İNTERTROKANTERİK FEMUR KIRIKLARINDA EKSTRAMEDÜLLER TESPİT, FONKSİYONEL SONUÇLAR VE GÜNCEL LİTERATÜR

Pertrokanterik kırıklar kalça kırıklarının yaklaşık %50’sini oluşturan, yüksek oranlarda mortaliteye sahip kırıklardır. Tedavideki temel amaç anatomik redüksiyon,redüksiyonun stabil bir tespit ile korunması ve erken mobilizasyon ile rehabilitasyondur. Dinamik kalça vidaları (DHS) intertrokanterik kırıkların tedavisinde altın standart olarak kabul edilmekle beraber, sabit açılı plaklar, intramedüller çiviler ve eksternal fiksatörler de kullanılmaktadır. Ancak, özellikle instabil kırıklarolmak üzere kesin kabul görmüş bir tespit materyali yoktur. Bu çalışma ile intertrokanterik kırıkların ekstramedüller tespitinin fonksiyonel sonuçlarının güncelliteratürün ışığında tartışılması amaçlandı.Evans tip 1 ve tip 2 intertrokanterik femur kırığı tanısı ile açık redüksiyon ve internal tespit yapılan, ameliyat sonrası 1 yılı tamamlamış 18 yaş üstü hastalar retrospektif olarak değerlendirildi. Anteroposterior ve lateral radyografilerde, varus – valgus açılanması ve redüksiyon kaybına bakıldı. Fonksiyonel skorlama amacı ileHarris Kalça Skoru (HHS) ve Travmatik Kalça Skalası (TKS) kullanıldı.Çalışmaya 18 hasta alındı. Yaş ortalaması 52,5 yıl, hastanede kalış süresi ortalama 7 gün ve takip süresi 22 ay idi. Hastaların 4’ü trafik kazası, 14’ü düşme nedeni ile başvurmuş idi. Kırıkların 17’si tip 1, biri tip 2 idi. Tip 1 kırıkların 10’u stabil, 7’si instabil idi. 13 hastada dinamik kalça vidası (DHS), 5 hastada dinamik kondiler vida (DCS) kullanılmış idi. Fonksiyonel sonuçlar HHS göre 14 hastada mükemmel, 3 hastada iyi, 1 hastada kötü sonuç. TKS göre 9 hasta mükemmel, 7 hasta iyi,1 hasta kötü, 1 hasta başarısız olarak değerlendirildi. 12 hastada varus açılanması (ortalama 8,25°), 3 hastada valgus açılanması (ortalama 4,6°) saptandı. 3 hastada (Evans tip 1 instabil) boyuncisim açısında değişim saptanmadı. Kayma miktarıinstabil kırıklarda ortalama 5,34 mm. ve stabil kırıklarda 1,76 mm. idi. Hiçbir hastada non-union, cut-out ve femur cisim medializasyonu, enfeksiyon, derin ventrombozu, pulmoner emboli ve myositis ossifikans görülmedi. Bir hastada mal-union gelişti ancak revizyon yapılmadı.Kırık tipi ameliyat sonrası dönemde mortaliteyi etkileyen önemli faktörlerden olup mekanik olarak stabil redüksiyon ve bunun korunması başarıyı sağlayan anaetkendir. Artan revizyon insidansı mortaliteyi de arttırmaktadır. Mevcut literatür ideal implantı tarif etmekten uzak olmakla beraber her bir implantın kendine özgüavantaj ve dezavantajları vardır. Proksimal femoral çiviler, implant yetmezliği, kanama miktarı, kısa hastanede kalış süresi ile DHS’ye göre daha avantajlı gözükmektedir. Proksimal femoral anatomik plaklar da kırık tipine göre alternatif olarak akılda bulundurulmalıdır.

EXTRAMEDULLARY FIXATION, FUNCTIONAL RESULTS AND THE CURRENT LITERATURE IN INTERTROCHANTERIC FRACTURES OF FEMUR

Pertrochanteric fractures consist 50% of the hip fractures with a high rate of morbidity. The primary aim in treatment is anatomic reduction, preserving of the reduction with stable fixation and early mobilization with rehabilitation. Dynamic hip screws (DHS) are accepted as the golden standard in treatment of the these fractures. On the other hand, fixed angle plates, intramedullary nails and external fixators are also used. However, there is no consensus on the implant choice in the management of intertrochanteric fractures particularly for the unstable fractures. The aim of the present study is to discuss the functional results of the extramedullary stabilization of intertrochanteric fractures in the light of the current literature. In the present study, the patients over 18 years of age who had Evans type 1 and type 2 intertrochanteric fractures that were managed by open reduction and internal fixation and, completed post-operative 1year retrospectively evaluated. Varus, valgus angulation and loss of reduction evaluated in the anteriorposterior radiographs. Harris Hip Score (HHS) and Traumatic Hip Scale (THS) were used to assess functional evaluation. Eighteen patients were included in the study. Mean age of the patients was 52,5 years old, mean stay in the hospital was 7 days and mean follow-up time was 22 months. Cause of the admission to the hospital was traffic accident in 4 patients and was falling in 14 patients. Seventeen of the fractures were type 1 and one was type 2. Ten of the type 1 fractures were stable and, 7 were unstable. DHS was used in 13 of the patients and, DCS was used in 5 of the patients. Functional results according to HHS; 14 excellent, 3 good, 1 poor and according to THS; 9 excellent, 7 good, 1 poor and 1unsuccessful.Varus angulation occurred in 12 patients with a mean angle of 8,25°and, valgus angulation occurred in 3 patients with a mean angle of 4,6°. In 3 patients (Evans type 1 unstable) no change occurred in neck-shaft angle. Mean sliding was 5,34 mm in unstable fractures and, was 1,76 mm in stable fractures.Non-union, cutout and femoral shaft medialization, infection, deep venous thrombosis, pulmoner emboli and myositis ossificans was seen in none of the patients. Type of the fracture is one of the important factors affecting mortality. Mechanically stable reduction and preserving of the reduction is the main effect that provides success. The increased revision incidence also increases mortality. The present literature is far away from describing the ideal implant. But, every implant has own advantages and disadvantages. Proximal femoral nails seem more advantageous than DHS considering implant failure, bleeding amount and shorter hospitalization time. And also, proximal anatomic plates must be kept in mind for the certain types of the fractures.

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