YAŞLI HASTALARDA FEMUR İNTRAMEDÜLLER ÇİVİ UYGULAMALARINDA TUZAKLAR

Year 2020, Volume: 27 Issue: 1, 31 - 38, 01.03.2020

Hasan Ulaş Oğur , Osman Çiloğlu , Fırat Seyfettinoğlu , Ümit Tuhanioğlu , Hakan Uslu Burç Özcanyüz

Abstract

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. 

Keywords

femur intramedüller çivileme, yaşlı hasta, tuzaklar

PITFALL IN FEMORAL INTRAMEDULLAR NAIL APPLICATIONS IN ELDERLY PATIENTS

Abstract

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.

Keywords

femoral intrameduller nailing, elderly, pitfall

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