Results of Surgical Treatment of Leg Shaft Mal-Union in Adults at CHU-Brazzaville. A Five Case Retrospective Observation

Objective: To assess the anatomical and functional results after surgical management of leg shaft mal-union in African environment. Methodology: This was a retrospective study of patients operated for leg mal-union at Brazzaville University Hospital between January 2014 and December 2018. The studied parameters were epidemiological and therapeutic. The anatomical evaluation was based on the quality of the leg’s relaxation and bone healing, which was indicated on standard X-rays. The functional evaluation was based on Thorensen’s criteria. Results: Five patients were selected for this study. There were 3 men and 2 women with an average age of 39 years with extremes of 27 and 59 years. Three patients were treated with locked intramedullary nail and 2 patients with screwed plate. At an average follow-up of 9 months, bone consolidation was achieved in all our patients. The average consolidation time was 4 months (range 3 to 7 months). We noted 1 case of residual mal-union in valgus (5˚) on screwed plate and 1 case of valgus angulation (5˚) on locked intramedullary nail. Walking was considered normal in 3 patients. The wearing of a 2 cm heel was indicated in 2 patients. According to Thorensen’s criteria, the overall results were considered good in 3 patients and average in 2 patients. Conclusion: Leg shaft mal-union are likely to cause serious functional issues. Their treatment is strictly surgical and osteotomy is the only management option to restore the anatomy of the deformed limb.


Introduction
Leg shaft mal-union are one of the late complications of limb fractures [1]. They fragments have united or consolidated in a non-anatomical position [2]. The measures used to evaluate mal-union are 10˚ for varus, flessum, recurvatum and internal rotation, 15˚ for valgus and external rotation, 2 cm for shortening [3].
In North American literature, they are 5˚ for angulation, 10˚ for rotation and 1 cm for shortening [3]. Their frequency has decreased considerably in developed countries because of the preference for surgical treatment for an early recovery.
But in developing countries, leg shaft mal-union are often due to traditional treatment or inadequate surgical materials to ensure appropriate management in hospital [1] [4]. The purpose of this work was to evaluate the anatomical and functional results of the surgical treatment of leg shaft mal-union in African environment.

Patients
This was a retrospective study of patients operated for Leg shaft mal-union at Brazzaville University Hospital between January 2014 and December 2018. 1755 patients were admitted in our department, 23 patients presented with limb shaft mal-union (1.3%). 9 of them presented with leg shaft mal-union. Of these 9 patients, 5 were selected for they met the inclusion criteria patients: Laming leg shaft mal-union. Shortening of more than 2 cm of the pelvic limb, an angulation of more than 10˚ in the tibial segment, patients meeting 6 months or more a following the initial management. The studied parameters were epidemiological, including: frequency, age, sex, etiology, type of first management, type of mal-union, Clinical including: pain, type of deformation, quality of the walk, and therapeutic including: type of treatment offered and the results.

Evaluation Methods
The anatomical evaluation was based on the quality of the leg's relaxation and bone healing, which is appreciated on the standard X-ray film. The functional

Results
5 patients were selected for the study. They included 3 males and 2 females.

Discussion
Shaft mal-union is a post-traumatic orthopedic pathology whose frequency is variable in the literature. In a series of osteosynthesis managed by screwed plate, the incidence of leg shaft mal-union varies from 1% to 22% in a study leg shaft mal-union managed by intramedullary nail the incidence varies from 0 to 37% [6]. In our study the percentage was 1.3%. Gogoua [1] and Boucher [7] Reported respectively 28.69% and of 77% of mal-unions in their series. The average age of our patients was 39, it is comparable to the results found in a study by Gogoua et al. [1]. The male predominance was also de case in our study, similar to the conclusion observed in various papers.
In our study, leg shaft mal-union were found to be caused by the recourse of traditional healers, poorly conducted orthopedic treatment in health institution lacking appropriate machinery and materials, and also the financial issues that prevented the patients from undergoing surgery.
Leg shaft mal-union due to traditional treatment are reported by many Afri-  [10].
Regarding the realignment of the leg, it was difficult and required minimal bone resection in a patient operated for varus mal-union and overlap. This is explained by muscle retraction due to the age of the fracture. The stability of the reduction was insured by a locked intramedullary nail or a screwed plate. In our study, alignment was more anatomical by nail than by screwed plate.
Intramedullary nailing is the treatment of choice for shaft fractures of long limb bones. Locking has extended its indications to complex shaft fractures and metaphyseal-diaphyseal fractures [11]. In our study, we observed a case of residual valgus on locked nail in a patient operated for distal leg mal-union. This can be explained by the lack of distal locking screws or premature standing. For Omar Margal et al. [11], the distal locking must have at least 2 screws to promote the stability of the assembly. Thoreux et al. [6] in his study reports that valgus leg shaft mal-union are often seen when the fracture sits at the distal quarter of the leg.

Conclusion
Leg shaft mal-union are common in developing countries. They cause serious functional consequences and considerably modify the quality of the walk. Osteotomy is the only therapeutic option to restore anatomy of the deformed limb and improve the quality of the walk.

Informed Consent
The publication of this clinical fact has been approved by the patient.

Conflicts of Interest
The authors declare that they have no competing interests.