Zur Nutzung von DensiProbe™ bei der Rückfußarthrodese. Kann das Versagen durch eine mechanische Bestimmung der Knochenfestigkeit vorhergesagt werden?

Zusammenfassung

Studienziel: Ziel dieser Studie ist es, ein mechanisches Messinstrument (DensiProbe™) zur Bestimmung der lokalen Knochenfestigkeit weiter zu evaluieren, um damit zukünftig dem Operateur ein intraoperatives Messinstrument an die Hand geben zu können. Dabei soll in dieser Studie bestimmt werden, ob das Versagen einer Marknagelarthrodese vorhergesagt werden kann. Methoden: Es wurden 19 Unterschenkel verwendet. Die Proben wurden in 2 Gruppen aufgeteilt. In Gruppe 1 (n = 13) wurde der Nagel mit 2 Schrauben im Kalkaneus verriegelt. In Gruppe 2 (n = 6) erfolgte die Verriegelung mit einer Schraube und einer Klinge. Zur Messung wurde eine Sonde entwickelt, die in den Bereich des späteren Schraubenlagers eingebracht wurde. Dort wurde das Spitzendrehmoment ermittelt, das nötig war, um spongiöse Knochenstruktur zu brechen. Die Stabilität der Arthrodese wurde in einem biomechanischen Test beurteilt. Ergebnisse: Für beide Gruppen ergab sich eine signifikante Korrelation zwischen Spitzendrehmoment und Versagenszyklen. Die Korrelation zwischen BMD und Drehmoment sowie Versagenszeitpunkt war ebenfalls signifikant. Schlussfolgerung: In diesem biomechanischen Versuch konnte das Versagen einer Marknagelarthrodese mit DensiProbe™ vorhergesagt werden. Im klinischen Alltag ist das Versagen allerdings multifaktoriell, sodass die Spitzendrehmomentmessung nicht als alleiniger Prädiktor herangezogen werden kann.

Abstract

Aim: Bone quality is a main factor in implant fixation. After having shown promising results, we have further investigated the use of the DensiProbe™ as an intraoperative measurement tool for evaluation of calcaneal bone quality and prediction of nailed hindfoot arthrodesis failure. Method: In this add-on study 19 nail arthrodeses were performed using a conventional screw plus a locked blade (n = 6) or plus a locked screw (n = 13) in the calcaneus. A specially devised tool was inserted at the fixation sites of the screws and the cancellous break-away torque was measured. The constructs were then cyclically loaded to failure. Results: We saw a wide range of BMD (1.9–185.9 mgHA/cm³, mean 102.4 mg/cm³, SD 53.5). The peak torque was 0.47–1.78 Nm (mean 0.92 Nm, SD 0.46) at the proximal screw site (PSS) and 0.24 and 1.2 Nm (mean 0.63 Nm, SD 0.37) at the distal screw site (DSS), respectively, and 0.42 and 1.52 Nm (mean 1.00 Nm, SD 0.36) in the screw plus blade group (PSS). The number of cycles correlated with peak torque (two screws group PSS: p = 0.002, r² = DSS: 0.61 p = 0.001, r² = 0.90; screw plus blade group PSS: p = 0.001, r² = 0.99). Peak torque also correlated with BMD in both groups (two screws group PSS: p = 0.01, r² = 0.71; DSS: p = 0.001; r² = 0.83; screw plus blade group PSS: 0.42 and 1.52 Nm, mean 1.00 Nm, SD 0.36). Conclusion: A mechanical bone measurement tool like the DensiProbe™ seems to be suitable for predicting tibiotalocalcaneal arthrodesis failure in a biomechanical test set-up. As a restriction in clinical practice failure is multifactorial and prediction cannot be based upon these measurements only.

Schlüsselwörter

Marknagelarthrodese - Biomechanik - Rückfuß - Knochenstärke - Knochenqualität

Key words

tibiotalocalcaneal arthrodesis - biomechanics - hindfoot - bone strength - bone quality

Literatur

• 1 Goebel M, Gerdesmeyer L, Mückley T et al. Retrograde intramedullary nailing in tibiotalocalcaneal arthrodesis: a short-term, prospective study.  J Foot Ankle Surg. 2006;  45 98-106
• 2 Goebel M, Mückley T, Gerdesmeyer L et al. [Intramedullary nailing in tibiotalocalcaneal arthrodesis].  Unfallchirurg. 2003;  106 633-641
• 3 Nagashima M, Tachihara A, Matsuzaki T et al. Follow-up study of ankle arthrodesis in severe hind foot deformity in patients with rheumatoid arthritis using an intramedullary nail with fins.  Mod Rheumatol. 2005;  15 269-274
• 4 Niinimaki T T, Klemola T M, Leppilahti J I. Tibiotalocalcaneal arthrodesis with a compressive retrograde intramedullary nail: a report of 34 consecutive patients.  Foot Ankle Int. 2007;  28 431-434
• 5 Mückley T, Hoffmeier K, Klos K et al. Angle-stable and compressed angle-stable locking for tibiotalocalcaneal arthrodesis with retrograde intramedullary nails. Biomechanical evaluation.  J Bone Joint Surg [Am]. 2008;  90 620-627
• 6 O'Neill P J, Parks B G, Walsh R et al. Biomechanical analysis of screw-augmented intramedullary fixation for tibiotalocalcaneal arthrodesis.  Foot Ankle Int. 2007;  28 804-809
• 7 Rupprecht M, Pogoda P, Barvencik F et al. [The calcaneus as the site of manifestation for osteoporosis-associated fractures: age- and sex-specific changes in calcaneal morphology correlate with the incidence and severity of intra-articular calcaneal fractures].  Unfallchirurg. 2007;  110 197-204
• 8 Amirfeyz R, Bacon A, Ling J et al. Fixation of ankle fragility fractures by tibiotalocalcaneal nail.  Arch Orthop Trauma Surg. 2008;  128 423-428
• 9 Anderson T, Linder L, Rydholm U et al. Tibio-talocalcaneal arthrodesis as a primary procedure using a retrograde intramedullary nail: a retrospective study of 26 patients with rheumatoid arthritis.  Acta Orthop. 2005;  76 580-587
• 10 Boer R, Mader K, Pennig D et al. Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail.  Clin Orthop Relat Res. 2007;  463 151-156
• 11 Chou L B, Mann R A, Yaszay B et al. Tibiotalocalcaneal arthrodesis.  Foot Ankle Int. 2000;  21 804-808
• 12 De Smet K, De Brauwer V, Burssens P et al. Tibiocalcaneal Marchetti-Vicenzi nailing in revision arthrodesis for posttraumatic pseudarthrosis of the ankle.  Acta Orthop Belg. 2003;  69 42-48
• 13 Hammett R, Hepple S, Forster B et al. Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail. The results of 52 procedures.  Foot Ankle Int. 2005;  26 810-815
• 14 Millett P J, O'Malley M J, Tolo E T et al. Tibiotalocalcaneal fusion with a retrograde intramedullary nail: clinical and functional outcomes.  Am J Orthop. 2002;  31 531-536
• 15 Moore T J, Prince R, Pochatko D et al. Retrograde intramedullary nailing for ankle arthrodesis.  Foot Ankle Int. 1995;  16 433-436
• 16 Franck H, Gottwalt J. Associations with subregional BMD-measurements in patients with rheumatoid arthritis.  Rheumatol Int. 2008;  29 47-51
• 17 Herbst S A, Jones K B, Saltzman C L. Pattern of diabetic neuropathic arthropathy associated with the peripheral bone mineral density.  J Bone Joint Surg [Br]. 2004;  86 378-383
• 18 Jirkovska A, Kasalicky P, Boucek P et al. Calcaneal ultrasonometry in patients with Charcot osteoarthropathy and its relationship with densitometry in the lumbar spine and femoral neck and with markers of bone turnover.  Diabet Med. 2001;  18 495-500
• 19 Raska jr. I, Broulik P. The impact of diabetes mellitus on skeletal health: an established phenomenon with inestablished causes?.  Prague Med Rep. 2005;  106 137-148
• 20 Schwartz A V, Sellmeyer D E. Diabetes, fracture, and bone fragility.  Curr Osteoporos Rep. 2007;  5 105-111
• 21 Strotmeyer E S, Cauley J A. Diabetes mellitus, bone mineral density, and fracture risk.  Curr Opin Endocrinol Diabetes Obes. 2007;  14 429-435
• 22 Sterner W, Messow C, Schultz A. [Osteoporotic bone changes as the result of immobilization and their control by drugs].  Med Welt. 1975;  6 1149-1153
• 23 Laroche M, Pouilles J M, Ribot C et al. Comparison of the bone mineral content of the lower limbs in men with ischaemic atherosclerotic disease.  Clin Rheumatol. 1994;  13 611-614
• 24 Suhm N, Hengg C, Schwyn R et al. Mechanical torque measurement predicts load to implant cut-out: a biomechanical study investigating DHS anchorage in femoral heads.  Arch Orthop Trauma Surg. 2007;  127 469-474
• 25 Klos K, Windolf M, Schwieger K et al. Intraoperative mechanical bone strength determination in tibiotalocalcaneal fusion: a biomechanical investigation.  Foot Ankle Int. 2009;  12 1183-1189
• 26 Mückley T, Eichorn S, Hoffmeier K et al. Biomechanical evaluation of primary stiffness of tibiotalocalcaneal fusion with intramedullary nails.  Foot Ankle Int. 2007;  28 224-231
• 27 Windolf M, Muths R, Braunstein V et al. Quantification of cancellous bone-compaction due to DHS blade insertion and influence upon cut-out resistance.  Clin Biomech (Bristol, Avon). 2009;  24 53-58
• 28 Windolf M, Braunstein V, Dutoit C et al. Is a helical shaped implant a superior alternative to the dynamic hip screw for unstable femoral neck fractures? A biomechanical investigation.  Clin Biomech (Bristol, Avon). 2009;  24 59-64
• 29 Suhm N, Haenni M, Schwyn R et al. Quantification of bone strength by intraoperative torque measurement: a technical note.  Arch Orthop Trauma Surg. 2008;  128 613-620
• 30 Carrier D A, Harris C M. Ankle arthrodesis with vertical Steinmann's pins in rheumatoid arthritis.  Clin Orthop Relat Res. 1991;  268 10-14
• 31 Alfahd U, Roth S E, Stephen D et al. Biomechanical comparison of intramedullary nail and blade plate fixation for tibiotalocalcaneal arthrodesis.  J Orthop Trauma. 2005;  19 703-708
• 32 Santangelo J R, Glisson R R, Garras D N et al. Tibiotalocalcaneal arthrodesis: a biomechanical comparision of multiplanar external fixation with intramedullary fixation.  Foot Ankle Int. 2008;  29 936-941
• 33 Chiodo C P, Acevedo J I, Sammarco V J et al. Intramedullary rod fixation compared with blade-plate-and-screw fixation for tibiotalocalcaneal arthrodesis: a biomechanical investigation.  J Bone Joint Surg [Am]. 2003;  85 2425-2428
• 34 O'Neill P J, Logel K J, Parks B G et al. Rigidity comparison of locking plate and intramedullary fixation for tibiotalocalcaneal arthrodesis.  Foot Ankle Int. 2008;  29 581-586