Soner ŞAHİN, Eden ERTÜRER, İRFAN ÖZTÜRK, Serdar TOKER, Faik SEÇKİN, Şenol AKMAN

Stabil olmayan intertrokanterik femur kırıklarının tedavisinde proksimal femoral çivi antirotasyon (PFNA) osteosentezinin radyografik ve fonksiyonel sonuçları

Amaç: Stabil olmayan intertrokanterik femur kırı nedeniyle proksimal femoral çivi antirotasyon (PFNA) uygulanan hastaların radyografik ve fonksiyonel sonuçları değerlendirildi. Çalışma planı: Çalışmaya stabil olmayan intertrokanterik kırık tanısıyla PFNA çivisiyle osteosentez uygulanan 45 hasta (25 kadın, 20 erkek; ort. yaş 72; dağılım 27-97) alındı. Yirmi beş hastanın sağ, 20 hastanın sol kalçasında intertrokanterik kırık vardı. Kırıklar AO sınıflamasına göre sınıflandırıldı. Bir hastada ateşli silah yaralanması sonucu gelişen açık kırık (Gustilo-Anderson 3A) vardı. Hastalar travma tarihinden itibaren ortalama sekizinci günde (dağılım 2-21 gün) ameliyat edildi. Hastaların hastanede kalış süresi ortalama 13.5 gündü (dağılım 4-25 gün). Hastaların tümünde redüksiyon kapalı olarak gerçekleştirildi. Sonuçlar klinik ve radyografik olarak değerlendirildi. Boyun-cisim açısı (kollodiyafizer açı) ve implant ucu-femur başı apeks mesafesi ölçüldü. Helikal vidanın femur başı içindeki konumu, Cleveland ve Bosworth’un tanımladığı yöntem ile belirlendi. Klinik değerlendirmede Harris kalça skoru kullanıldı. Ameliyat sırasında ve sonrasında gelişen komplikasyonlar kaydedildi. Ortalama takip süresi 17.3 ay (dağılım 6-23 ay) idi. Sonuçlar: Ortalama ameliyat süresi 37.8 dakika (dağılım 22-118 dk), ortalama kan kaybı 225 ml (dağılım 150-450 ml) bulundu. Ameliyat sırasında üç hastada femur cisim kırığı, dokuz hastada büyük trokanter kırığı gelişti. Takip dönemi içinde tüm kırıklar sorunsuz olarak kaynadı. Dört hastada (%8.9) kötü, yedi hastada (%15.6) kabul edilebilir, 34 hastada (%75.6) iyi redüksiyon sağlandığı görüldü. Kollodiyafizer açı ortalaması 136.7° (dağılım 125°-148°) ölçüldü. Tepe-apeks mesafesi 36 hastada (%80) Çıkarımlar: Stabil olmayan intertrokanterik femur kırıklarının cerrahi tedavisinde PFNA osteosentezi, yüksek kaynama oranı, stabil tespit sonrası erken dönemde harekete izin vermesi ve ameliyat süresinin kısa olmasından dolayı öncelikle tercih edilmesi gereken bir yöntemdir.

Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotation (PFNA) in the treatment of unstable intertrochanteric femoral fractures

Objectives: We evaluated the radiographic and functional results of the proximal femoral nail antirotation (PFNA) system in patients with unstable intertrochanteric femoral fractures. Methods: The study included 45 patients (25 women, 20 men; mean age 72 years; range 27 to 97 years) who underwent osteosynthesis using the PFNA for unstable intertrochanteric femoral fractures. The fractures were in the right hip in 25 patients, and in the left hip in 20 patients. The fractures were classifed according to the AO system. One patient had an open fracture due to frearm injury (Gustilo-Anderson 3A). The patients underwent surgery within a mean of eight days (range 2 to 21 days) from injury. The mean hospital stay was 13.5 days (range 4 to 25 days). Closed reduction was achieved in all the patients. The results were assessed clinically and radiographically. The neck-shaft angle of the femur (collodiaphysial angle) and the tip-apex distance were measured. The position of the helical screw within the femoral head was determined using the method of Cleveland and Bosworth. Clinical evaluation was made using the Harris hip score. Perioperative and postoperative complications were recorded. The mean follow-up period was 17.3 months (range 6 to 23 months). Results: The mean operation time was 37.8 min (range 22 to 118 min) and the mean blood loss was 225 ml (range 150 to 450 ml). During surgery, femoral shaft fracture occurred in three patients, and greater trochanter fracture occurred in nine patients. Union was obtained in all the patients. Reduction was poor in four patients (8.9%), acceptable in seven patients (15.6%), and good in 34 patients (75.6%). The mean collodiaphysial angle was 136.7° (range 125° to 148°). The tip-apex distance was <25 mm in 36 patients (80%), and ≥25 mm in nine patients (20%). The position of the helical screw in the femoral head was appropriate in 38 patients (84.4%). Postoperative complications included secondary varus (n=2, 4.4%), calcifcation at the tip of the greater trochanter (n=7, 15.5%), sensitivity over the fascia lata (n=7), medial thigh pain (n=11, 24.4%), and screw cut-out (n=1, 2.2%). Nine patients developed femoral shortness (mean 9.4 mm; range 8 to 13 mm). Screws showed lateral displacement in fve patients (11.1%), which was less than 5 mm in four patients. Secondary surgery was required in four patients (8.9%). The mean Harris hip score was 77.8. Harris hip scores were very good in 11 patients (24.4%), good in 19 patients (42.2%), moderate in nine patients (20%), and poor in six patients (13.3%). Conclusion: Due to advantages of high union rate, early postoperative mobilization, and short operation time, PFNA osteosynthesis is the method of choice for surgical treatment of unstable intertrochanteric femoral fractures.

___

1. Hornby R, Evans JG, Vardon V. Operative or conservative treatment for trochanteric fractures of the femur. A randomised epidemiological trial in elderly patients. J Bone Joint Surg [Br] 1989;71:619-23.
2. Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg [Br] 2005;87:1123-6.
3. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg [Am] 1969;51:737-55.
4. 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.
5. Cleveland M, Bosworth DM, Thompson FR. Intertrochanteric fractures of the femur: a survey of treatment in tractin and by internal fixation. J Bone Joint Surg [Am] 1947; 29:1049-82.
6. Fogagnolo F, Kfuri M Jr, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with the short AOASIF proximal femoral nail. Arch Orthop Trauma Surg 2004;124:31-7.
7. Hay D, Parker MJ. Hip fracture in the immobile patient. J Bone Joint Surg [Br] 2003;85:1037-9.
8. Kesmezacar H, Oğüt T, Bilgili MG, Gökay S, Tenekecioğlu Y. Treatment of intertrochanteric femur fractures in elderly patients: internal fixation or hemiarthroplasty. [Article in Turkish] Acta Orthop Traumatol Turc 2005;39:287-94.
9. Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res 1980;(146):53-61.
10. Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res 2004;(425):82-6.
11. Banan H, Al-Sabti A, Jimulia T, Hart AJ. The treatment of unstable, extracapsular hip fractures with the AO/ASIF proximal femoral nail (PFN)-our first 60 cases. Injury 2002;33:401-5.
12. Dodds SD, Baumgaertner MR. The sliding hip screw. Curr Opin Orthop 2004;15:12-7.
13. Jacobs RR, McClain O, Armstrong HJ. Internal fixation of intertrochanteric hip fractures: a clinical and biomechanical study. Clin Orthop Relat Res 1980;(146):62-70.
14. Parker MJ, Pryor GA. Gamma versus DHS nailing for extracapsular femoral fractures. Meta-analysis of ten randomised trials. Int Orthop 1996;20:163-8.
15. Rha JD, Kim YH, Yoon SI, Park TS, Lee MH. Factors affecting sliding of the lag screw in intertrochanteric frac- tures. Int Orthop 1993;17:320-4.
16. Steinberg GG, Desai SS, Kornwitz NA, Sullivan TJ. The intertrochanteric hip fracture. A retrospective analysis. Orthopedics 1988;11:265-73.
17. Wolfgang GL, Bryant MH, O’Neill JP. Treatment of intertrochanteric fracture of the femur using sliding screw plate fixation. Clin Orthop Relat Res 1982;(163):148-58.
18. Pervez H, Parker MJ, Vowler S. Prediction of fixation failure after sliding hip screw fixation. Injury 2004;35:994-8.
19. Simpson AH, Varty K, Dodd CA. Sliding hip screws: modes of failure. Injury 1989;20:227-31.
20. Gotfried Y. Percutaneous compression plating of intertrochanteric hip fractures. J Orthop Trauma 2000;14:490-5.
21. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg [Am] 2001;83:643-50.
22. Doppelt SH. The sliding compression screw-today’s best answer for stabilization of intertrochanteric hip fractures. Orthop Clin North Am 1980;11:507-23.
23. Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg [Am] 2002;84:372-81.
24. Seral B, García JM, Cegoñino J, Doblaré M, Seral F. Finite element study of intramedullary osteosynthesis in the treatment of trochanteric fractures of the hip: Gamma and PFN. Injury 2004;35:130-5.
25. Takigami I, Matsumoto K, Ohara A, Yamanaka K, Naganawa T, Ohashi M, et al. Treatment of trochanteric fractures with the PFNA (proximal femoral nail antirotation) nail system - report of early results. Bull NYU Hosp Jt Dis 2008;66:276-9.
26. Lenich A, Mayr E, Rüter A, Möckl Ch, Füchtmeier B. First results with the trochanter fixation nail (TFN): a report on 120 cases. Arch Orthop Trauma Surg 2006;126:706-12.
27. Sommers MB, Roth C, Hall H, Kam BC, Ehmke LW, Krieg JC, et al. A laboratory model to evaluate cutout resistance of implants for pertrochanteric fracture fixation. J Orthop Trauma 2004;18:361-8.
28. Mereddy P, Kamath S, Ramakrishnan M, Malik H, Donnachie N. The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures. Injury 2009;40:428-32.
29. Simmermacher RK, Ljungqvist J, Bail H, Hockertz T, Vochteloo AJ, Ochs U, et al. The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study. Injury 2008;39:932-9.
30. Schipper IB, Bresina S, Wahl D, Linke B, Van Vugt AB, Schneider E. Biomechanical evaluation of the proximal femoral nail. Clin Orthop Relat Res 2002;(405):277-86.
31. Boldin C, Seibert FJ, Fankhauser F, Peicha G, Grechenig W, Szyszkowitz R. The proximal femoral nail (PFN)-a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a followup of 15 months. Acta Orthop Scand 2003;74:53-8.
32. Brunner A, Jöckel JA, Babst R. The PFNA proximal femur nail in treatment of unstable proximal femur fractures-3 cases of postoperative perforation of the helical blade into the hip joint. J Orthop Trauma 2008;22:731-6.
33. Schipper IB, Steyerberg EW, Castelein RM, van der Heijden FH, den Hoed PT, Kerver AJ, et al. Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. J Bone Joint Surg [Br] 2004;86:86-94.
34. Menezes DF, Gamulin A, Noesberger B. Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures? Clin Orthop Relat Res 2005;(439):221-7.
35. Domingo LJ, Cecilia D, Herrera A, Resines C. Trochanteric fractures treated with a proximal femoral nail. Int Orthop 2001;25:298-301.
36. Ekström W, Karlsson-Thur C, Larsson S, Ragnarsson B, Alberts KA. Functional outcome in treatment of unstable trochanteric and subtrochanteric fractures with the proximal femoral nail and the Medoff sliding plate. J Orthop Trauma 2007;21:18-25.
37. Tyllianakis M, Panagopoulos A, Papadopoulos A, Papasimos S, Mousafiris K. Treatment of extracapsular hip fractures with the proximal femoral nail (PFN): long term results in 45 patients. Acta Orthop Belg 2004;70:444-54.
38. Al-yassari G, Langstaff RJ, Jones JW, Al-Lami M. The AO/ ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury 2002;33:395-9.