Hayrettin KESMEZACAR, Tahir ÖĞÜT, M. Gökhan BİLGİLİ, Selim GÖKAY, Yüksel TENEKECİOĞLU

Yaşlılarda intertrokanterik femur kırıklarının tedavisi: İnternal tespit mi, hemiartroplasti mi?

Amaç: Yaşlı hastalardaki intertrokanterik femur kırıklarında internal tespit mi, yoksa ideal tedavi yöntemi olmasa da, hemiartroplasti mi yapılması gerektiği konusu tartışmalıdır. Endoprotezin avantajı hastayı bir an önce ayağa kaldırmak, internal tespitin avantajı ise kalça eklemini koruyarak protezin getireceği risklerden kaçınmaktır. Çalışmamızda iki uygulamanı n erken dönem sonuçları karşılaştırıldı. Çalışma planı: Femur intertrokanterik kırığı nedeniyle ameliyat edilen ve takiplerde ulaşılabilen 81 hasta çalışmaya alındı. İnternal tespit uygulanan 38 hastanın (ort. yaş 77.7; dağılım 65-99) 25’inin, hemiartroplasti uygulanan 43 hastanı n (ort. yaş 80; dağılım 67-97) 22’sinin sağ olduğu saptandı. İki grup ameliyat öncesi özellikler, ameliyattan sonra harekete başlama zamanı, komplikasyon ve ölüm oranı, Barthel Günlük Yaşam Aktivite İndeksi’ne göre değerlendirilen günlük yaşam aktiviteleri açısından karşılaştırıldı. Ortalama takip süresi internal tespit grubunda 22.7 ay (dağılım 6-39 ay), hemiartroplasti grubunda 22.3 ay (dağılım 7-39 ay) idi. Sonuçlar: İnternal tespit yapılanların %34.2’sinin ameliyat sonrası ortalama 13 ay (1-36 ay), endoprotez yapılan hastaların ise %48.8’inin ortalama 6 ay (1-24 ay) sonra ölmüş oldukları saptandı. İki grup arasında yatak içinde hareket, ayağa kalkma, desteksiz tam yük verme, komplikasyonlar, günlük yaşam aktiviteleri açısından anlamlı farklı- lık bulunmadı. Ancak, hemiartroplasti yapılan olgular, çift destek ile tam yük vererek daha kısa sürede yürüyebilmişlerdi (p

Anahtar Kelimeler:

Kalça protezi, Yaşlı, Kalça eklemi, Kalça kırıkları, Artroplasti, replasman, kalça, Kırık tespiti, internal, Osteoporoz

Treatment of intertrochanteric femur fractures in elderly patients: Internal fixation or hemiarthroplasty

Objectives: There is no consensus as to whether internal fixation or hemiarthroplasty is more appropriate for the treatment of intertrochanteric femur fractures in elderly patients. While the latter offers early mobilization, internal fixation preserves the hip joint and avoids long-term complications associated with the prosthesis. This retrospective study aimed to compare the early results of these treatment modalities. Methods: The study included 81 patients who were available for follow-up after surgery for intertrochanteric femur fractures. Of 38 patients (mean age 77.7 years; range 65 to 99 years) treated with internal fixation, 25 were alive; of 43 patients (mean age 80 years; range 67 to 97 years) treated with hemiarthroplasty, 22 were alive at the last follow-ups. The two groups were compared with regard to perioperative characteristics, mobilization time, complications, mortality, and daily activities according to the Barthel Activities of Daily Living Index. The mean follow-up was 22.7 months (range 6 to 39 months) in internal fixation, and 22.3 months (range 7 to 39 months) in hemiarthroplasty groups. Results: Subsequent to the operation, mortality occurred in 34.2% after a mean of 13 months (range 1 to 36 months) and in 48.8% after a mean of six months (range 1 to 24 months) in patients treated with internal fixation and endoprosthesis, respectively. There were no significant differences with respect to mobilization in bed, standing, weight bearing without support, complications, and daily activity scores. The only significant difference in favor of hemiarthroplasty was that full weight bearing with two crutches took a shorter time (p<0.05). Conclusion: Short-term results suggest that hemiarthroplasty is not an advantageous alternative to internal fixation; moreover, its postoperative survival is shorter and mortality rate is higher. Osteosynthesis seems to be the first choice in the treatment of elderly patients with intertrochanteric femur fractures.

Keywords:

Hip Prosthesis, Aged, Hip Joint, Hip Fractures, Arthroplasty, Replacement, Hip, Fracture Fixation, Internal, Osteoporosis,

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1. Akman Ş, Şen C, Aşık M, Akpınar S, Gedik HK. İntertrokanterik femur kırıklarında Leinbach protezi uygulamaları- mız. Ulusal Travma Dergisi 1999;5:208-12.
2. Roder F, Schwab M, Aleker T, Morike K, Thon KP, Klotz U. Proximal femur fracture in older patients-rehabilitation and clinical outcome. Age Ageing 2003;32:74-80.
3. Sarmiento A, Williams EM. The unstable intertrochanteric fracture: treatment with a valgus osteotomy and I-beam nailplate. A preliminary report of one hundred cases. J Bone Joint Surg [Am] 1970;52:1309-18.
4. Miller K, Atzenhofer K, Gerber G, Reichel M. Risk prediction in operatively treated fractures of the hip. Clin Orthop Relat Res 1993;(293):148-52.
5. Şen C, Akman Ş, Boynuk B, Aşık M, Tözün R. 70 yaş üzerindeki femur boyun kırıklı hastalarda düz saplı (straight stem) parsiyel protez uygulamalarımız. Ulusal Travma Dergisi 2000;6:160-5.
6. DeLee JC. Fractures and dislocations of the hip. In: Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, editors. Rockwood and Green’s fractures in adults. Vol. 2, 4th ed. Philadelphia: Lippincott-Raven; 1996. p. 1659-825.
7. Eastwood EA, Magaziner J, Wang J, Silberzweig SB, Hannan EL, Strauss E, et al. Patients with hip fracture: subgroups and their outcomes. J Am Geriatr Soc 2002;50:1240-9.
8. Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Md State Med J 1965;14:61-5.
9. 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.
10. Sarmiento A. Unstable intertrochanteric fractures of the femur. Clin Orthop Relat Res 1973;(92):77-85.
11. Laros GS, Moore JF. Complications of fixation in intertrochanteric fractures. Clin Orthop Relat Res 1974;(101):110-9.
12. Haentjens P, Casteleyn PP, De Boeck H, Handelberg F, Opdecam P. Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients. Primary bipolar arthroplasty compared with internal fixation. J Bone Joint Surg [Am] 1989;71:1214-25.
13. Rosenfeld RT, Schwartz DR, Alter AH. Leinbach prosthesis in intertrochanteric fractures. J Bone Joint Surg [Am) 1973;55:420-6.
14. Stern MB, Angerman A. Comminuted intertrochanteric fractures treated with a Leinbach prosthesis. Clin Orthop Relat Res 1987;(218):75-80.
15. Rodop O, Kiral A, Kaplan H, Akmaz I. Primary bipolar hemiprosthesis for unstable intertrochanteric fractures. Int Orthop 2002;26:233-7.
16. Stappaerts KH, Deldycke J, Broos PL, Staes FF, Rommens PM, Claes P. Treatment of unstable peritrochanteric fractures in elderly patients with a compression hip screw or with the Vandeputte (VDP) endoprosthesis: a prospective randomized study. J Orthop Trauma 1995;9:292-7.
17. Sernbo I, Johnell O, Gentz CF, Nilsson JA. Unstable intertrochanteric fractures of the hip. Treatment with Ender pins compared with a compression hip-screw. J Bone Joint Surg [Am] 1988;70:1297-303.
18. Green S, Moore T, Proano F. Bipolar prosthetic replacement for the management of unstable intertrochanteric hip fractures in the elderly. Clin Orthop Relat Res 1987;224:169-77.