İnstabil femur boyun kırıklarının internal tespitinde vida sayısı ve yöneliminin stabiliteye etkisi

Yıl 2014, , 673 - 678, 16.01.2015

Seyit Ali Gumustas Hacı Bayram Tosun Ismail Agir Mehmet Mufit Orak Tolga Onay Guvenir Okcu

https://doi.org/10.3944/AOTT.2014.14.0088

Öz

Amaç: Bu çalışmada instabil femur boyun kırıklarının tedavisinde 3 farklı kanüllü vida konfigürasyonu kullanılarak yapılan internal tespitin biyomekanik olarak karşılaştırılması amaçlandı.

Çalışma planı: Çalışmada 28 adet sentetik sol femur rastgele olarak 4 eşit gruba ayrıldı. İlk üç gruptaki örnekler Pauwels Tip 3 kırık oluşturacak şekilde bazoservikal bölgeden osteotomize edildi. Tespit kanüllü vidalarla yapıldı. Birinci gruba 4 adet vida, 3’ü boyuna paralel ters üçgen konfigürasyonda, dördüncüsü ise kalkara çapraz şekilde; ikinci gruba 3 adet vida, 2’si boyuna paralel konfigürasyonda, üçüncüsü ise kalkara çapraz şekilde; üçüncü gruba ise 3 adet vida, 3’ü de boyuna paralel ters üçgen konfigürasyonda olacak şekilde kanüle vida ile fiksasyon uygulandı. Dördüncü gruba ise osteotomi veya tespit uygulanmadı. Tüm gruplara yüklenme testi yapıldı ve vida tespitlerinin aksiyel yüklenmeye dayanma gücü ve yer değişimi miktarı ölçüldü.

Bulgular: Grup 1’de ortalama maksimum dayanım 36.1±3.2 N/mm2, Grup 2’de 27.3±4.1 N/mm2 ve Grup 3’te 21.9±3.2 N/mm2 olarak saptandı. Grup 3’teki ortalama maksimum dayanım anındaki (21.9±3.2 N/mm2) osteotomi hattındaki ortalama yer değişimi 11.5±2.1 mm iken, Grup 2’de aynı değerde yer değişimi 6±1.3 mm, Grup 1’de 5.8±1.1 mm olarak bulundu (p<0.05). Ayrıca Grup 2’deki ortalama maksimum dayanım (27.3±4.1 N/mm2) anındaki yer değişimi 9.1±1.7 mm iken, aynı stres değeri altında Grup 1’deki şekil değişiminin 9±1.7 mm olduğu gözlendi (p>0.05).

Çıkarımlar: İnstabil femur boyun kırıklarının tedavisinde boyuna paralel gönderilen kanüllü vidalara ek olarak kalkara gönderilen çapraz vidanın stabiliteye olumlu katkı sağlayacağı görüşündeyiz.

Anahtar Kelimeler

Femur boyun kırıkları; instabil; kanüllü vida; tespit.

Influence of number and orientation of screws on stability in the internal fixation of unstable femoral neck fractures

Öz

Objective: The aim of this study was to biomechanically compare 3 different cannulated screw configurations used in internal fixation of unstable femoral neck fractures.

Methods: The study included 28 synthetic left femurs randomly divided into 4 equal groups. Samples in the first 3 groups were osteotomized in the basicervical region to create Pauwels Type 3 fractures. Fixation was carried out using cannulated screws. In Group 1, four screws were used including 3 in an inverted triangle configuration in parallel with the neck and the fourth screw transversely into the calcar. In Group 2, three screws were used including 2 in parallel with the neck and the third transversely into the calcar. In Group 3, three screws were used in an inverted triangle configuration in parallel with the neck. No osteotomy or fixation was carried out in Group 4. Load test was performed on all the groups and the strength of the screw fixations against axial load and their amount of relocation were measured.

Results: Average maximum strength was 36.1±3.2 N/mm2 in Group 1, 27.3±4.1 N/mm2 in Group 2 and 21.9±3.2 N/mm2 in Group 3. The average relocation in the line of osteotomy in the moment of average maximum stress (21.9±3.2 N/mm2) was 11.5±2.1 mm in Group 3, 6±1.3 mm in Group 2 and 5.8±1.1 mm in Group 1 (p<0.05). It was also observed that while the relocation in the moment of average maximum stress (27.3±4.1 N/mm2) was 9.1±1.7 mm in Group 2, the deformation under the same stress value was 9±1.7 mm in Group 1 (p>0.05).

Conclusion: The use of a transverse screw in the calcar in addition to cannulated screws parallel to the neck appear to provide stability benefit in the treatment of unstable femoral neck fractures.

Anahtar Kelimeler

Cannulated screw, femoral neck fractures, fixation, unstable

Kaynakça

• Christodoulou NA, Dretakis EK. Significance of mus- cular disturbances in the localization of fractures of the proximal femur. Clin Orthop Relat Res 1984;187:215-7.
• Parker MJ. The management of intracapsular fractures of the proximal femur. J Bone Joint Surg Br 2000;82:937-41.
• Frihagen F, Nordsletten L, Madsen JE. Hemiarthro- plasty or internal fixation for intracapsular displaced femoral neck fractures: randomised controlled trial. BMJ 2007;335:1251-4. CrossRef
• Ly TV, Swiontkowski MF. Management of femoral neck fractures in young adults. Indian J Orthop. 2008;42:3-12.
• Zdero R, Keast-Butler O, Schemitsch EH. A biomechani- cal comparison of two triple-screw methods for femoral neck fracture fixation in a synthetic bone model. J Trauma 2010;69:1537-44. CrossRef
• Tan V, Wong KL, Born CT, Harten R, DeLong WG Jr. Two-screw femoral neck fracture fixation: a biomechanical analysis of 2 different configurations. Am J Orthop (Belle Mead NJ) 2007;36:481-5.
• Satish BR, Ranganadham AV, Ramalingam K, Tripathy SK. Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients. Indian J Orthop 2013;47:174-81. CrossRef
• Gurusamy K, Parker MJ, Rowlands TK. The complica- tions of displaced intracapsular fractures of the hip: the ef- fect of screw positioning and angulation on fracture heal- ing. J Bone Joint Surg Br 2005;87:632-4. CrossRef
• Yang JJ, Lin LC, Chao KH, Chuang SY, Wu CC, Yeh TT, et al. Risk factors for nonunion in patients with intracap- sular femoral neck fractures treated with three cannulated screws placed in either a triangle or an inverted triangle configuration. J Bone Joint Surg Am 2013;95:61-9. CrossRef
• Bartonícek J. Pauwels’ classification of femoral neck frac- tures: correct interpretation of the original. J Orthop Trauma 2001;15:358-60. CrossRef
• Scolaro JA, Mehta S, Chip Routt ML. Femoral neck frac- tures in the physiologically young. University of Pennsyl- vania Orthopaedic Journal 2010;20:5-10.
• Filipov O. Biplane double-supported screw fixation (F- technique): a method of screw fixation at osteoporotic fractures of the femoral neck. Eur J Orthop Surg Trauma- tol 2011;21:539-43. CrossRef
• LePine MS, Barfield WR, DesJardins JD, Hartsock LA. The effect of moment arm length on high angled femoral neck fractures (Pauwels’ III). J Biomed Sci Eng 2010;3:448-53. CrossRef
• Clark DI, Crofts CE, Saleh M. Femoral neck fracture fixa- tion. Comparison of a sliding screw with lag screws. J Bone Joint Surg Br 1990;72:797-800.
• Alves T, Neal JW, Weinhold PS, Dahners LE. Biome- chanical comparison of 3 possible fixation strategies to resist femoral neck shortening after fracture. Orthopedics 2010;33.
• Baitner AC, Maurer SG, Hickey DG, Jazrawi LM, Kum- mer FJ, Jamal J, et al. Vertical shear fractures of the femo- ral neck. A biomechanical study. Clin Orthop Relat Res 1999;367:300-5. CrossRef
• Aminian A, Gao F, Fedoriw WW, Zhang LQ, Kalainov DM, Merk BR. Vertically oriented femoral neck fractures: mechanical analysis of four fixation techniques. J Orthop Trauma 2007;21:544-8. CrossRef
• Kauffman JI, Simon JA, Kummer FJ, Pearlman CJ, Zuck- erman JD, Koval KJ. Internal fixation of femoral neck frac- tures with posterior comminution: a biomechanical study. J Orthop Trauma 1999;13:155-9. CrossRef
• Parker MJ, Dynan Y. Is Pauwels classification still valid? Injury 1998;29:521-3. CrossRef
• Jewell DP, Gheduzzi S, Mitchell MS, Miles AW. Locking plates increase the strength of dynamic hip screws. Injury 2008;39:209-12. CrossRef
• Blair B, Koval KJ, Kummer F, Zuckerman JD. Basicervi- cal fractures of the proximal femur. A biomechanical study of 3 internal fixation techniques. Clin Orthop Relat Res 1994;306:256-63.
• Deneka DA, Simonian PT, Stankewich CJ, Eckert D, Chapman JR, Tencer AF. Biomechanical comparison of internal fixation techniques for the treatment of unstable basicervical femoral neck fractures. J Orthop Trauma 1997;11:337-43. CrossRef
• Van Audekercke R, Martens M, Mulier JC, Stuyck J. Ex- perimental study on internal fixation of femoral neck frac- tures. Clin Orthop Relat Res 1979;141:203-12.
• Madsen F, Linde F, Andersen E, Birke H, Hvass I, Poulsen TD. Fixation of displaced femoral neck fractures. A com- parison between sliding screw plate and four cancellous bone screws. Acta Orthop Scand 1987;58:212-6. CrossRef
• Walker E, Mukherjee DP, Ogden AL, Sadasivan KK, Albright JA. A biomechanical study of simulated femo- ral neck fracture fixation by cannulated screws: effects of placement angle and number of screws. Am J Orthop (Belle Mead NJ) 2007;36:680-4.
• Huang HK, Su YP, Chen CM, Chiu FY, Liu CL. Dis- placed femoral neck fractures in young adults treated with closed reduction and internal fixation. Orthopedics 2010;33:873.
• Probe R, Ward R. Internal fixation of femoral neck frac- tures. J Am Acad Orthop Surg 2006;14:565-71.
• Papanastassiou ID, Mavrogenis AF, Kokkalis ZT, Niko- lopoulos K, Skourtas K, Papagelopoulos PJ. Fixation of femoral neck fractures using divergent versus paral- lel cannulated screws. J Long Term Eff Med Implants 2011;21:63-9. CrossRef
• Wu CC. Using biomechanics to improve the surgical tech- nique for internal fixation of intracapsular femoral neck fractures. Chang Gung Med J 2010;33:241-51.
• Asnis SE, Wanek-Sgaglione L. Intracapsular fractures of the femoral neck. Results of cannulated screw fixation. J Bone Joint Surg Am 1994;76:1793-803.
• Parker MJ, Blundell C. Choice of implant for internal fixation of femoral neck fractures. Meta-analysis of 25 randomised trials including 4,925 patients. Acta Orthop Scand 1998;69:138-43. CrossRef
• Spangler L, Cummings P, Tencer AF, Mueller BA, Mock C. Biomechanical factors and failure of transcervical hip fracture repair. Injury 2001;32:223-8. CrossRef
• Swiontkowski MF, Harrington RM, Keller TS, Van Pat- ten PK. Torsion and bending analysis of internal fixation techniques for femoral neck fractures: the role of implant design and bone density. J Orthop Res 1987;5:433-44.
• Basso T, Klaksvik J, Syversen U, Foss OA. Biomechani- cal femoral neck fracture experiments--a narrative review. Injury 2012;43:1633-9. CrossRef