İntramedüller Çivileme ile Tedavi Edilen İntertrokanterik Femur Kırıklarında Mekanik Yetmezliğe Etki Eden Risk Faktörlerinin Değerlendirilmesi

Year 2021, Volume: 23 Issue: 3, 282 - 288, 30.12.2021

Samet Erinç , Mustafa Hacı Özdemir

https://doi.org/10.18678/dtfd.1004245

Cited By: 1

Abstract

Amaç: Bu çalışmanın amacı intramedüller çivileme ile tedavi edilen pertrokanterik femur kırıklı hastalarda proksimal çektirme vidasının mekanik yetmezliğine sebep olabilecek radyolojik ve klinik risk faktörlerini değerlendirmektir.
Gereç ve Yöntemler: Tüm intertrokanterik kırık vakaları retrospektif olarak değerlendirildi ve 24’ünde mekanik yetmezliği olan 298 hasta bu çalışmaya dahil edildi. Hastalar, demografik veriler, Singh indeksi, Baumgartner skalasına göre redüksiyon kalitesi, Cleveland-Bosworth kadranlarına ve Parker oranı göre proksimal çektirme vida pozisyonu, femoral kalkarın restorasyonu ve tip-apeks mesafesi açısından karşılaştırıldı.
Bulgular: İki grup arasında cinsiyet (p=0.745), yaş (p=0.848), Amerikan Anesteziyoloji Derneği (American Society of Anesthesiology) skorları (p=0.725), vücut kitle indeksi (p=0.648) ve Singh indeksi (p=0.119) açısından istatistiksel olarak anlamlı bir farklılık yoktu. Aşağıdaki değişkenler açısından iki grup arasında istatistiksel olarak anlamlı farklılıklar vardı; stabil olmayan kırığı olan hasta sayısı (p<0,001), kötü redüksiyon kalitesi (p<0,001), femoral kalkar restorasyonu (p<0,001), merkez-merkez/merkez-alt çektirme vidası pozisyonu (p<0,001) ve lateral görünümde Parker oranı (p=0,002). Lojistik regresyon analizine göre merkez-merkez/merkez-alt çektirme vidası pozisyonu, iyi redüksiyon kalitesi ve femoral kalkar restorasyonunun üstün sonuçları öngören parametreler olduğu saptandı.
Sonuç: Bu çalışmanın sonuçlarından; proksimal çektirme vidasının mekanik yetmezliğinin önlenebilmesi için kırığın redüksiyon kalitesine ve uç-apeks mesafesine dikkat edilmesinin zorunlu olması ile birlikte, intramedüller çivileme ile sabitlenen interochanterik femur kırığı tedavisinde posteromedial kalkar restorasyonunun ve çektirme vidasının femur başı içindeki konumunun ciddi bir role sahip olduğu sonucuna varıldı.

Keywords

: intertrokanterik femoral kırık, intrameduller çivileme, proksimal femoral çivileme

Evaluation of the Risk Factors for Mechanical Failure of Intertrochanteric Femoral Fracture Treated with Intramedullary Nailing

Abstract

Aim: The aim of this study was to evaluate the radiological and clinical risk factors predisposing the proximal lag screw to mechanical failure in patients with pertrochanteric femur fractures treated with intramedullary nailing.
Material and Methods: All intertrochanteric fracture cases were evaluated retrospectively and 298 patients (24 had mechanical failure) were included in this study. The patients were compared in terms of demographic data, Singh index, reduction quality according to the Baumgaertner scale, proximal lag screw position according to Cleveland-Bosworth quadrants and the Parker ratio, and the calcar femorale restoration and tip-apex distance.
Results: There was no statistically significant difference in terms of gender (p=0.745), age (p=0.848), American Society of Anesthesiology scores (p=0.725), body mass index (p=0.648) and Singh index (p=0.119) between the two groups. There were statistically significant differences between the two groups in terms of the following variables; number of patients with unstable fracture (p<0.001), poor reduction quality (p<0.001), calcar femorale discontinuity (p<0.001), center-center/center-inferior lag screw position (p<0.001), and Parker ratio on the lateral view (p=0.002). The center-center/center-inferior lag screw position, good reduction quality and calcar femorale restoration were found to be parameters predicting superior outcomes according to logistic regression analyses.
Conclusion: From the results of this study, it was concluded that although the preoperative reduction of the fracture and tip-apex distance are mandatory to prevent failure of the proximal lag screw, posteromedial discontinuity and lag screw position have a vital role in the treatment of interochanteric femur fracture fixed with intramedullary nailing.

Keywords

Intertrochanteric fracture, intramedullary nailing, proximal femoral nailing

References

• Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006;17(12):1726-33.
• Schipper IB, Steyerberg EW, Castelein RM, van Vugt AB. Reliability of the AO/ASIF classification for pertrochanteric femoral fractures. Acta Orthop Scand. 2001;72(1):36-41.
• Baldwin PC 3rd, Lavender RC, Sanders R, Koval KJ. Controversies in intramedullary fixation for intertrochanteric hip fractures. J Orthop Trauma. 2016;30(12):635-41.
• Hardy DC, Descamps PY, Krallis P, Fabeck L, Smets P, Bertens CL, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients. J Bone Joint Surg Am. 1998;80(5):618-30.
• Pajarinen J, Lindahl J, Savolainen V, Michelsson O, Hirvensalo E. Femoral shaft medialisation and neck-shaft angle in unstable pertrochanteric femoral fractures. Int Orthop. 2004;28(6):347-53.
• Jiamton C, Boernert K, Babst R, Beeres FJP, Link BC. The nail-shaft-axis of the of proximal femoral nail antirotation (PFNA) is an important prognostic factor in the operative treatment of intertrochanteric fractures. Arch Orthop Trauma Surg. 2018;138(3):339-49.
• Geller JA, Saifi C, Morrison TA, Macaulay W. Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop. 2010;34(5):719-22.
• Yam M, Chawla A, Kwek E. Rewriting the tip apex distance for the proximal femoral nail anti-rotation. Injury. 2017;48(8):1843-7.
• 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(7):1058-64.
• Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2018;32(Suppl 1):S1-170.
• Hsueh KK, Fang CK, Chen CM, Su YP, Wu HF, Chiu FY. Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients. Int Orthop. 2010;34(8):1273-6.
• Ye KF, Xing Y, Sun C, Cui ZY, Zhou F, Ji HQ, et al. Loss of the posteromedial support: a risk factor for implant failure after fixation of AO 31-A2 intertrochanteric fractures. Chin Med J. 2020;133(1):41-8.
• Cleveland M, Bosworth DM, Thompson FR, Wilson HJ Jr, Ishizuka T. A ten-year analysis of intertrochanteric fractures of the femur. J Bone Joint Surg Am. 1959;41-A:1399-408.
• Herman A, Landau Y, Gutman G, Ougortsin V, Chechick A, Shazar N. Radiological evaluation of intertrochanteric fracture fixation by the proximal femoral nail. Injury. 2012;43(6):856-63.
• Rubio-Avila J, Madden K, Simunovic N, Bhandari M. Tip to apex distance in femoral intertrochanteric fractures: a systematic review. J Orthop Sci. 2013;18(4):592-8.
• Güven M, Yavuz U, Kadıoğlu B, Akman B, Kılınçoğlu V, Ünay K, et al. Importance of screw position in intertrochanteric femoral fractures treated by dynamic hip screw. Orthop Traumatol Surg Res. 2010;96(1):21-7.
• Hwang JH, Garg AK, Oh JK, Oh CW, Lee SJ, Myung-Rae C, et al. A biomechanical evaluation of proximal femoral nail antirotation with respect to helical blade position in femoral head: A cadaveric study. Indian J Orthop. 2012;46(6):627-32.
• Turgut A, Kalenderer Ö, Karapınar L, Kumbaracı M, Akkan HA, Ağuş H. Which factor is most important for occurrence of cutout complications in patients treated with proximal femoral nail antirotation? Retrospective analysis of 298 patients. Arch Orthop Trauma Surg. 2016;136(5):623-30.
• Zhang W, Antony Xavier RP, Decruz J, Chen YD, Park DH. Risk factors for mechanical failure of intertrochanteric fractures after fixation with proximal femoral nail antirotation (PFNA II): a study in a Southeast Asian population. Arch Orthop Trauma Surg. 2021;141(4):569-75.
• Zhang Q, Chen W, Liu H, Li ZY, Song ZH, Pan JS, et al. The role of the calcar femorale in stress distribution in the proximal femur. Orthop Surg. 2009;1(4):311-6.
• Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Br. 1949;31B(2):190-203.
• Chang SM, Zhang YQ, Ma Z, Li Q, Dargel J, Eysel P. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg. 2015;135(6):811-8.
• Liang C, Peng R, Jiang N, Xie G, Wang L, Yu B. Intertrochanteric fracture: Association between the coronal position of the lag screw and stress distribution. Asian J Surg. 2018;41(3):241-9.
• Puram C, Pradhan C, Patil A, Sodhai V, Sancheti P, Shyam A. Outcomes of dynamic hip screw augmented with trochanteric wiring for treatment of unstable type A2 intertrochanteric femur fractures. Injury. 2017;48(Suppl 2):S72-7.
• Kim GM, Nam KW, Seo KB, Lim C, Kim J, Park YG. Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable intertrochanteric fractures: A modified candy-package wiring technique. Injury. 2017;48(2):406-13.
• Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001;83(5):643-50.
• Hsu CE, Shih CM, Wang CC, Huang KC. Lateral femoral wall thickness. A reliable predictor of post-operative lateral wall fracture in intertrochanteric fractures. Bone Joint J. 2013;95-B(8):1134-8.
• Tan BY, Lau AC, Kwek EB. Morphology and fixation pitfalls of a highly unstable intertrochanteric fracture variant. J Orthop Surg (Hong Kong). 2015;23(2):142-5.
• Tawari AA, Kempegowda H, Suk M, Horwitz DS. What makes an intertrochanteric fracture unstable in 2015? Does the lateral wall play a role in the decision matrix? J Orthop Trauma. 2015;29(Suppl 4):S4-9.
• Han SK, Lee BY, Kim YS, Choi NY. Usefulness of multi-detector CT in Boyd-Griffin type 2 intertrochanteric fractures with clinical correlation. Skeletal Radiol. 2010;39(6):543-9.
• Gotfried Y. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89(11):2552-3.
• Yun HH, Lee YI, Kim KH, Yun SH. Use of auxiliary locking plates for the treatment of unstable pertrochanteric femur fractures. Orthopedics. 2015;38(5):305-9.
• Kulkarni SG, Babhulkar SS, Kulkarni SM, Kulkarni GS, Kulkarni MS, Patil R. Augmentation of intramedullary nailing in unstable intertrochanteric fractures using cerclage wire and lag screws: a comparative study. Injury. 2017;48(Suppl 2):S18-22.
• Akan K, Cift H, Ozkan K, Eceviz E, Tasyikan L, Eren A. Effect of osteoporosis on clinical outcomes in intertrochanteric hip fractures treated with a proximal femoral nail. J Int Med Res. 2011;39(3):857-65.
• Barrios C, Broström LA, Stark A, Walheim G. Healing complications after internal fixation of trochanteric hip fractures: the prognostic value of osteoporosis. J Orthop Trauma. 1993;7(5):438-42.