YAŞLI HASTALARDA FEMUR İNTRAMEDÜLLER ÇİVİ UYGULAMALARINDA TUZAKLAR

Öz

Amaç: Yaşlı osteoporotik hastalarda  kalça bölgesi kırıkları kadar sık görülmesede femur cisim kırıklarıyla da karşılaşılmakta ve  tedavi konusunda sorunlar yaşanabilmektedir. Çalışmanın amacı yaşlılarda düşük enerjili travma ile meydana gelen femur cisim kırıklarında kaynama problemlerini incelemek  fiksasyon yönteminin yetersizliklerini değerlendirmektir.

Gereç ve Yöntem: 2012- 2016 yılları arası femur cisim kırığı nedeniyle opere edilen 65 yaş üstü osteopenik ve osteoporotik  (BMD≤-2) 34 hasta çalışmaya dahil edildi. 26 hastaya kapalı yöntemle  kilitli intramedüller çivi(İMN), 8 hastaya açık cerrahi yöntemle kilitli İMN  uygulandı, bunlardan  2’si plak yetmezliği sonrası sekonder çivi uygulaması yapılan hastalar idi.  28 kadın  6 erkek  çalışmaya dahil edildi. Kırık  sınıflamasında AO/OTA sınıflaması kullanıldı.  6 hasta  1/3 proksimal-orta birleşim, 20 hasta orta bölge,  8 hasta 1/3 distal-orta birleşim kesimde idi. Klinik, fonksiyonel skorlar, kaynama zamanı, desteksiz mobilizasyon süreleri ve komplikasyonlar değerlendirildi.

Bulgular : Çalışmaya  katılan 34  hastanın  yaş ortalaması 73.8, ortalama takip süresi 26 ay(12-36) idi. Erken dönem klinik sonuçlar,kan kaybı(187+/- 35 ml) ve medial  kallus görülmesi açısından  kapalı uygulanan intramedüller çivilerle daha iyi sonuçlar elde edildi(p<0.001).  6. ayın  sonunda açık cerrahi ile İMN uygulanan 1 hastada kaynamama, 1 hastada kaynama gecikmesi görülürken,  Primer  kapalı   İMN yapılan hastaların  4’ünde kaynamama  ve revizyon gerekliliği  oluştu.   2 hastada çivinin distalde anterior  kortekse dayanması sonucu diz bölgesi  ağrısı ve 1 hastada o bölgede  fissür kırığı oluştu. 

Sonuç: Yaşlı hastalarda osteoporoza bağlı kortekste incelme, medullada genişleme, kırık tespitinde  zorluğa sebep olmaktadır.  Artmış sagittal ve koronal plan  eğrilikleri  dolayısıyla intramedüler çivi uygulaması sırasında  kırık riski artmakta, artmış sagital eğimde distalde  anterior kortekse dayanma,  kırık oluşturabilme  ve kaynamama  problemleri  içerebilmektedir. Biyomekanik üstünlüklerine rağmen günümüzde mevcut olan yük paylaşıcı materyallerin (intramedüller çivi )hiç  birinin geriatrik femur diafiz kırıkları için  optimum seviyede uygun olmadığı  düşünülmektedir. 

Anahtar Kelimeler

• femur intramedüller çivileme,yaşlı hasta,tuzaklar

PITFALL IN FEMORAL INTRAMEDULLAR NAIL APPLICATIONS IN ELDERLY PATIENTS

Öz

Purpose : Femoral shaft fractures are not seen in elderly osteoporotic patients as often as fractures in the hip region and problems may be experienced in treatment. The aim of this study was to examine union problems in femoral shaft fractures which occurred with low-energy trauma in the elderly and to evaluate deficiencies in the fixation method.  

Methods: The study included 34 osteopenic and osteoporotic (BMD ≤ -2) patients, aged >65 years who underwent surgery for a femoral shaft fracture between 2012 -2016. Locking intramedullary nailing (IMN) was applied to 26 patients with the closed method and to 8 patients with open surgery, and in 2 of these cases, secondary nailing was applied after plate failure. The patients comprised 28 females and 6 males. The fractures were classified according to the AO/OTA classification. In 6 patients, the fracture was in the proximal third -mid region, in 20 patients in the mid region, and in 8 patients in the distal third-mid region. Evaluation was made of the clinical and functional scores, time to union, time to unassisted mobilisation, and complications.

Results: The mean age of the 34 patients was 73.8 years, and the mean follow-up time was 26 months (range, 12-36 months). Better results were obtained from the patients applied with closed IMN in respect of early stage clinical results, blood loss (187±35 ml) and visualisation of medial callus (p<0.001). At the end of 6 months, non-union was seen in 1 patient and delayed union in 1 patient in the open surgery group. Non-union and revision was necessary in 4 patients of the primary closed surgery IMN group. Knee region pain developed in 2 patients as a result of the nail leaning on the anterior cortex and a fissure fracture formed in that area in 1 patient.

Conclusion: In elderly patients, difficulties in fracture fixation may be caused by thinning of the cortex and widening of the medulla, associated with osteoporosis. The risk of fracture during the application of IMN is increased because of increased sagittal and coronal plane inclines. In the increased sagittal slope, problems can include leaning on the anterior cortex, the development of fracture and non-union. Despite the biomechanical superiority, none of the currently available load-distributing materials (IMN) can be considered appropriate at an optimum level for geriatric femoral diaphyseal fractures.

Anahtar Kelimeler

• femoral intrameduller nailing,elderly,pitfall

Kaynakça

1. 1.Court-Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long bone fractures. Injury 1998;29(7):529-534
2. 2.Bengner U, Ekbom T, Johnell O, Nilsson BE. Incidence of femoral and tibial shaft fractures. Epidemiology 1950-1983 in Malmö, Sweden. Acta Orthop Scand 1990;61(3):251-254
3. 3.Salminen ST,Pihlajamaki HK, Avikainen VJ, Böstman OM. Population based epidemiologic and morphologic study of femoral shaft fractures. Clin Orthop Relat Res. 2000;(372):241-249.
4. 4.Helfet DL, Haas NP, Schatzker J, Matter P, Moser R, Hanson B. AO philosophy and principles of fracture management-its evolution and evaluation. J Bone Joint Surg Am 2003 85-A(6): 1156–1160
5. 5.Heiney JP, Barnett MD, Vrabec GA, Schoenfeld AJ, Baji A, Njus GO .Distal femoral fixation: a biomechanical comparison of trigen retrograde intramedullary (i.m.) nail, dynamic condylar screw (DCS), and locking compression plate (LCP) condylar plate. J Trauma 2009;66:443–449
6. 6.Giannoudis PV, Kanakaris NK, Tsiridis E. Principles of internal fixation and selection of implants for periprosthetic femoral fractures.Injury 2007;38:669-687
7. 7.Thoresen BO, Alho A, Ekeland A, Stromsoe K, Folleras G, Haukebo A. Interlocking intramedullary nailing in femoral shaft fractures. A report of forty-eight cases. J Bone Joint Surg [Am] 19 8 5 ; 6 7 : 1313-20
8. 8.Ostrum RF, Verghese GB, Santner TJ. The lack of association between femoral shaft fractures and hypotensive shock.J Orthop Trauma. 1993;7(4):338-42

9. 9.Sartoretti C, Sartoretti-Schefer S, Ruckert R, Buchmann P. Comorbid conditions in old patients with femur fractures.J Trauma. 1997 Oct;43(4):570-7
10. 10.Tornetta P 3rd, Kain MS, Creevy WR.Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol.J Bone Joint Surg Am. 2007 Jan;89(1):39-43
11. 11.Lampropoulou-Adamidou K, Karampinas PK, Chronopoulos E, Vlamis J, Korres DS. Currents of plate osteosynthesis in osteoporotic bone. Eur J Orthop Surg Traumatol. 2014;24:427–33
12. 12.Riemer BL, Butterfield SL,Burke CJ 3rd, Mathews D. Immediate plate fixation of highly comminuted femoral diaphyseal fractures in blunt politrauma patients. Orthopaedics 1992;15(8):907-916.
13. 13.Davis C, Stall A, Knutsen E, Whitney A, Becker E, Hsieh AH, O’Toole RV. Locking plates in osteoporosis: a biomechanical cadaveric study of diaphyseal humerus fractures. J Orthop Trauma 2012 26(4):216–221
14. 14.Smith WR, Ziran BH, Anglen JO, Stahel PF. Locking plates: tips and tricks. J Bone Joint Surg Am 2007.89(10):2298–2307
15. 15.Greiwe RM, Archdeacon MT Locking plate technology: current concepts. J Knee Surg. 2007 20(1):50–55
16. 16.Koseoglu E, Durak K, Bilgen MS, Kuçukkalp A, Bayyurt S.Comparison of two biological internal fixation techniques in the treatment of adult femur shaft fractures (plate-screws and locked intramedullary nail).Ulus Travma Acil Cerrahi Derg. 2011 Mar;17(2):159-65
17. 17. Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG. Low-energy femoral shaft fractures associated with alendronate use J Orthop Trauma.2008 May-Jun;22(5):346-50
18. 18.Einhorn TA, Bogdan Y, Tornetta P 3rd. Bisphosphonateassociated fractures of the femur: pathophysiology and treatment. J Orthop Trauma 2014;28:433-8
19. 19.Graham J, Irgit K, Smith WR, Bowen TR. Diaphyseal femur fractures associated with bisphosphonate use. Acta Orthop Traumatol Turc 2013;47:255-60
20. 20.Weil YA, Rivkin G, Safran O, Liebergall M, Foldes AJ. The outcome of surgically treated femur fractures associated with long-term bisphosphonate use. J Trauma 2011;71:186-90.
21. 21.Clatworthy MG, Clark DI, Gray DH, Hardy AE. Reamed versus unreamed femoral nails. A randomised, prospective trial. J Bone Joint Surg Br. 1998;80:485–489
22. 22. Wu CC, Shih CH, Ueng WN, Chen YJ. Treatment of segmental femoral shaft fractures. Clin Orthop Relat Res. 1993;287:224–230
23. 23. Namkung-Matthai H, Appleyard R, Jansen J, Hao Lin J, Maastricht S, Swain M, Mason RS, Murrell GA, Diwan AD, Diamond T (2001) Osteoporosis influences the early period of fracture healing in a rat osteoporotic model. Bone 28(1):80–86
24. 24.Yu CW, Wu CC, Chen WJ Aseptic nonunion of a femoral shaft treated using exchange nailing. Chang Gung Med J 200225(9):591–598
25. 25.Webb LX, Winquist RA, Hansen ST Intramedullary nailing and reaming for delayed union or non-union of the femoral shaft: a report of 105 consecutive cases. Clin Orthop 1986 212:133–141
26. 26.Banaszkiewicz PA, Sabboubeh A, McLeod I, Maffulli N Femoral exchange nailing for aseptic non-union: not the end to all problems. Injury 2003 34(5):349–356
27. 27.Choi YS, Kim KS Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures. Int Orthop 2005 29(5):287–290
28. 28.Taitsman LA, Lynch JR, Agel J, Barei DP, Nork SE. Risk factors for femoral nonunion after femoral shaft fracture. J Trauma. 2009 Dec;67(6):1389-92