Ali TURGUT, Onder KALENDERER, Burak GUNAYDİN, Burak ONVURAL, Levent KARAPİNAR, Haluk AGUS

İntertrokanterik femur kırıklarının proksimal femoral çivi antirotasyon (PFNA) ile lateral dekübit pozisyonda tespiti

Amaç: Bu çalışmanın amacı, intertrokanterik femur kırıklarının Proksimal Femoral Çivi Antirotasyon (PFNA) kullanılarak, traksiyon masasız, lateral dekübit pozisyonda uygun bir şekilde redükte edilip tespit edilip edilemediğinin değerlendirilmesi idi.Çalışma planı: Çalışmaya 81’i erkek, 126’sı kadın olmak üzere 207 hasta (ortalama yaş: 75, dağılım: 22-95) dahil edildi. Evans sınıflamasına göre; 7 Tip 1, 40 Tip 2, 33 Tip 3, 38 Tip 4, 61 Tip 5 ve 28 ters oblik kırık mevcuttu. Ameliyat sonrası röntgenlerde; implant ucu-apeks mesafesi, helikal bıçağın Cleveland ve Bosworth kadranı, Ikuta redüksiyon alt grubu, kollodiyafizer açı ve redüksiyon aralıkları ölçüldü.Bulgular: Ortalama takip süresi 20.4 (dağılım: 6-38) ay olan hastalarda Ikuta sınıflamasına göre 176 kırık (%85) normal alt tip, 15 kırık (%7.2) posterior alt tip ve 16 kırık (%7.7) anterior alt tip olarak redükte edilmişti. Herman kriterlerine göre hastaların %99’unda iyi veya kabul edilebilir redüksiyon sağlandığı görüldü. Ortalama implant ucu-apeks mesafesi 29.2 mm, ortalama ameliyat süresi 57.2 dakika olarak ölçüldü. Uygun kadran (merkez-merkez, alt-merkez) yerleşimi hastaların %53.5’inde sağlanmışken, üst-arka kadran yerleşimi hastaların sadece %2.4’ünde görüldü. Dokuz hastada (%4.3) sıyrılma komplikasyonu gerçekleşti.Çıkarımlar: İntertrokanterik kırıkların lateral dekübit pozisyonda çivilenmesi uygun kadran yerleşiminin sağlanması ve implant ucu-apeks mesafesinde ideal değerlerin elde edilmesinde başarılı olmasa da, muhtemelen PFNA tarafından sağlanan mükemmel stabilite sayesinde sonuçlar cesaret vericidir.

Anahtar Kelimeler:

İntertrokanterik kırıklar; lateral dekübit pozisyon; ; Proksimal Femoral Çivi Antirotasyon; traksiyon masası.

Fixation of intertrochanteric femur fractures using Proximal Femoral Nail Antirotation (PFNA) in the lateral decubitus position without a traction table

Objective: The aim of this study was to evaluate whether intertrochanteric femur fractures can be reduced and nailed properly in the lateral decubitus position using Proximal Femoral Nail Antirotation (PFNA) as a fixation device without the use of a traction table.Methods: The study included 207 patients (81 male and 126 female; mean age: 75 years, range: 22 to 95 years). According to the Evans classification, there were 7 Type 1, 40 Type 2, 33 Type 3, 38 Type 4, 61 Type 5 and 28 reverse oblique fractures. Radiographs were used to measure the tip-apex distance (TAD), the quadrant of the helical blade according to Cleveland and Bosworth, Ikuta’s reduction subgroup, collodiaphyseal angle and reduction gaps postoperatively.Results: Mean follow-up time was 20.4 (range: 6 to 38) months. According to Ikuta’s classification, 176 (85%) reduced fractures were of subtype N, 15 (7.2%) subtype P and 16 (7.7%) subtype A. Good or acceptable reduction according to the Herman criteria was obtained in 99% of fractures. Mean TAD was 29.2 millimeters. Mean operation time was 57.2 minutes. Optimal blade position (center-center or inferior-center) was achieved in 53.5% of patients and was in the superior-posterior quadrants in only 2.4% of patients. Cut-out complication occurred in 9 patients (4.3%).Conclusion: While the nailing of intertrochanteric fractures in a lateral decubitus position does not provide ideal quadrant placement and TAD, results are encouraging probably due to the excellent stability that is provided by PFNA.

Keywords:

Intertrochanteric fractures, lateral decubitis position, Proximal Femoral Nail Antirotation traction table,

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Aguado-Maestro I, Escudero-Marcos R, García-García JM, Alonso-García N, Pérez-Bermejo D D, AguadoHernández HJ, et al. Results and complications of pertrochanteric hip fractures using an intramedullary nail with a helical blade (proximal femoral nail antirotation) in 200 patients. [Article in Spanish] Rev Esp Cir Ortop Traumatol 2013;57:201-7. [Abstract]
Frei HC, Hotz T, Cadosch D, Rudin M, Käch K. Central head perforation, or “cut through,” caused by the helical blade of the proximal femoral nail antirotation. J Orthop Trauma 2012;26:102-7.
Vaquero J, Munoz J, Prat S, Ramirez C, Aguado HJ, Moreno E, et al. Proximal Femoral Nail Antirotation versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures. A randomised comparative study. Injury 2012;43 Suppl 2:47-54.
Brandt E, Verdonschot N. Biomechanical analysis of the sliding hip screw, cannulated screws and Targon1 FN in intracapsular hip fractures in cadaver femora. Injury 2011;42:183-7.
Oh JH, Hwang JH, Sahu D. Nailing of intertrochanteric fractures: review on pitfalls and technical tips. JOTR 2010;14:3-7.
Takigawa N, Moriuchi H, Abe M, Yasui K, Eshiro H, Kinoshita M. Complications and fixation techniques of trochanteric fractures with the TARGON(®) PF. Injury 2014;45 Suppl 1:44-8.
Herman A, Landau Y, Gutman G, Ougortsin V, Chechick A, Shazar N. Radiological evaluation of intertrochanteric fracture fixation by the proximal femoral nail. Injury 2012;43:856-63.
Callanan I, Choudhry V, Smith H. Perineal sloughing as a result of pressure necrosis from the traction post during prolonged bilateral femoral nailing. Injury 1994;25:472.
Brumback RJ, Ellison TS, Molligan H, Molligan DJ, Mahaffey S, Schmidhauser C. Pudendal nerve palsy complicating intramedullary nailing of the femur. J Bone Joint Surg Am 1992;74:1450-5.
Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Br 1949;31B:190-203.
Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 1995;77:1058-64. Journal 2013;2013:276015.
Soucanye de Landevoisin E, Bertani A, Candoni P, Charpail C, Demortiere E. Proximal femoral nail antirotation (PFN-ATM) fixation of extra-capsular proximal femoral fractures in the elderly: retrospective study in 102