Uzun dönem takipli bir retrospektif analiz: AO/OTA 43-C pilon kırıklarında tüm kolonların ayrı ayrı tespit gerekliliğinin değerlendirilmesi
Küçük Resim Yok
Dosyalar
Tarih
2021
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Amaç: Çoğunlukla yüksek enerjili travmayla meydana gelen ve uygun tedavisi henüz standart bir şekil almamış olan AO/OTA 43-C kırık tipine sahip pilon kırıklarıyla ilgili literatüre bilgi aktarmak amacıyla bu çalışma dizayn edildi. Çalışmanın esas amacı pilon kırıklarını dört kolon teorisine göre sınıflandırıp plaklı vidalı osteosentez uygulanmış olan olgulardan herhangi bir plak vida sistemiyle direkt olarak desteklenmeyen ancak farklı kolonlardan uzanan vidaların tespit ettiği kolonların klinik, radyolojik, fonksiyonel ve hasta bazlı sübjektif sonuçlar üzerinde etkili olup olmadığını değerlendirmektir. Bunun dışındaki bir diğer amacımız, 43-C kırık tipine sahip pilon kırıklı olguların uzun dönem takipli klinik, radyolojik, fonksiyonel ve hasta bazlı sübjektif verilerin tümünü bir arada sunacak geniş bir veri oluşturmaktır. Hastalar ve Yöntem: Ocak 2010-Aralık 2019 arasındaki on yıllık dönemde cerrahi olarak tedavi edilmiş pilon kırıklı hastalardan AO/OTA 43-C tipine sahip, takip muayenelerine düzenli katılmış olan, 18 yaşın üstünde olan ve minimum takip süresi 12 ay olan olgular çalışmaya dahil edildi. Bunlardan 58 hasta ve 59 kırıklı olgudan plaklı vidalı osteosentez uygulanan olgular dört kolon sınıflandırmasına göre ve tespit edilen kolonlar çerçevesinde Tamamen Destekli Kolonlar (TDK), Desteksiz Bir Kolon (DBK) ve Desteksiz İki Kolon (DİK) olarak oluşturuldu. Ayrıca tüm komplikasyonlar belirlenip ilişkili olabilecek risk faktörleri üzerinden tahmini rölatif risk hesaplaması yapıldı. AO/OTA 43-C tipi kırıkların alt tiplerinin klinik sonuçlara etkisi araştırıldı. Klinik nicel sonuç olarak hem dorsifleksiyonda hem plantar fleksiyonda Eklem Hareket Açıklığı (EHA) hem de toplam EHA ve karşı ayak bileğe göre EHA kısıtlılığı değerlendirildi. Radyolojik olarak Burwell ve Charnley’nin redüksiyon değerlendirme kriterleri kullanıldı. Ayrıca Kellgren-Lawrence ayak bilek osteoartrit evreleme sistemine göre hastalar değerlendirildi. Fonksiyonel skorlama için American Orthopedic Foot and Ankle Society (AOFAS) Skorlama Sistemi kullanıldı. Hasta bazlı sübjektif veri elde etmek için ise Kısa Form-36 (KF-36) ölçeği kullanıldı. Bulgular: Hastaların son muayenedeki ortalama takip süresi 73 (12-131) aydı. AO/OTA sınıflandırmasına göre 9 kırığın C1 (%15.3), 20 kırığın C2 (%33.9) ve 30 kırığın C3 (%50.8) tipinde olduğu görüldü. Cerrahi tedavi şekli olarak 32 kırığa distal tibia medial anatomik plak uygulaması (%54.2), 12 kırığa kombine plaklı vidalı osteosentez (%20.3), 8 kırığa distal tibia anterolateral anatomik plak (%13.6), 2 kırığa vidalı osteosentez (%3.4) ve 5 kırığa kalıcı Eksternal Fiksatör (EF) uygulandığı (%8.5) görüldü. TDK, DBK ve DİK grupları tüm demografik veriler açısından benzer dağılım sergilemesine rağmen gruplar arasında klinik, radyolojik AOFAS ve KF-36 skorları açısından istatistiksel anlamlı fark saptanmadı.C1 kırık tipinden C3 kırık tipine doğru hem ayak bilek dorsifleksiyon hareket açıklığı (p=0.000), hem plantar fleksiyon hareket açıklığı (p=0.024), hem de toplam EHA’nın (p=0.002) belirgin şekilde azaldığı görüldü. Komplikasyonlara sebep olan faktörler Tahmini Rölatif Risk testiyle değerlendirildiğinde, açık kırıkta; derin enfeksiyon oluşma riski 8.1 kat, toplam enfeksiyon oluşma riski 5.6 kat, nekroz oluşma riski 6.3 kat, kaynamama oluşma riski 43.2 kat ve toplam komplikasyon oluşma riski 5.5 kat artmış olarak bulundu. Diyabet varlığının osteomiyelit riskini 6.6 kat arttırdığı, EF tedavisinin Açık Redüksiyon ve İnternal Fiksasyon (ARİF) tedavisine göre kısalık gelişme ihtimalini 12.3 kat arttığı saptandı. Hastalarımız ameliyat sonrası redüksiyon başarı kriterlerine göre değerlendirildiğinde; 41 kırıkta redüksiyon başarısı anatomik (%69.5), 14 kırıkta iyi (%23.7) ve 4 kırıkta kötü (%6.8) bulundu. Kellgren-Lawrence ayak bilek osteoartrit evreleme sistemine göre osteoartriti mevcut 26 kırık (%45.6) ve olmayan 31 kırık (%54.4) mevcuttu. Hasta grubumuzun AOFAS skor ortalaması 82.5 olup, 18’i mükemmel (%31), 24’ü iyi (%41.4), 15’i orta (%25.9) ve bir hasta kötü (%1.7) sonuç olarak kategorilendirildi. Enfeksiyon gelişmesi (p=0.001), komplikasyon gelişmesi (p=0.000), redüksiyon başarısı (p=0.032), EHA kısıtlılığı olup olmamasının (p=0.001) AOFAS skoru üzerinde istatistiksel anlam oluşturacak ölçüde etkili olduğu görüldü. KF-36 değerleri incelendiğinde enfeksiyona sahip olguların fiziksel fonksiyon (p=0.009), fiziksel rol güçlüğü (0.099), fiziksel özet (p=0.028) ve canlılık (p=0.030) skorlarında; komplikasyona sahip olguların da fiziksel fonksiyon (p=0.007), fiziksel rol güçlüğü (0.023), fiziksel özet (p=0.012), canlılık (p=0.023), sosyal fonksiyon (p=0.048) skorlarında geride kaldığı görüldü. Sonuç: Dört kolon sınıflandırma sistemi ve cerrahi fiksasyon öneri şemasının popülasyonumuzda anlamlı fark oluşturmadığı ortaya çıkmış olup, pilon kırıklarında uzun dönem başarının anahtarının anatomik redüksiyona mutlak sadakat gösterilmesi dışında temel olarak enfeksiyon ve komplikasyonlardan kaçınmak olduğu ortaya çıkmıştır.
Aim: This study was designed to inform the literature on AO/OTA 43-C pilon fractures. The proper treatment of AO/OTA 43-C pilon fractures that are mostly caused by high-energy trauma has not yet taken a standard form. The main purpose of this study is to evaluate the effectiveness of the plate screw osteosynthesis treatment according to four column theory. The plate screw osteosynthesis that was applied on our patients was not directly supported by any plate screw system but it was fixed by screws extending from other columns. Thus, this dissertation aims to analyze the effectiveness of the treatment on clinical, radiological, functional results, and patient-reported outcome scores. The study also serves the purpose of creating a large data collection that presents clinical, radiological, functional results and patient-reported outcome scores with 43-C pilon fractures with long-term follow-up. Materials and methods: Patients with AO/OTA 43-C type who were treated surgically between January 2010 and December 2019, who attended follow-up examinations regularly, were over 18 years old, and had a minimum 12 months follow-up were included in the study. Among these patients, 59 fractures and 58 patients who underwent plate screw osteosynthesis were categorized based on the fixed columns. These groups were formed as Fully Supported Columns (TDK in Turkish), One Unsupported Column (DBK in Turkish), and Two Unsupported Columns (DİK in Turkish). The groups were compared on the basis of demographic data they represent and treatment outcomes they achieved over time. During the follow-up, a specific attention was paid to detect possible complications of the treatment which were later assessed by calculating the Odds Ratio of the risk factors associated with these complications. The effects of the AO/OTA 43-C subtypes on clinical outcomes were assessed, too. The range of motion (ROM) and ROM limitation in both dorsiflexion and plantar flexion were evaluated as a part of clinical outcomes. Moreover, Burwell and Charnley's reduction evaluation criteria, Kellgren-Lawrence ankle osteoarthritis staging system, and American Orthopedic Foot and Ankle Society (AOFAS) Scoring System were used for evaluating radiological and functional results. Lastly, Short Form-36 (KF-36 in Turkish) scale was used to obtain the patient-reported outcomes. Results: The mean follow-up of the patients at the last examination was 73 (12-131) months. According to the AO/OTA classification, 9 fractures were C1 (15.3%), 20 fractures were C2 (33.9%), and 30 fractures were C3 (50.8%). As surgical treatments, 32 distal tibia medial anatomical plates (54.2%), 12 combined plate screw osteosynthesis (20.3%), 8 distal tibia anterolateral anatomical plates (13.6%), 2 screw osteosynthesis (3.4%), and 5 permanent External Fixator (8.5%) were applied. Although the TDK, DBK, and DİK groups showed a similar distribution in terms of demographic data, no statistically significant result was found between the groups in clinical and radiological results, and AOFAS and SF-36 scores. It was observed that both ankle dorsiflexion ROM (p=0.000), plantar flexion ROM (p=0.024), and total ROM (p=0.002) decreased significantly from C1 fracture type to C3 fracture type. When the factors causing complications were evaluated with the Odds Ratio test, the risk of deep infection was 8.1 times, the total risk of infection was 5.6 times, the risk of necrosis was 6.3 times, the risk of nonunion was 43.2 times, and the total complication risk was 5.5 times higher in open fractures. It was determined that the presence of diabetes increased the risk of osteomyelitis 6.6 times, and External Fixator treatment increased the probability of developing shortness 12.3 times compared to Open Reduction and Internal Fixation (ARIF) treatment. When evaluated according to postoperative reduction success criteria, reduction success was found anatomically (69.5%) in 41 fractures, fair in 14 (23.7%) and poor in 4 fractures (6.8%). According to the Kellgren-Lawrence ankle osteoarthritis staging system, there were 26 fractures (45.6%) with osteoarthritis and 31 (54.4%) without osteoarthritis. The mean AOFAS score of our patient group was 82.5, with 18 categorized as excellent (31%), 24 as good (41.4%), 15 as moderate (25.9%) and a patient as poor (1.7%). It was observed that the development of infection (p=0.001), the development of complications (p=0.000), reduction success (p=0.032), and presence of ROM restriction (p=0.001) had a statistically significant effect on the AOFAS score. When the KF-36 values were examined, the physical functioning (p=0.009), role limitations due to physical health (0.099), physical summary (p=0.028), and vitality (p=0.030) scores decreased for the infected patients. The patients with complications were also found to lag behind in physical functioning (p=0.007), role limitations due to physical health (0.023), physical summary (p=0.012), vitality (p=0.023), social functioning (p=0.048) scores. Conclusion: Four-column classification system and surgical fixation of the proposed scheme does not constitute a significant result based on our sample. It has been revealed that the key to long-term success in pilon fractures is to avoid infection and complications in addition to the absolute fidelity to the anatomical reduction.
Aim: This study was designed to inform the literature on AO/OTA 43-C pilon fractures. The proper treatment of AO/OTA 43-C pilon fractures that are mostly caused by high-energy trauma has not yet taken a standard form. The main purpose of this study is to evaluate the effectiveness of the plate screw osteosynthesis treatment according to four column theory. The plate screw osteosynthesis that was applied on our patients was not directly supported by any plate screw system but it was fixed by screws extending from other columns. Thus, this dissertation aims to analyze the effectiveness of the treatment on clinical, radiological, functional results, and patient-reported outcome scores. The study also serves the purpose of creating a large data collection that presents clinical, radiological, functional results and patient-reported outcome scores with 43-C pilon fractures with long-term follow-up. Materials and methods: Patients with AO/OTA 43-C type who were treated surgically between January 2010 and December 2019, who attended follow-up examinations regularly, were over 18 years old, and had a minimum 12 months follow-up were included in the study. Among these patients, 59 fractures and 58 patients who underwent plate screw osteosynthesis were categorized based on the fixed columns. These groups were formed as Fully Supported Columns (TDK in Turkish), One Unsupported Column (DBK in Turkish), and Two Unsupported Columns (DİK in Turkish). The groups were compared on the basis of demographic data they represent and treatment outcomes they achieved over time. During the follow-up, a specific attention was paid to detect possible complications of the treatment which were later assessed by calculating the Odds Ratio of the risk factors associated with these complications. The effects of the AO/OTA 43-C subtypes on clinical outcomes were assessed, too. The range of motion (ROM) and ROM limitation in both dorsiflexion and plantar flexion were evaluated as a part of clinical outcomes. Moreover, Burwell and Charnley's reduction evaluation criteria, Kellgren-Lawrence ankle osteoarthritis staging system, and American Orthopedic Foot and Ankle Society (AOFAS) Scoring System were used for evaluating radiological and functional results. Lastly, Short Form-36 (KF-36 in Turkish) scale was used to obtain the patient-reported outcomes. Results: The mean follow-up of the patients at the last examination was 73 (12-131) months. According to the AO/OTA classification, 9 fractures were C1 (15.3%), 20 fractures were C2 (33.9%), and 30 fractures were C3 (50.8%). As surgical treatments, 32 distal tibia medial anatomical plates (54.2%), 12 combined plate screw osteosynthesis (20.3%), 8 distal tibia anterolateral anatomical plates (13.6%), 2 screw osteosynthesis (3.4%), and 5 permanent External Fixator (8.5%) were applied. Although the TDK, DBK, and DİK groups showed a similar distribution in terms of demographic data, no statistically significant result was found between the groups in clinical and radiological results, and AOFAS and SF-36 scores. It was observed that both ankle dorsiflexion ROM (p=0.000), plantar flexion ROM (p=0.024), and total ROM (p=0.002) decreased significantly from C1 fracture type to C3 fracture type. When the factors causing complications were evaluated with the Odds Ratio test, the risk of deep infection was 8.1 times, the total risk of infection was 5.6 times, the risk of necrosis was 6.3 times, the risk of nonunion was 43.2 times, and the total complication risk was 5.5 times higher in open fractures. It was determined that the presence of diabetes increased the risk of osteomyelitis 6.6 times, and External Fixator treatment increased the probability of developing shortness 12.3 times compared to Open Reduction and Internal Fixation (ARIF) treatment. When evaluated according to postoperative reduction success criteria, reduction success was found anatomically (69.5%) in 41 fractures, fair in 14 (23.7%) and poor in 4 fractures (6.8%). According to the Kellgren-Lawrence ankle osteoarthritis staging system, there were 26 fractures (45.6%) with osteoarthritis and 31 (54.4%) without osteoarthritis. The mean AOFAS score of our patient group was 82.5, with 18 categorized as excellent (31%), 24 as good (41.4%), 15 as moderate (25.9%) and a patient as poor (1.7%). It was observed that the development of infection (p=0.001), the development of complications (p=0.000), reduction success (p=0.032), and presence of ROM restriction (p=0.001) had a statistically significant effect on the AOFAS score. When the KF-36 values were examined, the physical functioning (p=0.009), role limitations due to physical health (0.099), physical summary (p=0.028), and vitality (p=0.030) scores decreased for the infected patients. The patients with complications were also found to lag behind in physical functioning (p=0.007), role limitations due to physical health (0.023), physical summary (p=0.012), vitality (p=0.023), social functioning (p=0.048) scores. Conclusion: Four-column classification system and surgical fixation of the proposed scheme does not constitute a significant result based on our sample. It has been revealed that the key to long-term success in pilon fractures is to avoid infection and complications in addition to the absolute fidelity to the anatomical reduction.
Açıklama
Anahtar Kelimeler
Pilon Kırığı, Dört Kolon, 43-C, AOFAS, Kısa Form-36, Pilon Fracture, Four Column, 43-C, AOFAS, Short Form-36
