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

Year 2021, Volume: 28 Issue: 3, 371 - 378, 13.09.2021

Emrah Kovalak

https://doi.org/10.17343/sdutfd.459407

Abstract

Objective
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.
Materials and Methods
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.
Results
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.
Conclusion
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.

Keywords

intertrochanteric fracture, dynamic hip screw, hip fracture

İNTERTROKANTERİK FEMUR KIRIKLARINDA EKSTRAMEDÜLLER TESPİT, FONKSİYONEL SONUÇLAR VE GÜNCEL LİTERATÜR

Abstract

Amaç
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 kırıklar
olmak üzere kesin kabul görmüş bir tespit materyali
yoktur. Bu çalışma ile intertrokanterik kırıkların ekstramedüller
tespitinin fonksiyonel sonuçlarının güncel
literatürün ışığında tartışılması amaçlandı.
Gereç ve Yöntem
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 ile
Harris Kalça Skoru (HHS) ve Travmatik Kalça Skalası
(TKS) kullanıldı.
Bulgular
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 miktarı
instabil kırıklarda ortalama 5,34 mm. ve stabil kırıklarda
1,76 mm. idi. Hiçbir hastada non-union, cut-out
ve femur cisim medializasyonu, enfeksiyon, derin ven
trombozu, pulmoner emboli ve myositis ossifikans görülmedi.
Bir hastada mal-union gelişti ancak revizyon
yapılmadı.
Sonuç
Kırık tipi ameliyat sonrası dönemde mortaliteyi etkileyen
önemli faktörlerden olup mekanik olarak stabil redüksiyon
ve bunun korunması başarıyı sağlayan ana
etkendir. Artan revizyon insidansı mortaliteyi de arttırmaktadır.
Mevcut literatür ideal implantı tarif etmekten
uzak olmakla beraber her bir implantın kendine özgü
avantaj 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.

Keywords

intertrokanterik kırık, dinamik kalça çivisi, kalça kırıkları

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