Evaluating the outcome for distal metaphyseal tibia fractures treated with metaizeau nail

Journal of military pharmaco-medicine n 0 1-2020 201 EVALUATING THE OUTCOME FOR DISTAL METAPHYSEAL TIBIA FRACTURES TREATED WITH METAIZEAU NAIL Nguyen Duc Binh1; Nguyen Hanh Quang1; Nguyen Tien Binh2 SUMMARY Objectives: To determine the radiographic and clinical outcomes for distal metaphyseal tibia fractures treated with Metaizeau nail, indication, advantages and disadvantages of this method. Subjects and methods: Prospective study on a total of 51 patients with distal tibia fractures treated with Metaizeau nail at the Trauma-Orthopedic Department, St. Paul Hospital, Hanoi from 01 - 2014 to 12 - 2018. Results: Exellent: 8.3%, good: 80.6%, fair: 8.3%, bad: 2.8%. There were no osteitis, pseudarthrosis. Conclusion: Metaizeau nail could be reasonable indication for unstable distal metaphyseal tibia fractures. * Keywords: Distal tibia fracture; Metaizeau nail. INTRODUCTION Distal tibial fractures have historically been treated with open reduction and internal fixation using plates. Although this technique provides predictable reduction quality, it increases the risk of additional soft tissue injury [1]. Operation site infection rate of up to 50% has been reported as the main disadvantage associated with this technique [2]. Olerud and Karlstrom [3] reported that delayed healing, infection and implant problems are often associated with plate osteosynthesis of the distal tibia. To lessen these risks, alternative treatment methods including external fixation, staged fixation and minimally invasive surgery have arisen. Intramedullary nailing (IMN) is considered the ideal choice for treatment of diaphyseal tibial fractures [4] and has been expanded to distal metaphyseal tibial fractures to provide indirect reduction (minimally invasive), stable fixation (load sharing) and multiple fixation points [5]. However, because of metaphyseal widening, short segment fixation and intra-articular extension, IMN can be complicated by malunion, nonunion or implant failure [6]. To overcome these problems, we used Metaizeau nail which combines narrow flexible nails and have curved distal tips [7]. These nails are bent by the surgeon before insertion, so that distal locking can be achieved when they spread out and obtain a hold in the distal part of the bone. The combination of two nails is the basic requirement, but insufficient if using alone, one or two additional flexible nails are also inserted into the medullary canal. Therefore, the purpose of this study was: To determine the radiographic and clinical outcomes of distal metaphyseal tibia fractures treated with Metaizeau nail and indication, advantages and disadvantages of this method. 1. St. Paul Hospital 2. Vietnam Military Medical University Corresponding author: Nguyen Duc Binh (binhstpaul@gmail.com) Date received: 18/12/2019 Date accepted: 26/12/2019 Jourrnal of military pharmaco-medicine n 0 1-2020 SUBJECTS AND METHODS 1. Subjects. 51 patients, age from 30 to 87 years old, 32 males and 19 females. * Selection criteria: - Patients ≥ 18 years old. - Closed fractures of distal tibia 43A and 43C1 (the OTA/AO classification of the fractures) with grade of closed injuries 0, 1, 2 (Tschern classification) and open fractures grade 1, 2, 3a (Gustilo classification). * Exclusion criteria: - Pathological fractures. - The patients did not accept to participate into study. 2. Methods. * Design: Prospective analysis. * Research content: - Clinical and radiological evaluation. - Equipements: C-arm, fracture reduction table. - Local or total anaesthesia. - Operative technique: + Patients were placed on a fracture reduction table using radioscopic control. Picture 1: Patient position. + When the fibula fracture was located on its peripheral third (up to 10 cm from the edge of the lateral malleolus), the fibular was fixated with the use of neurtralisation plate or Kirschner pin. + The nails with angle distal ends were introduced through a hole drilled in the centre of the medial-anterior and lateral-anterior aspect of the proximal epiphysis. The procedure was radioscopically controlled, the distal beaks were driven to the distal end of the bone and directed to splay from the midline into the lateral cortex as seen in the frontal plane, to ensure effective distal locking. 202 Journal of military pharmaco-medicine n 0 1-2020 203 Picture 2: Post oteosynthesis. + Under C-arm, if there was syndesmosis injury, one syndesmosis screw was placed. - Follow-up: + In all cases, immediately after surgery, short leg plaster cast was applied until the six week. + After 48 hours drain was removed. + Antibiotics. + Analgesia, anti-edematous. + X-ray post-operation to evaluate the outcome of osteosynthesis. + Active knee and ankle exercises were started after 48 hours. + Suture was removed on the 12th post-operation day and the patient was discharged. + Weight-bearing: Patients with 3 or 4 nails fixation were allowed partial weight-bearing of about 20 kg until the sixth week. On the contrary, patients with 2 nails fixation were not allowed partial weight-bearing until the sixth week. + Follow-up radiological and clinical examination were done at 6, 12, 24 weeks and after 1 year. + Removal implants after one year. * Result evaluation: Make a patient follow-up sheet and schedule an appointment for the patient to be examined every 6 weeks (short outcomes), 3, 6 months and after 1 year (long-term results). All patients were evaluated on the following results: wound healing, bone healing time, anatomical axis, functional outcome of ankle and complications recorded. RESULTS 1. Statistical characteristics. * General characteristics: - Age: 30 - 87 (mean 56.1 years). - Gender: Males: 33 patients (64.7%); females: 18 patients (35.3%). Journal of military pharmaco-medicine n 0 1-2020 204 - Mode of injury: Traffic accident: 35 patients (68.6%), domestic accident: 15 patients (29.4%), sport accident: 1 patient (2%). * Injury characteristics: - Tibia: + Closed fracture: 37 patients (72.5%), open fractures: 14 patients (27.5%). + Open fractures classification (Gustilo): Grade 1: 5 patients; grade 2: 7 patients; grade 3a: 2 patients. + Closed injuries classification: Grade 0: 16 patients (43.2%); grade 1: 15 patients (40.5%); grade 2: 6 patients (16.3%). + Pattern fracture classification (Muller- AO): A1: 16 patients (31.4%); A2: 23 patients (45.1%); A3: 9 patients (17.6%); C1: 3 patients (5.9%). + The distal tibial joint line to the fractures: Below 3 cm: 32 patients (62.7%); above 3 cm: 19 patients (37.3%). - Fibular: + Fibular fracture: 42 patients. + Syndesmosis injury: 6 patients (11.8%). + Fibular fixation: Plate: 33 patients (64.7%); Kirschner pin: 4 patients (7.8%). + The number of Metaizeau nails to use for fixation: 2 nails: 8 patients (15.7%); 3 nails: 27 patients (52.9%); 4 nails: 16 patients (31.4%). 2. Short results. - Wound: Primary wound heal: 48 patients (94.1%); superficial wound infection: 3 patients (5.9%). - Tibial alignment (n = 51): Excellent: 10 patients (19.6%); good: 38 patients (74.5%); fair: 2 patients (3.9%); bad: 1 patient (2%). 2. Long-term results (n = 36). Of the 51 distal metaphyseal tibia fractures, 15 cases were lost to follow-up. Mean follow-up was 30.25 months (range 12 - 59 months). - Scar: good (100%). - Union: 36/36 patients. - Tibial alignment (n = 36): Excellent: 5 patients (13.9%); good: 26 patients (72.2%); fair: 4 patients (11.1%); bad: 1 patient (2.8%). - Functional outcomes (n = 36): Excellent: 5 patients (13.9%); good: 28 patients (77.8%); fair: 3 patients (8.3%); there was no case of bad outcome. - Final results (n = 36): Excellent: 3 patients (8.3%); good: 29 patients (80.6); fair: 3 patients (8.3%); bad: 1 patient (2.8%). DISSCUSION * Correlation between open fracture and mode injury: We found that traffic accidents with strong trauma (11/35 patients = 31.4%) often caused a higher fracture rate than domestic accidents (3/15 patients = 20%). * Correlation between soft tissue injury in closed fractures and mode injury: Soft tissue injuries of grade 0 and 1 were the majority (83.7%), only 6 patients with grade 2 (16.3%). * Correlation between mode injury and syndesmosis injury: Patients with indirect trauma mechanism (4/22 patients = 18.2%) had a higher rate of syndesmosis injury of grade 3 than patients with direct trauma mechanism (2/29 patients = 6.9%). Journal of military pharmaco-medicine n 0 1-2020 205 * Fibular fixation: The majority of fibular fractures should be fixed, in which 33/51 patients were screwed (64.7%), 4 patients were nailed (7.8%) and 14 patients (27.5%) did not need to be fixed. * Correlation between pattern fractures and union time: The rate of patients with torsion fractures united before 3 months (16/25 patients = 64%) higher than the rate of traversal and oblique fractures (9/25 patients = 36%). * Correlation between closed/open fracture and union time: The rate of patients with closed fractures united before 3 months (22/34 patients = 64.7%) was higher than open fractures (3/14 patients = 21.4%), this result was statistically significant with p < 0.05. * Correlation between soft tissue injury in closed fractures and union time: The rate union time before 3 months of soft tissue injuries in closed fractures grades 0 and 1 (20/28 patients = 71.4%) were higher than grade 2 (2/6 patients = 33.3%). * Correlation between tibial alignment outcome and pattern fractures (Muller/AO), closed/open fractures: There was no difference in the alignment result between the pattern of fracture as well as the number of nails used. This indicated that fixation using Metaizeau nail models ensured anatomical reduction as well as was adequate strong to maintain the reduction results. However, we found that open fractures often had malalignment results than closed fractures. * Correlation between functional outcome and soft tissue injury in closed fractures: The results showed that 28 patients with soft tissue injuries in closed fractures grade 0 and 1, only 1 case had fair functional outcome. Whereas in soft tissue injuries in closed fractures grade 2, up to 2/6 cases of fair outcome. There was no case for bad outcome. * Correlation between functional outcome and alignment outcome: In 43 patients with good and very good alignment results, no patients had fair functional outcome, while 4 patients had fair alignment outcome, the alignment results were also fair. * Correlation between functional outcome and age, sex, closed/open fracture: In our study, it was shown that age, gender, closed/open fractures did not affect functional outcome. CONCLUSION Through the study of the application of Metaizeau technique to treat the distal tibia fractures under C-arm controlling, we had some conclusions: - Treatment outcomes: Excellent: 8.3%; good: 80.6%; fair: 8.3%; bad: 2.8%; there was no osteitis, pseudarthrosis. - Indications, techniques, advantages and disadvantages: + Indication: Metaizeau nail is a good indication for the distal tibia fractures, especially those with metaphyseal fractures when the intramedullary nail is difficult to work. Journal of military pharmaco-medicine n 0 1-2020 206 + Technique: The majority of patients had surgery under C-arm, after the anatomical reduction on the orthopedic table. + Advantages: Not having to open tibial fracture, it preserved elements of the healing bone process, reduced the risk of bacterial infections, osteoarthritis. + Disadvantages: Patients with 2 nails fixation were not allowed partial weight- bearing until the sixth week. REFERENCES 1. Wyrsch B.M.M, McAndrew M et al. Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am. 1996, 78, pp.1646-1675. 2. McCann P.A.J.M, Mitchell S.T et al. Complications of definitive open reduction and internal fixation of pilon fractures of the distal tibia. Orthop Rev. 2011, 35, pp.413-418. 3. Olerud S.K.G. Tibial fractures treated by AO compression osteosynthesis. Experiences from a five year material. Acta Orthop Scand Suppl. 1972, 140, pp.1-104. 4. Whittle A.P.W.G. Fractures of the lower extremity. Campbells’s Operative Orthopaedics. 2003, pp.2757-2761. 5. Robinson C.M, G.J McLauchlan, I.P McLean et al. 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 (5), pp.781-787. 6. Nork S.E, A.K Schwartz, J Agel et al. Intramedullary nailing of distal metaphyseal tibial fractures. J Bone Joint Surg Am. 2005, 87 (6), pp.1213-1221. 7. de la Caffiniere J.Y, F Pelisse, M de la Caffiniere. Locked intramedullary flexible osteosynthesis. A mechanical and clinical study of a new pin fixation device. J Bone Joint Surg Br. 1994, 76 (5), pp.778-788.