İntertrokanterik femur kırığı bulunan 70 yaş ve üstü, ASAIII-IV olan cerrahi açıdan riskli hastalarda eksternal fiksatör ile osteosentez tedavisi uygulamalarımız ve sonuçları
Our practices and results of osteosynthesis treatment with external fixator in surgically risky patients aged 70 years and older with intertrochanteric femur fracture and ASAIII-IV
Yazar: AHMET AYBAR
Danışman: DOÇ. DR. MUSTAFA CEVDET AVKAN
Sağlık Bakanlığı / İstanbul Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi / Ortopedi ve Travmatoloji Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2009
Konu: Ortopedi ve Travmatoloji = Orthopedics and Traumatology

Özet:
Bakırköy Dr Sadi Konuk Eğit. Ve Arş. Hastanesi Acil Ortopedi ve Travmatoloji Kliniğine Şubat 2008-Ocak 2009 tarihleri arasında kalça kırığı nedeniyle başvuran 70 yaş ve üzeri ASA (Amerikan Anestezi Cemiyeti) kriterlerine göre ASA-lll ve üzeri, eksternal fiksatör uygulanmasına karar verilen, 43 hasta çalışmaya alındı. Tek kenarlı, çok planlı eksternal fiksatör uygulandı. Hastalardan 4‟ü (%9,3) ameliyattan sonraki 1 ay, 1 hasta (%2,3) ise 3 ay içinde kaybedildi. Otuz sekiz hastanın takipleri yapıldı. Tüm olgulardaki kırkların oluş nedeni ev içi düşme veya yürürken düşme gibi düşük enerjili travmalardı. Hastalar radyolojik olarak, Foster‟in radyolojik değerlendirme skorlamasına ( Tablo 9) ve fonksiyonel olarak Bartel günlük yaşam aktivite indeksine (BAI) (Form 1) göre değerlendirildi. 
Kırıkların kaynamaları, radyolojik olarak değerlendirildi ve ortalama kaynama süresi 123 gün (62-186) olarak tespit edildi. Eksternal fiksatörler hastaların hastaneye yatması gerekmeden poliklinik şartlarında çıkarıldı. Ortalama 1,29 cm (0-4) kısalık tespit edildi. Ortalama varus derecesi 12,7⁰ (0-25) olarak ölçüldü. Bartel Günlük Yaşam Aktivite İndeksi (BAI) Preoperatif olarak ortalama 55,23 ( 10-100), postoperatif 6. ayda orta-lama 47,04( 5-95), postoperatif 1. yılda (takipleri yeterli olan hastalarda) ortalama 50,13 ( 5-90) olarak bulundu. BAI preoperatif ve postoperatif 6. ay karşılaştırmasında 8,19‟luk (%14,83), preoperatif ve postoperatif 1. yıl karşılaştırmasında 5,10‟luk (%9,24) bir kayıp mevcuttu (Tablo 13). 
Foster‟in radyolojik değerlendirme skorlamasına göre 8 hasta(%21,06) Grade 1, 12 hasta (%31,57) Grade 2, 6 hasta(%15,8) Grade 3, 12 hasta( %31,57) Grade 4 olarak tespit edildi (Tablo 12). 
Cerrahi ve anestezi açısından yüksek risk taşıyan ASA III ve üstü intertrokanterik femur kırığı olan hastalarda; ameliyat süresinin kısa olması, kan kaybının yok denecek kadar az olması, ameliyat kapalı yapıldığı için kırık hematomunun boşaltılmaması, dola-yısıyla kaynamanın hızlı olması, hastaların erken hareket kabiliyeti ile günlük aktivitelere hızlı geri dönüş kazanması, eksternal fiksatörün çıkarılması için anestezi gerekmemesi, eksternal fiksatör ile tedavi yönteminin avantajlarıdır. Pin dibi enfeksiyonu, shanz çivisi migrasyonu ve kozmetik açıdan rahatsız edici olması ise dezavantajlarıdır.

Abstract:
Intertrochanteric fractures of the femur were disabling conditions for old patients who have risks of different accompanying diseases. The aim of treatment of these fractures are to achieve a stable bone structure without so much bleeding and harm to the local area and to return the patients to their daily life, in the shortest time. As nearly all the patients have other diseases, it is very hard to get the patient in an optimal condition for the operation. So many different techniques were used for intertrochanteric fractures. Dynamic hip screw, proximal femoral nail, cannulated screws and external fixators were used for fixation of the fractures. All have different indications for use and different surgical techniques. As the operative technique is simple and fast, the patients could be prepared for the operation so much easily. But in some instances, stable fixation and harder techniques are needed. External fixation is a simple, time-saving surgical procedure for these patients. 
Forty-three patients older than 70 years old with intertrochanteric femur fractures, were evaluated at the Bakırköy Dr. Sadi Konuk Educational and Research Hospital between february 2008 -january 2009. All the patients were ASA 3 and over. Twenty-five (58,14%) of the patients were female,18 (41,86 %) of them were male. Mean age was 80,35 ( range, 69-93) (Table 4). Twenty-two (51%) of the patients have right and 21 ( 49%) of them have left intertrochanteric femur fracture. Five of patients(11,6 %) died. Thirty-eight of patients was followed. Mean follow-up period is 10,9 months ( range, 9-16 months). All patients have accompanyig diseases like cardiac diseases, hepatitis C, gastrointestinal system disorders, renal diseases, serebral ischemic conditions, tuberculosis and Alzheimer. All the patients had an external fixation surgery under anesthesia. General anesthesia was used for 12 (28%) patients and all other patients (31, 72%) were operated under spinal anesthesia. On the traction table, after achieving a good reduction under floroscopic control, 2 or 3 spongious schanz screws were send to the proximal and 3 cortical schanz screws were placed in the distal femoral shaft. No intraoperative complication was occurred. Deep pin-track infection was found in two patients. Osteomyelitis was not noted in any patients. Varus malalignment of more than 20° and limb shortening greater than 2 cm were noted in 3 patients. Varus deformity was observed in two patients. Complete fracture healing was achieved in all patients. The fixator was removed after an average of 123 days (62 to 186 days) at the outpatient condition. First generation cephalosporine was used preoperatively and 3 days postoperatively. Low-density heparin (0.4 ml enoxaparine) was used daily preoperatively and 10 days postoperatively. 
On the first postoperative day, intensive active and passive rehabilitation program was begun. If a stable fixation was achieved, rehabilitation was continued with partial weight bearing. After a mean days ( range, 2-15) postoperatively, all the patients were discharged. Home rehabilitation program was given and all the patienrs were invited for control examination at the 45th day, 3rd and 6 th months. All the patients were evaluated by means of accompanying diseases, ASA grade, postoperative transfusion and complications. Also all of them were evaluated with Barthel Index of Activities of Daily Living(BAI) preoperatively and at 6th month postoperatively . All the fractures were healed completely and all the external fixators were removed after then. Two patients ( 4,65 %) had deep pin tract infection that one of was treated completely with debridement and antibiotics. And another died because of accompanying illness. Seven patients (16,28 %) had superficial infection those had no need for treatment. Also schanz screw migration was detected in three patients (6,97 %). All the patients were evaluated with Foster‟s radiology score ( Table 9) and Barthel Index of Activities of Daily Living (BAI) (Form 1) preoperatively and at 6th month postoperatively. Mean value of BAI was found as 55,23 ( 5-100) preoperatively and as 47,04( 5-95) postoperatively at 6th month and as 50,13 ( 5-90) postoperatively at first year. Approximately 9,24 % decrease of this mean value of the index was found between preoperative and postoperative first year BAI values. Foster‟s radiology evaluation score was found as Grade 1 in eight patients (21,06 %), as Grade 2 in twelve patients (31,57 %), as Grade 3 in six patients (15,80 %), as Grade 4 in twelve patients( 31,57 %) (Table 12). 
No implant failure, refracture or stiffness of knee and hip joint movements was recorded. We concluded that the treatment of intertrochanteric fractures of the elderly patients with our modification provides significant advantages such as minimal operative and anesthetic risks, no blood loss, early weight-bearing, short hospitalisation time and rapid union time. The decrease of BAI values was thought to be related with pertrochanteric fracture, additional systemic diseases and difficulty in aftertreatment. 
The external fixation surgery is still an effective alternative surgical technique as it has the advantages of shorter surgery time, minimal hemorrhage, decreased cardiac risks and easy implant removal without general anesthesia and also has the disadvantages of pin-tract infection, screw migration and undesirable cosmesis.