MINISTRY OF EDUCATION MINISTRY OF DEFENSE VIETNAM MILITARY MEDICAL UNIVERSITY NGUYEN VIET DUNG ANATOMICAL STUDY OF APPLYING THE TIBIAL PLATEAU WITH CLOSED INTERLOCKING INTRAMEDULLARY NAIL TO TREAT THE FRACTURES OF 1/3 LOWER TIBIA AND LOWER END OF THE TIBIA Specialization: Surgical Code: 9720104 SUMMARY OF PHD THESIS IN MEDICINET HANOI – 2019 This thesis was conducted at: LIST OF PUBLICATIONS FROM THE THESIS Vietnam Military Medical University Nguyen Viet Dung, Nguyen Tien Binh, Vu Nhat Dinh, Nguyen Hai An (2018).“Evaluation of results of tibial plateau with interlocking intramedullary nail and fibular plateau with screw fixation in treatment of fractures of the distal third tibia below both distal leg bones”, Vietnamese medicine journal, Vol 470, September, Issue No.1, p.67-71 Supervisors: Prof Nguyen Tien Binh, MD, PhD Assoc Prof Vu Nhat Dinh, MD, PhD Nguyen Viet Dung, Nguyen Tien Binh, Vu Nhat Dinh, (2018) “Study of tibia anatomy in Vietnamese aldults, appication in treatment of lower and distal tibia fracture by intra medullary with locking nail”, Military medicine and pharmacy journal, Issue No.9/2018 Peer-review 1: Peer-review 2: Peer-review 3: The thesis will be defensed at Council of Vietnam Military Medical University at …… …… …… 2019 24 INTRODUCTION LIMITATIONS OF THE TOPIC Fracture in 1/3D segment - the lower end of the tibia is one of the bone fractures that are difficult to treat (due to broken bone characteristics and The number of patients returning to fix bone fixation facilities in our hospital anatomical structure) Methods of treatment: Cast wrapping, external fixation, is not much (due to different reasons and subjective reasons) So we have not continuous pulling, splinting screw, locking plate & screw, interlocking encountered difficult cases to remove bone fixation to share with scientists and intramedullary nailing in which each method has its own advantages and colleagues disadvantages Bone fixation tools in our study are not common, so it is difficult for other medical facilities to apply this method widely Treatment of the tibial stem fracture with intramedullary nail has been applied in the world and in Vietnam from the 1960s of the 20th century to the present The In order to be able to apply this method of bone combination effectively, it tibial plateau with interlocking intramedullary nail is the top-choice “gold requires medical facilities to have a digital X-ray machine, complete equipment, standard”, because the nail fixes the fracture area firmly, without causing bulge and and a team of qualified and experienced surgeons exposing the nail in the event of the opened incision For Fracture in 1/3D segment - the lower end of the tibia (wide flared medullary canal, thin bone wall), the tibial RECOMMENDATIONS plateau with interlocking intramedullary nail has the risk of bone axis misalignment or unstable fixed fracture (especially when there is also a fibula fracture) In order From the research practice of the subject we find that the usual intramedullary to contribute to completing the technique of treating fractures in this position and interlocking nail size for Vietnamese people is: 9mm x 320mm; 9mm x 300mm; still ensuring good results, minimizing complications, promoting the advantages of 9mm x 340mm; 9mm x 280mm; 8mm x 320mm; 8mm x 300mm; 8mm x 280mm; intramedullary nails, we conducted to study the topic titled “Anatomical study of 10mm x 320mm; 10mm x 300mm; 10mm x 340mm So the length of the nail is applying the tibial plateau with closed interlocking intramedullary nail to treat over 340mm, we have not met Nails with a diameter greater than 10mm and the fractures of 1/3 lower tibia and lower end of the tibia” smaller than 8mm we also not use in this study When surgery does not have C.arm, the surgeon must have experience to reduce complications for the patient There should be a policy for patients to get back to the medical facility of bone fixation to remove bone fixation facilities Thus patients will be monitored and treated more effectively Strengthening communication and education for patients to see the benefits of practicing rehabilitation after surgery With the objectives: Surveying some anatomical features of tibia on X-ray images of adults, applications in surgery of the tibial plateau with closed interlocking intramedullary nail to treat the fractures of 1/3 lower tibia and lower end of the tibia Evaluating the results of surgery of the tibial plateau with closed interlocking intramedullary nail to treat the fractures of 1/3 lower tibia and lower end of the tibia New contributions of the thesis The tibial plateau with the interlocking intramedullary nail to treat Fracture in 1/3D segment - the lower end of the tibia, if it can firmly fix the fracture, there are 23 many more advantages when internally fixing bones with screw This is a CONCLUSION minimally invasive surgical technique suitable for the current trend The difficulties Studying a number of anatomical characteristics of 228 tibia of 114 of fixing bones with interlocking intramedullary nail in this position is the distal Vietnamese adults (67 males, 47 females) and the results of treatment of 63 cases end of the intramedullary nail must pass through the long enough fracture area to of closed fracture 1/3D, outer tibial plateau joint with or without attached low be fixed with the the anti-rotating screw, anti-angled screw without opening the fibula fractures, we give some conclusions as follows: fracture area Characteristics of tibia anatomy of the Vietnamese adult group The research topic is practical and further study the characteristics of tibia of - Features of tibia anatomy: Vietnamese adults on digital X-ray film: Identifying size indicators, important + The average tibial absolute length of the study group: 36.28 ± 2.30cm anatomical landmarks, expected nail length, nail diameter, screw size in order to + The tibial body length of the study group: 23.84 ± 1.91cm help fit patients to limit seizures, complications during surgery and promote the + The absolute length and length of the tibia body is proportional to the height advantages of intramedullary interlocking nailing Younger group with average tibial length longer than the elderly group The structure of the thesis + The size of the baseball bone marrow, wide at ends, gradually narrowed in The dissertation has: 115 pages, including parts: Introduction: pages; position 1/3G - D (in the range of - 10cm from the joint of the slug baseball) The Chapter 1: Literature overview: 30 pages; Chapter 2: Rearch subjects and methods: narrowest spinal canal size; before - after: 1.00 ± 0.12cm 19 pages; Chapter 3: Research results: 33 pages; Chapter 4: Discussion: 29 pages; + The size of the medullary bone marrow is the narrowest part in-outside: 1.15 ± 0.14cm Conclusion: pages; limitations of the topic: page; recommendations: page + The size of the inner and outer spinal canal is wider than before - after measuring There are tables, charts, and illustrations There are two published studies related to on the same position, the size of the pulp is not dependent on the height The size of the thesis The appendix contains a list of 114 adults who were studied the tibial the lumbar spinal canal size in the older group is larger than that of the young group anatomy; the tibia surgery survey note; a list of 63 patients treated for the fracture - Suitable intramedullary nail interlocking length is 280mm, 300mm, 320mm, 340mm in 1/3D segment - the lower end of the tibia (23 patients were fixed the fibula - Suitable intramedullary nail interlocking diameter is 8mm, 9mm, 10mm because the tibial fracture can only be fixed with one screw at the peripheral end), Results of treatment of Fracture in 1/3D segment – the outer joint lower end the studied medical record, treatment result follow-up report, the medical record of the tibia illustration References: There are 108 references, including 18 documents in Vietnamese, and 90 documents in English * 100% of patients had first-term, non-infectious, no hypertrophic scars, did not affect the motor function * There are no patients who slide the screw to the distant end * The result of bone healing is 100%, in which bone reshaping and correcting bone axis is very good with 57 patients, bone healing is good with patients, patients with bone fracture correcting medium bone axis * Overall results were very good: 54/63 patients (85.71%); good: 7/63 patients (11.11%); average: 2/63 patients (3.17%); There are no bad cases 22 rate), average results of patients (3,17%), For patients with average results: Chapter patient with the size of the fracture to the tibial plateau of the fracture group from 31 - 40mm due to the size of the lower medulla tubule flaring so the nail does not have The spot is pressed against the bone wall and a patient tightened screws but has 1/3D fibula fracture but no bone fixation marks For patients with good results similar to the above: patient is in the fracture group from 31 - 40mm and patients still tightened 02 screws but have 1/3D fibula fracture but not bone fixation marks No poor results Compared to the results of the authors Klaus, W, Klemm M.D also apply bone fixation sealed by interlocking intramedullary nail to treat two leg bones closed fracture resulting in 100% reconstruction of the anatomy Our results are also equivalent The condition of rectification fracture is very good and good for months and 12 months without change, there is no secondary deviation The results of functional rehabilitation after months ranked on average include patients with average corrections of corrective results, limiting ankle movement and normal travel time over months, patients with good fractures Good has good rehabilitation results.There is no case of limiting knee joint movement 61 patients with normal anklet joints (rate 96.82%), patients (3.17% rate) limited movement of little ankle joints 4.2.6.2 Evaluating distant results 100% of patients are healed bones, no patient with slow bone healing, false joints; no patients with osteomyelitis When stabilizing, patients can move normally 4.2.6.3 General results Evaluating the results in our study as follows: - Very good : 54/63 patients (85.72%) - Good : 7/63 patients (11.11%) - Average : 2/63 patients (3.17%) and no patients achieved poor results LITERATURE OVERVIEW 1.1 Anatomical features of the leg related to the injury and the treatment The leg is limited from the knee joint space to the ankle joint space * Characteristics of bone The leg consists of bones: large tibia, bearing 9/10 weight, in the triangular prism shape, upper large and lower small, the weak point in 1/3G - D area The fibula bears 1/10 weight; the bone is long, thin and bigger at both ends * Vascular system nourishing the tibia: Bone marrow, periosteum, metaphyse ends are connected together * Characteristics of soft tissue: The leg muscles are unevenly distributed; the tibial crest and the inner surface of the tibia are located just below the skin attached to the periosteum, less movable In 1/3D leg, the muscles have turned into tendons, poor nourishing, fractured bones hart to be healed , easy to expose braces, incision dislocated when splinting the screws 1.3 The methods of treating the closed fracture in 1/3D segment - the lower end of the tibia 1.3.1 Conservative treatment * Cast wrapping correction * Continuously pulling 1.3.2 Surgical treatment * External fixation * Fixing bones with the splint screws * Fixing bones with the locking splint screws * Fixing bones with the interlocking intramedullary nailing Treatment of the tibial stem fracture with interlocking intramedullary nail has been widely used, many advantages and reducing complications when bones are in the leg, especially for the segment 1/3D and the tibial end Fixing bones with interlocking bone intramedullary nail which has the fastest healing time is the closed nailing * Advantages of fixing bone with closed interlocking intramedullary nail, not opening the facture area Fixing bones with closed interlocking intramedullary nail without opening the fracture, the method completely respects the bone healing physiology of the 21 fracture area and significantly reduce the complications of incision infection and hand, when screwing, it is necessary to observe the longitudinal fractures on the X- osteomyelitis Because the fracture area is screwed, the bone fracture area is fixed firmly and ray film straight and inclined to avoid further fracture of the tibial peripheral head it prevents the bone healing slowness, false joints and amyotrophy The incision is small and fast healed, small and soft scar, ensuring aesthetics for patients; low treatment cost, short postoperative period, simple removal of bone fixing facilities 1.3.3 Treating the 1/3D fracture – lower end of outer leg bones with interlocking intramedullary nail and fixing fibula with screw braces Bonnevialle P and Cs (2010) reported the study results at the Specialized Congress of the French Society for Orthopedic and Trauma Surgery (SOFCOT) for 4.2.4 The role of fibular fixation For cases with tibia and fibula fractures at the low level of the lower leg, the result of bone fixation pestle by interlocking intramedullary nail combined with bone fixation fibula by splint screw would be better than just bone fixation pestle by interlocking intramedullary nail Simple Many authors have bone fixation with screw splints for the purpose of adjusting the deflection to the side, strengthening the ankles, preventing rotation, counteracting pestering, restoring the limb length * Assign to screw one end, two ends, parallel screws, perpendicular cases of fractures of the outer joint lower tibial ends The authors concluded that: It is necessary to strengthen the fracture area to enhance the tibial fracture area screws depending on the fracture pattern, fracture properties, anti-rotation fixation The fibula fracture areas are pre-fixed to ensure the length of the limb and limit the lateral misalignment anatomy on the X-ray flim and the traumatic fracture trait, the composition of the rotation, stack displacement, displacement angled Based on the study of tibia Wasudeo G and Cs (2015) evaluated the results of bone fracture of the outer joint tibial fracture with an intramedullary interlocking nail in the period from 2007 interlocking intramedullary nail IME we have applied and determines the number to 2013 Evaluate results according to Johner and Wruhs: very good with 70.54%, good with 25.90%, average of 3.56% * Specify bone fixation marks by screw splint before bone fixation pestle with of screws and screws interlocking intramedullary nail with case of fibula fracture at Fracture level in Studies by authors around the world have shown that: For cases of fracture of the tibia and fibula and the lower level of the lower leg, the result of intact tibial 1/3D segment - the lower end of the tibia 23 cases of 1/3D fracture - head under interlocking nail interlocking with splint Bone marrow screws are better than just tibia by interlocking intramedullary nail alone The bone fracture is pre-fixed to with low fractures, fracture joints way slugs baseball 80mm has 14 patients tightened 02 screws under the parallel fracture Tightened 02 screws under the perpendicular we rely on the characteristics of the fracture properties to avoid the displacement before and after, at the distance of the fracture way, the joint of the 41- 60mm tibet tightened 02 screws under the perpendicular patients, 61-80mm screwed perpendicular to patients IME nail screw characteristics are screwed on two different planes and many advantages with intramedullary interlocking nail types only bolster screws on parallel surfaces According to our study, the anterior-posterior canal size in these sites is narrower than the internal-external size, so we assign diagonal fractures to the anterior plane - the latter is at risk of displacement of the first corner after surgery On the other The estimated sample size in a population is calculated according to the above formula ≥ 96 people (The studied sample size was 114 people: 228 tibia) * Research facilities: Digital X-ray machine TOSHIBA Model Bone fixation O - 32R, connected with the computer with the digitized software, scanning medical film images (EFILM) and photo storage (DICOM) to measure research indicators; using Perfect Screen Ruler software for measuring, dividing the distance ratio and displacement angle * Research contents: - Characteristics of the research group: Age, gender, average height - Measuring the indicators of the vertical and inclined tibia on conventional X-ray: + The size of the upper end, the lower end of the tibia, the bone body (absolute length, relative length) + Size of the canal bed in the positions and the inner ankle length - Studying the relationship between age, gender, height with the indexes of tibia 2.2 Evaluating the result of the bone fixation surgery with interlocking intramedullary nail to treat 1/3D fracture - the lower end of the outer joint tibia 2.2.1 Research subjects 63 patients with fracture in 1/3D segment - the lower end of the outer joint tibia on the tibiotalar joint > 3cm (with or without broken fibula) The tibial fixation with intramedullary interlocking nail, the fibular fixation with screw braces (if the fibular fracture is low) are at Department of Orthopaedics, Viet - Czech Friendship Hospital, Hai Phong, from April 2013 to December 2017 * Criteria for selecting patients: - Age ≥ 18 years old, voluntarily participated in the research - Closed 1/3D fracture – lower end of outer joint tibia (with or without) attached to the fibula - Full medical records, X-ray films before, after surgery, films of checking the treatment results * Exclusion criteria: - The fracture area is less than 3cm from the tibiotalar joint - Pathological fracture - Fractures of the limbs with sequelae such as paralysis, clubfoot, stiffness, limited movement of knee and ankle joints, and old fracture sequelae - Patients are not cooperative in research 2.2.2 Research Methods - Prospective study, cross-sectional clinical description combined with the 19 fracture has 52 patients (82, 54%) Fractured fragments leave 10 patients (15.87%), no broken fragments 53 patients (84.13%) 4.2.2 Selecting the time of surgery The patients underwent the surgery (within 24 hours): 47 patients (74.60%) from the 2nd to 4th days: patients (22.22%), from the 5th to the 7th day: patient (1 , 59%), after days: patient (1.59%) Surgery from day - or> days is a lot of swollen lower leg swelling 4.2.3 Reasons of selecting tibial fixation with interlocking intramedullary nail The fracture in this region is easy to suffer from delayed bone fractures, false joints When surgery needs to avoid further damage to the software, the periosteum, are the factors that provide blood for bones bone fixation sealed does not open fracture area that will respect the nourishing sources creating primitive bone cans, making bones more seamless In our study results, the lowest fracture area distance to tibiotalar joint has 14 patients in the lowest fracture group (31-40 mm), accounting for 22.22% 1.7cm from the lower end of the nail, can be applied at this distance and all 14 patients are able to tighten a bottom screw The patients were taken with perpendicular pegs of 12 patients and of which patients were in the fracture range of 41 - 60mm, the number of patients in the highest fracture group (> 80mm) included 16 patients and most of these patients Be caught screws head under parallel In the study we interlocking intramedullary nailing 100% sealed not opening into fracture area Applying the tibia anatomy study in Vietnamese adults, measuring indicators on X-ray film, using the guide with the knob at the top to prevent the drill from vertical monitoring - Evaluating postoperative results, near results (≥ months), distant results (> going too far into the tibiotalar joint Selection of nail size with nail length based on 12 months), deviation of fractures according to Larson - Bosman 2.2.2.1 Research contents narrowest medullary tibial cavity and final drilling size Using 300mm long nails is - Epidemiological characteristics - X-ray images before and after surgery - Surgical techniques tibia length on X-ray film and tibial tibial length, size based on the size of the the 28 most patients accounting for 44.44% and in the same group, the most commonly used 9mm diameter nails are 22/28 patients 18 The average size of the inner medullary tibial canal - beyond the average size of the anterior tibial bone marrow - in the same measurement position (with p