 점수를 비교하였다. 결과: 평균 골유합 시기는 IMN군에서 21.8주, MIPO군에서 23.1주였다(p=0.500). 최종 추시 평균 각 변형은 IMN군에서 관상면 1.8°, 시상면 1.6°를 보였고, MIPO군에서 관상면 1.2°, 시상면 1.7°를 보였다(p=0.131, p=0.850). 술 후 및 최종 추시 방사선 사진상 양 군 모든 환자에서 족관절 후과 골편의 전위는 없었고, 최종 추시에서 족관절 관절염은 없었다. 임상적 평가로 최종 추시에서 AOFAS 점수는 IMN군에서 평균 88.0점, MIPO 군에서 평균 87.6점을 보였다(p=0.905). 각 군에서 후과 골절에 대한 고정술 유무에 따른 족관절 관절 운동 범위 및 AOFAS 점수를 비교하였고 유의한 차이는 없었다. 결론: 족관절 후과 골절을 동반한 경골 원위부 나선상 골절의 치료에서 골수강 내 금속정 고정술과 최소 침습적 금속판 고정술은 영상학적, 임상적 결과에서 차이가 없이 모두 우수한 결과를 보였다.

Keywords

References

  1. Chen Q, Song L, Fang J, Qin X, Lv T, Li X. Effectiveness of diagnosis and treatment of spiral fracture of the distal third of the tibia combined with posterior malleolus fracture: a series of ten cases. J Am Podiatr Med Assoc. 2018;108:106-14. https://doi.org/10.7547/15-181
  2. Boraiah S, Gardner MJ, Helfet DL, Lorich DG. High association of posterior malleolus fractures with spiral distal tibial fractures. Clin Orthop Relat Res. 2008;466:1692-8. https://doi.org/10.1007/s11999-008-0224-5
  3. Hou Z, Zhang Q, Zhang Y, Li S, Pan J, Wu H. A occult and regular combination injury: the posterior malleolar fracture associated with spiral tibial shaft fracture. J Trauma. 2009;66:1385-90. https://doi.org/10.1097/TA.0b013e31817fdf0a
  4. Kukkonen J, Heikkila JT, Kyyronen T, Mattila K, Gullichsen E. Posterior malleolar fracture is often associated with spiral tibial diaphyseal fracture: a retrospective study. J Trauma. 2006;60:1058-60. https://doi.org/10.1097/01.ta.0000196700.74272.10
  5. Kempegowda H, Maniar HH, Richard R, et al. Posterior malleolar fractures associated with tibial shaft fractures and sequence of fixation. J Orthop Trauma. 2016;30:568-71. https://doi.org/10.1097/BOT.0000000000000629
  6. Zhang Y, Qin X, Song L, Li X. The risk of violating the posterior malleolar fracture when nailing the ipsilateral concomitant spiral distal tibial fracture. BMC Musculoskelet Disord. 2018;19:123. https://doi.org/10.1186/s12891-018-1994-x
  7. Hou Z, Zhang L, Zhang Q, et al. The "communication line" suggests occult posterior malleolar fracture associated with a spiral tibial shaft fracture. Eur J Radiol. 2012;81:594-7. https://doi.org/10.1016/j.ejrad.2011.01.039
  8. Guo J, Liu L, Yang Z, Hou Z, Chen W, Zhang Y. The treatment options for posterior malleolar fractures in tibial spiral fractures. Int Orthop. 2017;41:1935-43. https://doi.org/10.1007/s00264-016-3388-8
  9. Bostman OM. Displaced malleolar fractures associated with spiral fractures of the tibial shaft. Clin Orthop Relat Res. 1988;228:202-7. https://doi.org/10.1097/00003086-198803000-00031
  10. van der Werken C, Zeegers EV. Fracture of the lower leg with involvement of the posterior malleolus; a neglected combination? Injury. 1988;19:241-3. https://doi.org/10.1016/0020-1383(88)90035-6
  11. Byun SE, Lee SJ, Kim U, Choi YR, Han SH, Kim BG. Usefulness of computed tomography on distal tibia intra-articular fracture associated with spiral tibia shaft fracture. J Korean Fract Soc. 2016;29:114-20. https://doi.org/10.12671/jkfs.2016.29.2.114
  12. Georgiadis GM, Ebraheim NA, Hoeflinger MJ. Displacement of the posterior malleolus during intramedullary tibial nailing. J Trauma. 1996;41:1056-8. https://doi.org/10.1097/00005373-199612000-00022
  13. Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma. 1989;29:1565-70. https://doi.org/10.1097/00005373-198911000-00018
  14. Beytemur O, Baris A, Albay C, Yuksel S, Caglar S, Alagoz E. Comparison of intramedullary nailing and minimal invasive plate osteosynthesis in the treatment of simple intra-articular fractures of the distal tibia (AO-OTA type 43 C1-C2). Acta Orthop Traumatol Turc. 2017;51:12-6. https://doi.org/10.1016/j.aott.2016.07.010
  15. Katsenis DL, Begkas D, Spiliopoulos G, Stamoulis D, Pogiatzis K. The results of closed intramedullary nailing for intra-articular distal tibial fractures. J Orthop Trauma. 2014;28:108-13. https://doi.org/10.1097/BOT.0b013e31829e7358
  16. 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. https://doi.org/10.1097/BOT.0b013e31816ed974
  17. 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. https://doi.org/10.1097/BOT.0b013e318213f709
  18. Vallier HA. Current evidence: plate versus intramedullary nail for fixation of distal tibia fractures in 2016. J Orthop Trauma. 2016;30 Suppl 4:S2-6. https://doi.org/10.1097/BOT.0000000000000692
  19. Yu J, Li L, Wang T, et al. Intramedullary nail versus plate treatments for distal tibial fractures: a meta-analysis. Int J Surg. 2015;16(Pt A):60-8. https://doi.org/10.1016/j.ijsu.2015.02.004
  20. Xue XH, Yan SG, Cai XZ, Shi MM, Lin T. Intramedullary nailing versus plating for extra-articular distal tibial metaphyseal fracture: a systematic review and meta-analysis. Injury. 2014;45:667-76. https://doi.org/10.1016/j.injury.2013.10.024
  21. Li Y, Jiang X, Guo Q, Zhu L, Ye T, Chen A. Treatment of distal tibial shaft fractures by three different surgical methods: a randomized, prospective study. Int Orthop. 2014;38:1261-7. https://doi.org/10.1007/s00264-014-2294-1
  22. Polat A, Kose O, Canbora K, Yanik S, Guler F. Intramedullary nailing versus minimally invasive plate osteosynthesis for distal extra-articular tibial fractures: a prospective randomized clinical trial. J Orthop Sci. 2015;20:695-701. https://doi.org/10.1007/s00776-015-0713-9
  23. Bartonicek J, Rammelt S, Kostlivy K, Vanecek V, Klika D, Tresl I. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015;135:505-16. https://doi.org/10.1007/s00402-015-2171-4
  24. Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br. 1995;77:781-7.
  25. Konrath G, Moed BR, Watson JT, Kaneshiro S, Karges DE, Cramer KE. Intramedullary nailing of unstable diaphyseal fractures of the tibia with distal intraarticular involvement. J Orthop Trauma. 1997;11:200-5. https://doi.org/10.1097/00005131-199704000-00011
  26. Marcus MS, Yoon RS, Langford J, et al. Is there a role for intramedullary nails in the treatment of simple pilon fractures? Rationale and preliminary results. Injury. 2013;44:1107-11. https://doi.org/10.1016/j.injury.2013.02.014
  27. Kim YS, Chung PH, Hwang CS, Kang S, Kim JP, Lee HM. Interlocking intramedullary nailing in distal tibial metaphyseal fractures. J Korean Fract Soc. 2005;18:269-74. https://doi.org/10.12671/jkfs.2005.18.3.269
  28. Daolagupu AK, Mudgal A, Agarwala V, Dutta KK. A comparative study of intramedullary interlocking nailing and minimally invasive plate osteosynthesis in extra articular distal tibial fractures. Indian J Orthop. 2017;51:292-8. https://doi.org/10.4103/0019-5413.205674
  29. Kuhn S, Greenfield J, Arand C, et al. Treatment of distal intraarticular tibial fractures: a biomechanical evaluation of intramedullary nailing vs. angle-stable plate osteosynthesis. Injury. 2015;46 Suppl 4:S99-103. https://doi.org/10.1016/S0020-1383(15)30026-7
  30. Haines JF, Williams EA, Hargadon EJ, Davies DR. Is conservative treatment of displaced tibial shaft fractures justified? J Bone Joint Surg Br. 1984;66:84-8.