Die rotationsstabile intramedulläre Osteosynthese von proximalen extraartikulären Femurfrakturen

Zusammenfassung

Ziel: Mit dem proximalen Femurnagel (PFN) und dem Gleitnagel (GLN) stehen zwei moderne Verfahren zur intramedullären Osteosynthese von proximalen extraartikulären Femurfrakturen zu Verfügung, welche eine rotationsstabile Fixierung des proximalen Fragmentes ermöglichen. Beide Verfahren sollen bezüglich des klinischen Einsatzes vergleichend evaluiert werden. Methode: In einer prospektiven Studie werden die Behandlungsverläufe von 240 Patienten aus zwei unfallchirurgischen Kliniken mit mittlerem Follow-up von 10,2 Monaten analysiert. Ergebnisse: Neben speziellen osteosynthesebezogenen Komplikationen für PFN/GLN wie Kopfperforationen (4,8 %/2,6 %), Materialdislokationen (0,8 %/0 %), intraoperativen Femurschaftfrakturen (0,8 %/2,6 %), Pseudarthrosen (0 %/0,9 %) und Materialbrüchen (0,8 %/0 %) stellen Wundheilungsstörungen (9,7 %/5,2 %) und iatrogen bedingte Komplikationen wie Fehlplatzierung des Osteosynthesematerials und Repositionsfehler (0,8 %/4,3 %) Gründe für Revisionen dar. Schlussfolgerung: Die Gleitnagelosteosynthesen weisen an speziellen osteosynthesebedingten Komplikationen (6,0 %) und Wundheilungsstörungen (5,2 %) gegenüber den PFN-Osteosynthesen (7,3 % bzw. 9,7 %) ein günstigeres Komplikationsprofil auf. Dies gilt in besonderem Maße für die Kopfperforationsrate von 4,8 % beim PFN gegenüber 2,6 % beim GLN.

Abstract

Aim: The proximal femur nail (PFN) and the gliding nail (GLN) are two modern procedures available for intramedullary osteosynthesis of proximal extra-articular femur fractures; they allow a rotationally stable fixation of the proximal fragment. In a comparative analysis of complications, both methods should be evaluated. Methods: A comparative analysis of both procedures is presented in a prospective clinical study design. The treatment of 240 consecutive patients (124 PFN/116 GLN) with an average follow-up term of 10.2 months is analysed. Results: Both PFN and GLN give rise to head perforations (4.8 % and 2.6 %), dislocations of material (0.8 % and 0 %), intraoperative femoral shaft fractures (0.8 % and 2.6 %), pseudarthrosis (0 % and 0.9 %) and fractures of material (0.8 % and 0 %) in the way of complications as well as wound-healing impairments (9.7 % and 5.2 %) and iatrogenic complications such as false placement of the osteosynthesis material and errors in reposition (0.8 % and 4.3 %). Conclusion: The gliding nail osteosynthesis yields a more favourable complication profile with regard to specific osteosynthesis-caused complications (6.0 %) and wound-healing impairments (5.2 %) in comparison with the PFN osteosynthesis (7.3 % and 9.7 %, respectively). Especially the cut-out rate of the GLN (2.6 %) is lower than that of the PFN (4.8 %).

Schlüsselwörter

pertrochantäre Fraktur - subtrochantäre Fraktur - PFN - Gleitnagel - cut-out

Key words

pertrochanteric fracture - subtrochanteric fracture - PFN - gliding nail - cut-out

Literatur

• 1 Banan H, Al-Sabti T A, Jimulia T, Hart A J. The treatment of unstable, extracapsular hip fractures with the AO/ASIF proximal femoral nail (PFN) - our first 60 cases.  Injury. 2002;  33 401-405
• 2 Bridle S H, Patel A D, Bircher M, Calvert P T. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the gamma nail and the dynamic hip screw.  J Bone Joint Surg [Br]. 1991;  73 330-334
• 3 Fritz T, Hiersemann K, Krieglstein C, Friedl W. Prospective randomized comparison of gliding nail and gamma nail in the therapy of trochanteric fractures.  Arch Orthop Trauma Surg. 1999;  119 1-6
• 4 Habernek H, Wallner T, Aschauer E, Schmid L. Comparison of ender nails, dynamic hip screws, and gamma nails in the treatment of peritrochanteric fractures.  Orthopedics. 2000;  23 12-17
• 5 Herrera A, Domingo L J, Calvo A, Martinez A, Cuenca J. A comparative study of trochanteric fractures treated with the gamma nail or the proximal femoral nail.  Int Orthop. 2002;  26 365-369
• 6 Halder S C. The gamma nail for peritrochanteric fractures.  J Bone Joint Surg [Br]. 1992;  74 340-344
• 7 Leung K S, So W S, Shen W Y, Hui P W. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients.  J Bone Joint Surg [Br]. 1992;  74 345-351
• 8 Sadowski C, Lubbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or 95° screw-plate: a prospective, randomized study.  J Bone Joint Surg [Am]. 2002;  84 372-381
• 9 Curtis M J, Jinnah R H, Wilson V, Cunningham B W. Proximal femoral fractures: a biomechanical study to compare intramedullary and extramedullary fixation.  Injury. 1994;  25 99-104
• 10 Friedl W. Relevance of osteotomy and implant characteritics in inter- and subtrochanteric osteotomies.  Arch Orthop Trauma Surg. 1993;  113 5-11
• 11 Haynes R C, Pöll R G, Miles A W, Weston R B. An experimental study of the failure modes of the gamma locking nail and AO dynamic hip screw under static loading: a cadaveric study.  Med Eng Phys. 1997;  19 446-453
• 12 Aune A K, Ekeland A, Odegaard B, Grogaard B, Alho A. Gamma nail vs. compression screw for trochanteric femoral fractures. 15 reoperations in a prospective, randomized study of 378 patients.  Acta Orthop Scand. 1994;  65 127-130
• 13 Goldhagen P, O'Connor D, Schwarze D, Schwarz E. A prospective comparative study of the compression hip screw and the gamma nail.  J Orthop Trauma. 1994;  8 367-372
• 14 Hogh J, Andersen K, Duus B, Hansen D. Gamma nail versus DHS in the treatment of trochanteric and subtrochanteric fractures.  Acta Orthop Scand. 1992;  63 86-87
• 15 Parker M J, Handoll H H. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures (Cochrane Review). Cochrane Database Syst Rev 2002; 1
• 16 Radford P, Needorf M, Webb J. A prospective randomized comparison of the dynamic hip screw and the gamma locking nail.  J Bone Joint Surg [Br]. 1993;  75 789-793
• 17 Simmermacher R KJ, Bosch A M, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): a new device for the treatment of unstable proximal femoral fractures.  Injury. 1999;  30 327-332
• 18 Suckel A, Helwig P, Schirmer A, Garbrecht M, Mocke U. Complication rate in the treatment of inter- and subtrochanteric femur fractures with two intramedullary osteosynthesies, Gammanail and glidingnail.  Zentralbl Chir. 2003;  128 212-217
• 19 Al-yassari G, Langstaff R J, Jones W M, Al-Lami M. The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture.  Injury. 2002;  33 39-59
• 20 Kempf I, Grosse A, Taglang G, Favreul E. Gamma nail in the treatmant of closed trochanteric fractures. Results and indications apropos of 121 cases.  Rev Chir Orthop. 1993;  79 29-40
• 21 Rantanen J, Aro H T. Intramedullary fixation of high subtrochanteric femoral fractures: a study comparing two implant designs, the Gamma nail and the intramedullary hip screw.  J Orthop Trauma. 1998;  12 249-252
• 22 Adams C I, Robinson C M, Court-Brown C M, McQueen M M. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur.  J Orthop Trauma. 2001;  15 394-400
• 23 Sim E, Freimuller W, Reiter T J. Finite element analysis of the stress distributions in the proximal end of the femur after stabilization of a pertrochanteric model fracture: a comparison of two implants.  Injury. 1995;  26 445-449
• 24 Singh M, Nagrath A R, Maihi P S. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis.  J Bone Joint Surg [Am]. 1970;  52 457-467