Study of tibia anatomy in vietnamese adults: Appication in treatment of lower and distal tibia Fracture by intramedullary with locking nail – Nguyen Viet Dung

Journal of military pharmaco-medicine n o 8-2018 181 STUDY OF TIBIA ANATOMY IN VIETNAMESE ADULTS: APPICATION IN TREATMENT OF LOWER AND DISTAL TIBIA FRACTURE BY INTRAMEDULLARY WITH LOCKING NAIL Nguyễn Viet Dung1; Nguyen Tien Binh2; Vu Nhat Dinh3 SUMMARY Objectives: To study the characteristics of tibia anatomy in Vietnamese adults (absolute length of tibia, hard bone length of tibia, medullary canal diameter of tibia), application in treatment of lower and distal fracture of tibia with locked intramedullary nailing. Subjects: 228 tibias of 114 Vietnamese adults (67 males, 47 females), average age: 41.31 ± 15.59 years old (from 20 - 83 years old), average height: 161.77 ± 7.85 cm (from 143 - 176 cm) (average height of males: 167.39 ± 6.46 cm, from 158 - 176 cm; average height of females: 153.77 ± 4.64 cm, from 146 - 165 cm). The study was conducted at Radiographic Department, Viettiep Hospital, Haiphong. Methods: Taking digital radiography of 2 tibias at straight and inclined posture by radiographic machine TOSHIBA Model KXO-32R, connected to computer which has digitizer software, applied in scanning medical film (EFILM Workstation) and achieving images (DICOM) in order to measure study index. Results: Absolute length of tibia was 36.28 ± 2.30 cm (from 31.20 - 46.00 cm), males: 37.18 ± 2.08 cm (from 33.30 - 46.00 cm), females: 35.00 ± 1.99 cm (from 31.20 - 41.00 cm). Hard bone length of tibia was 23.84 ± 1.91 cm (from 20.00 - 29.00 cm), males: 24.44 ± 1.75 cm (from 20.00 - 29.00 cm), females: 22.98 ± 1.81cm (20.10 - 27.50 cm). The narrowest medullary canal of tibia was 8 - 12 cm from bare tibia cartilage. The narrowest medullary canal diameter of tibia in male group was: anterior - posterior 1.03 ± 0.11 cm (from 0.80 - 1.20 cm), internal - external 1.19 ± 0.12 cm (from 0.9 - 1.4 cm). The narrowest medullary canal diameter of tibia in female group was: anterior - posterior 0.96 ± 0.12 cm (from 0.70 - 1.30 cm), internal - external: 1.10 ± 0.14 cm (from 0.80 - 1.40 cm). The lower one third (2 cm from bare tibia cartilage), the largest internal - external medullary canal diameter of tibia was 2.00 ± 0.16 cm at distal tip (anterior - posterior: 1.84 ± 0.15 cm. Female group: The internal - external diameter: 2.02 ± 0.16 cm, anterior - posterior: 1.86 ± 0.14 cm. Male group: The internal - external diameter: 1.99 ± 0.16 cm, anterior - posterior: 1.83 ± 0.15 cm). * Keywords: Tibia anatomy; Distal tibia fracture; Lower tibia fracture; Locked intramedullary nailing; Vietnamese adults. INTRODUCTION Lower or distal fracture of tibia and both bones of legs is common due to work, traffic and daily activities accidents [1]. Options of fixation instruments in these positions are difficult because of special anatomy: Fixation by locked intramedullary nailing is not stable for the bone because medullary canal is not even at both sides, 1. Viettiep Hospital Haiphong 2. Vietnam Military Medical University 3. 103 Military Hospital Corresponding author: Nguyen Viet Dung (dungngoai10@gmail.com) Date received: 30/07/2018 Date accepted: 24/09/2018 Journal of military pharmaco-medicine n o 8-2018 182 it is narrow in the middle and enlarged toward bone tips. Tibia of Vietnamese people are smaller and shorter than in Westerner, so screws and plates which are imported abroad are not suitable. In addition, medial or lower one third tibia alter from triangle prism to round and soft tissue covering anterior - posterior aspect of tibia are weak which lead to tension or not closely when placing plate and results in decreasing stable, complicating infection, exposing plate, osteoclasis, ununion or pseudarthrosis [2, 3]. These days, with a view to limiting the disadvantages of fixation by plate screw, the domestic and overseas authors treated lower or distal fracture outer joint by locked intramedullary nailing [4, 7], but limited number and results. Therefore, we conducted a research on anatomic tibia characteristics in Vietnamese adults with desire to make contribution to the improvement of technique and indications in treatment of lower and distal fracture of tibia and both bones of the legs. SUBJECTS AND METHOD 1. Subjects. 228 tibias of 114 Vietnamese adults (67 males and 47 females), no displacement, no osteoarthritic diseases, no history of trauma, aged 20 to 83 years old at Radiographic Department in Viettiep Hospital, Haiphong from December 2012 to March 2013. 2. Method. - Methods: A cross sectional-descriptive study. - Equipment: Digital radiographic machine TOSHIBA Model KXO-32R connects to computer with digitizer software, applies in scanning medical film (EFILM Workstation) and storage of figure (DICOM) so as to measure study index. - Study contents: Taking radiographic film at standard straight and inclined posture (PA and LL): measure tibia length, size medullary canal of tibia by digitizer software. Figure 1: Digital radiographic film and measure index of tibia on PA and LL films (Source: Study Data). Journal of military pharmaco-medicine n o 8-2018 183 * Data analysis: - Getting information and write to study table: Age, sex, height, tibial length, size of medullary canal. - Calculating measured data by statistical algorithm SPSS 20.0. RESULTS AND DISCUSSION 1. Characteristics of study group. Table 1: Characteristics of sex, age and height (n = 114). Sex Amount Age (X ± SD) (Min - max) Height (X ± SD) (cm) (Min - max) Male 67 38.64 ± 13.66 (20 - 80) 167.39 ± 3.62 (158 - 176) Female 47 45.11 ± 17.35 (20 - 83) 153.77 ± 4.64 (146 - 165) Total 114 41.31 ± 15.59 (20 - 83) 161.77 ± 7.85 146 - 176 p p < 0.05 p < 0.05 Study of anatomic tibia in 114 patients (67 males, 47 females), average age was 41.31 ± 15.59 years old (from 20 - 83 years old). The average height of male patients was taller than that of female group, statistically significant difference with p < 0.05. 2. Length of tibia related to gender. Table 2: Absolute tibia and hard tibia trunk length related to gender (n = 228). Sex Amount Absolute tibia length (cm) (X ± SD) (Min - max) Length of hard tibia trunk (cm) (X ± SD) (Min - max) Male 134 37.18 ± 2.08 (33.30 - 46.00) 24.44 ± 1.75 (20.00 - 29.00) Female 94 35.00 ± 1.99 (31.20 - 41.00) 22.98 ± 1.81 (20.10 - 27.50) Total 228 36.28 ± 2.30 (31.20 - 46.00) 23.84 ± 1.91 (20.00 - 29.00) p < 0.05 < 0.05 The absolute tibia length of tibia trunk of the study group was 36.28 ± 2.30 cm (from 31.20 - 46.00 cm), that of hard tibia trunk was 23.84 ± 1.91 cm (from 20.00 - 29.00 cm), (that of the male group was longer than the female one with p < 0.05). The absolute tibia length of male group was longer than that of female group with statistical difference (p < 0.05). The hard bone length of tibia of male group was longer than that of female group with statistical difference (p < 0.05). Journal of military pharmaco-medicine n o 8-2018 184 Nguyen Viet Dung et al’s study [6] conducted a survey on 55 tibia of Vietnamese adults with mean age was 36.45 ± 15.68 years old [5]. The average length of tibia 36.72 ± 2.63 cm (males: 37.53 ± 2.65 cm and females: 35.40 ± 2.05 cm). The mean hard bone length of tibia was 24.59 ± 1.87 cm (males: 24.98 ± 1.88 cm, females: 23.96 ± 1.71 cm), these results were also equivalent to our outcome. Tosun N et al’s study on 45 tibias which were taken CT-scanner, the tibia length was 3 cm, lower tibia plateau and 2 cm upper bare tibia cartilage, bone length was 27.5 - 36.0 cm, mean length of tibia was 32.17 ± 1.77 cm, the lower and upper one third medullary canal was larger than the medial medullary canal [8]. Table 2: Diameter of medullary canal at the lower-medial one third tibia related to gender (n = 228). Diameter of medullary tibia canal (X ± SD) (cm) Location, (distance bare tibia, cm) Anterior - posterior (X ± SD) (cm) (Min - max) Internal - external (X ± SD) (cm) (Min - max) p Male 1.83 ± 0.15 (1.40 - 2.20) 1.99 ± 0.16 (1.50 - 2.40) < 0.01 Female 1.86 ± 0.15 (1.50 - 2.20) 2.02 ± 0.16 (1.50 - 2.40) < 0.01 2 cm Male + female 1.84 ± 0.15 (1.40 - 2.20) 2.00 ± 0.16 (1.50 - 2.40) < 0.01 Male 1.57 ± 0.15 (1.20 - 1.90) 1.72 ± 0.16 (1.30 - 2.10) < 0.01 Female 1.56 ± 0.14 (1.20 - 1.90) 1.74 ± 0.16 (1.30 - 2.10) < 0.01 4 cm Male + female 1.57 ± 0.15 (1.20 - 1.90) 1.73 ± 0.16 (1.30 - 2.10) < 0.01 Male 1.35 ± 0.13 (1.00 - 1.60) 1.50 ± 0.13 (1.10 - 1.80) < 0.01 Female 1.30 ± 0.16 (0.90 - 1.70) 1.46 ± 0.16 (1.00 - 1.90) < 0.01 6 cm Male + female 1.33 ± 0.14 (0.90 - 1.70) 1.48 ± 0.14 (1.10 - 1.90) < 0.01 Male 1.17 ± 0.11 (0.90 - 1.40) 1.32 ± 0.12 (1.00 - 1.50) < 0.01 Female 1.10 ± 0.14 (0.70 -1.50) 1.26 ± 0.16 (0.80 - 1.70) < 0.01 8 cm Male + female 1.14 ± 0.12 (0.70 - 1.50) 1.29 ± 0.14 (0.80 - 1.40) < 0.01 Journal of military pharmaco-medicine n o 8-2018 185 Male 1.03 ± 0.11 (0.80 - 1.30) 1.19 ± 0.12 (0.9 - 1.4) < 0.01 Female 0.96 ± 0.11 (0.70 - 1.30) 1.10 ± 0.14 (0.80 - 1.40) < 0.01 The narrowest medullary canal (8 - 10 cm) Male + female 1.00 ± 0.12 (0.70 - 1.30) 1.15 ± 0.14 (0.8 - 1.40) < 0.01 Male 1.04 ± 0.12 (0.80 - 1.40) 1.19 ± 0.13 (0.90 - 1.60) < 0.01 Female 1.00 ± 0.14 (0.70 - 1.40) 1.14 ± 0.16 (0.8 - 1.50) < 0.01 10 cm Male + female 1.02 ± 0.13 (0.70 - 1.40) 1.17 ± 0.15 (0.80 - 1.60 ) < 0.01 Male 1.18 ± 0.12 (0.90 - 1.60) 1.31 ± 0.12 (1.00 - 1.70) < 0.01 Female 1.11 ± 0.15 (0.90 - 1.50) 1.26 ± 0.14 (1.00 - 1.60) < 0.01 12 cm Male + female 1.15 ± 0.13 (0.90 - 1.60) 1.29 ± 0.13 (1.00 - 1.70) < 0.01 The anterior - posterior diameter of tibia was smaller than that of the internal - external one at the same site (p < 0.01). The narrowest medullary canal of tibia was 8 - 10 cm from bare tibia cartilage. In our study, we found that the narrowest medullary canal of tibia was about 8 - 12 cm from cartilage bare of tibia. The internal - external medullary canal diameter of tibia (straight) was larger than the anterior - posterior medullary canal diameter of tibia (oblique) at the same site with p < 0.01. In males, the narrowest anterior - posterior medullary canal diameter of tibia was 1.03 ± 0.11 cm (from 0.80 - 1.20 cm), internal - external medullary canal diameter of tibia was 1.19 ± 0.12 cm (from 0.9 - 1.4 cm), in females it was 0.96 ± 0.12 cm (from 0.70 - 1.30 cm) and 1.10 ± 0.14 cm (from 0.80 - 1.40 cm). At 1/3 lower position (2 cm from tibia cartilage), the largest internal - external medullary canal diameter of tibia was at distal tip 2.00 ± 0.16 cm, anterior - posterior medullary canal diameter of tibia was 1.84 ± 0.15 cm. In females, the largest internal - external medullary canal diameter of tibia was 2.02 ± 0.16 cm and anterior - posterior medullary canal diameter of tibia was 1.86 ± 0.14 cm larger compared to males (internal - external diameter: 1.99 ± 0.16 cm, anterior - posterior 1.83 ± 0.15 cm) with p < 0.01. Van Quang Sung [6] did a survey on the lower one third of bilateral tibiae in 50 Vietnamese adults by CT-scanner. The author found that the narrowest medullary canal was at lower an medial one third and enlarged toward inferiorly like hourglass, the anterior - posterior medullary canal diameter of tibia was narrower than the internal - external one, left leg unlike right leg, similar to our study. Journal of military pharmaco-medicine n o 8-2018 186 The author measured medullary canal diameter of tibia on the CT-scanner film 6 cm from cartilage bare of tibia, the average of anterior - posterior medullary canal diameter of tibia was 16.95 ± 1.99 mm, internal - external medullary canal diameter of tibia was 15.98 ± 2.24 mm. At 4 cm from cartilage bare of tibia, the average of anterior - posterior medullary canal diameter of tibia was 20.18 ± 2.11 mm, the average internal - external medullary canal diameter of tibia was 20.47 ± 2.41 mm. At 2 cm from cartilage bare of tibia, the average anterior - posterior medullary canal diameter of tibia was 27.25 ± 2.99 mm, the average internal - external medullary canal diameter of tibia was 28.36 ± 2.71 mm. Van Quang Sung’s study on CT-scanner at the same positions, the anterior - posterior and internal - external medullary canal diameter of tibia was larger than our study’s findings on digital X-ray film [6]. The authors also investigated the movement of intramedullary nail in canal, when the nail tip was about 6 cm from cartilage bare of tibia, the anterior - posterior medullary canal diameter of tibia movement in 8 nail was 8.95 ± 1.99 mm, lateral movement was 7.98 ± 2.24 mm, the anterior - posterior medullary canal diameter of tibia movement in 9 nail was 7.95 ± 1.99 mm, lateral movement 6.98 ± 2.24 mm. When the nail tip was about 4 cm from cartilage bare of tibia, the anterior - posterior medullary canal diameter of tibia movement in 8 nail was 12.18 ± 2.11 mm, lateral movement was 12.47 ± 2.41 mm, the anterior - posterior medullary canal diameter of tibia movement in 9 was 11.18 ± 2.11 mm, lateral movement was 11.47 ± 2.41 mm. When the nail tip was about 2 cm from cartilage bare of tibia, the anterior - posterior medullary canal diameter of tibia movement in 8 nail was 19.25 ± 2.99 mm, lateral movement was 20.36 ± 2.71 mm, the anterior - posterior medullary canal diameter of tibia movement in 9 nail was 18.25 ± 2.99 mm, lateral movement was 19.36 ± 2.71 mm. 3. Application of anatomical study in treatment. The authors treated lower or distal fracture of tibia or both bones of legs with locked intramedullary nailing and had several problems such as not define exactly length and diameter nail, if nail isn’t enough long, fixation will not be enough stable or if nail is too long, it will pass over cartilage bare of tibia, nail is loose, leading to open angle, displaced axis or if diameter of nail is greater than diameter of medullary canal, it will result in sticking nail, bone breaks, if diameter of nail is smaller than diameter of medullary nail, nail will be loose. With results of study of tibia anatomy and application in Vietnamese adults on digital X-ray film, we measured carefully the appropriate length to nail tibia cartilage, pass over fracture site and lock screw stably (2 screws were parallel or upright. Diameter was suitable for medullary canal, not need to stretch it more times, decreased injuries blooding supply system of bone, no complication when to fix nail. CONCLUSION Study of anatomical tibia in 114 Vietnamese adults (67 males, 47 females) with 228 tibia by digital radiography and digitized hardware, Journal of military pharmaco-medicine n o 8-2018 187 mean age was 41.31 ± 15.59 years old (from 20 - 83 years old), we concluded characteristics of tibia anatomy: - The height of study group was 161.77 ± 7.85 cm (from 143 - 176 cm), males was 167.39 ± 6.46 cm (from 158 - 176 cm) and females was 153.77 ± 4.64 cm (from 146 - 165 cm). - The absolute length of tibia was 36.28 ± 2.30 cm (from 31.20 - 46.00 cm), males 37.18 ± 2.08 cm (from 33.30 - 46.00 cm); females 35.00 ± 1.99 cm (from 31.20 - 41.00 cm). The hard bone length of tibia was 23.84 ± 1.91 cm (from 20.00 - 29.00 cm), males 24.44 ± 1.75 cm (from 20.00 - 29.00 cm); females 22.98 ± 1.81 cm (from 20.10 - 27.50 cm). - The narrowest medullary canal of tibia was 8 - 12 cm from cartilage bare of tibia. The narrowest medullary canal diameter of tibia in male group was: anterior - posterior 1.03 ± 0.11 cm (from 0.80 - 1.20 cm), internal - external: 1.19 ± 0.12 cm (from 0.9 - 1.4 cm). The narrowest medullary canal diameter of tibia in female group was anterior - posterior 0.96 ± 0.12 cm (from 0.70 - 1.30 cm), internal - external: 1.10 ± 0.14 cm (from 0.80 - 1.40 cm). - At the lower one third (2 cm from cartilage bare of tibia), the largest medullary canal of diameter tibia was distal tip: internal - external 2.00 ± 0.16 cm, anterior - posterior: 1.84 ± 0.15 cm. The internal - external diameter in female group was 2.02 ± 0.16 cm, anterior - posterior 1.86 ± 0.14 cm. The internal - external diameter in male group was 1.99 ± 0.16 cm, anterior - posterior: 1.83 ± 0.15 cm. REFERENCES 1. Phạm Đăng Ninh. Đánh giá kết quả điều trị gãy kín thân 2 xương cẳng chân bằng đóng đinh nội tủy kín có chốt tại Bệnh viện Quân y 103. Tạp chí Y - Dược học Quân sự. 2005, số 3. 2. Nguyễn Đức Dũng. 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