Tehnica i avantajele osteosintezei minim invazive cu plci n

fracturile subtrohanteriene
P.D. Srbu, N. Georgescu, D. Pencu, G. Ghionoiu, O. Cristea, R. Bruja, R.
Asaftei, R. Mihi
Abstract
!"# !#C"N$%&# AND !"# AD'AN!AG#S O( M$PO $N
S&B!ROC"AN!#R$C (#MORA) (RAC!&R#S. The purpose of this
prospective study is to evaluate the outcome of 38 subtrochanteric femoral
fractures treated by MIPO technique, using a 9! condylar blade plate
"#$P% in & cases, a classic dynamic condylar scre' "(#)% in *9 cases, a
titanium+made limited contact+dynamic condylar scre' ",#+(#)% in **
cases and * reverse titanium+made limited contact+condylar butress plate
",#+#$tP%-
The fractures 'ere classified according to )einsheimer ". type II$, 3 type
II#, type III/, 0 type III$, *0 type I1 and *2 type 1%- In order to limit the
amount of both medial and lateral dissection, the plates 'ere carefully
inserted through isolated pro3imal incision only, behind the vastus lateralis4
'hile the #$P 'as initially inserted 'ith the blade pointing to'ards the
surgeon, the MIPO technique 'as simplified by the use of the t'o+part and
t'o+plane alignment achieved by (#)- 5or reverse ,#+#$tP the
anterograde insertion under vastus lateralis 'as easily accomplished-
6hen adequate limb alignment, length and rotation 'ere confirmed by
reliable clinical and radiographic techniques, the plate 'as fi3ed to the
distal main fragment by 0 scre's inserted percutaneously or by minimal
incisions- 5or ,#+#$tP, 'e have used multiple canulated scre's in the
femoral nec7 and head-
/II fractures healed, 'ithin a mean time of *2-. 'ee7s "range 8+..
'ee7s%-There 'ere no infections or serious implant failure- One patient that
falled after operation undergone distal scre' brea7age 'ith secondary
displacement in varus, requiring reintervention- /t follo'+up, there 'ere
varus8valgus deformities above !, 0 leg length discrepancies over * mm
and * malrotation of .2!- The final outcome "according to the 9eer scale%
'as e3cellent in .0 cases, satisfactory in *3 cases and unsatisfactory in *
case-
This demanding technique has the advantages of a faster rate of union, 'ith
no need for bone grafting- /d:ustment of adequate a3ial and rotational
aligment is an essential aspect requiring careful attention- *e+,or-s.
subtrochanteric fe/ora fractures, M$PO, -+na/ic con-+ar scre, 0DCS1,
2ercutaneous+, /arotation.
Introducere
(racturie subtrohanteriene re2re3int 456478 -in fracturie -e a
ni9eu :o-uui sau -in 9ecintatea acestuia 0;,<4,==1. #e interesea3 o
regiune cu2rins ntre /icu trohanter :i un 2an situat a 7 c/ -ista, n
trei/ea 2ro>i/a a fe/uruui 0;,<;,==,=71, 2ut?n-u6se asocia cu fracturi
2ertrohanteriene sau ae -iafi3ei fe/urae.
Mecanis/u -e 2ro-ucere a fracturior subtrohanteriene este -e
obicei trau/atis/u -irect a fe/uruui 2ro>i/a@ n ti/2 ce 2acienAii tineri
sunt su2u:i unor trau/atis/e -e /are intensitate 0c-eri -e a nAi/e sau
acci-ente -e circuaAie1, 2acienAii 9?rstnici sufer o c-ere u:oar 2e :o-,
fractura 2ro-uc?n-u6se 2e un os osteo2orotic 0;,==,=71.
Regiunea subtrohanterian este su2us unui BstresC bio/ecanic
e>centric, forAee -e co/2resiune -e a ni9eu corte>uui /e-ia -e2:in-
forAee -e tensiune -e a ni9eu corte>uui atera 0;,4<,47,==,=71. Co/inuAia
corte>uui /e-ia n trau/atis/ee -e /are intensitate ri-ic 2robe/e
-ificie -e reconstrucAie :i -e fi>are intern. Pe -e at 2arte, 9ascuari3aAia
frag/enteor co/inuti9e 2oate fi serios co/2ro/is ntr6o regiune cu os
2re-o/inant cortica :i cu un 2otenAia -e consoi-are /ai re-us -ec?t a
osuui /etafi3ar trohanterian 0;,==,=71. Pentru aceste /oti9e, fracturie
subtrohanteriene necesit tehnici -e re-ucere care nu e3ea3 :i /ai /ut
a2ortu 9ascuar :i Aesuturie /oi ae frag/enteor inter/e-iare, 2recu/ :i o
fi>are intern cu o nat stabiitate /ecanic 0;,4D,4E,<E,=4,==1.
Re-ucerea anato/ic a frag/enteor :i osteosinte3a cu CBP sau
siste/ DCS necesit un abor- casic atera cu ri-icarea 9astuui e>tern
0E,4<,4D,4E,<=,==1. 'i3uai3area :i /ani2uarea -irect a frag/enteor
i/2ic -e2eriostri e>cesi9e cu -e9itai3area frag/enteor, -isecAii argi
ae Aesuturior /oi, igatura artereor 2erforante, co/2ro/ite6rea arterei
nutriti9e, -i/inuarea 2erfu3iei /e-uare :i 2eriostae
07,E,4F,4D,4G,4E,<E,=41. Cu aceste tehnici con9enAionae -e stabii3are
0ba3ate /ai /ut 2e factori /ecanici -ec?t 2e consi-eraAii bioogice1,
inci-enAa infecAiior 2seu-artro3eor, nt?r3ierior n consoi-are, fracturior
iterati9e :i a necesitAii grefrii 2ri/are :i secun-are este crescut
0;,4;,4F,4D,4G,4E,<F,==,=F1.
De3a9antajee re-ucerii anato/ice :i fi>rii rigi-e cu un i/2ant ti2
a/62ac sau :urub62ac au -us a a2ariAia conce2tuui -e Bosteosinte3
bioogicC cu 2ci 0<1. Prin intro-ucerea unor noi ti2uri -e 2ci 0Bri-ging
2ates. )i/ite- contact 6D+na/ic Co/2ression PateH)C6DCP, Point
Contact (i>atorHPC6(i>. )ocIe- Co/2ression PateH)CP1 :i -e39otarea
unor noi tehnici chirurgicae 2entru fracturie fe/uruui 2ro>i/a :i -ista
0Bre-ucerea in-irectC :i osteosinte3 /ini/ in9a3i9 6Mini/a+ $n9asi9e
Pate Osteos+nthesisHM$PO1, Bosteosinte3a bioogicC cu 2ci res2ect
2rAie /oi contribuin- a conser9area 9ascuari3aAiei osoase, cu
/buntAirea consoi-rii :i sc-erea necesitAii grefrii
0;,E,4<,4F,4D,4G,4E,==,=G1. Mai noi :i /ai 2retenAioase tehnic, aceste
2roce-ee co/2etea3 ceeate /eto-e -e osteosinte3 bioogic 0fi>area
centro/e-uar cu focar nchis fr ae3aj osteosinte3 eastic1.
Jn sco2u i/itrii -isecAiei 2rAior /oi :i a -e2eriostrior a ni9eu
focaruui -e fractur, tehnicie -e re-ucere in-irect 02rin foosirea
-istractoruui1 au fost -e39otate 2entru tratarea fracturior fe/uruui
2ro>i/a 0;,4;,4D,<<1 :i -ista 0=,4=,<F1. (iecare -in aceste tehnici i/itea3
abor-u a o e>2unere atera :i e9it -isecAia /e-ia, contribuin- a
sc-erea necesitAii grefrii 0=,4=,4;,<F1. Cu toate acestea, e>ist stu-ii 071
care -e/onstrea3 c o -isecAie atera 2oate -i/inua circuaAia 2eriosta
:i /e-uar 2rin e3iunea 2erforanteor :i a arterei nutriti9e. Kin?n- cont -e
aceste stu-ii :i -e a9antajee osteosinte3ei cu focar nchis, Len-a :i coab.
0=G1 au intro-us 2cie 2e sub 9astu e>tern 0fr -isecAia acestuia1, -u2 o
inci3ie e>tern a 2ieii :i a fasciei, -e39ot?n- astfe tehnica intituat M
tunei3are 0=51.
Osteosinte3a /ini/ in9a3i9 cu 2ci 0M$PO1 a re2re3entat 2asu
ur/tor n Bres2ectareaC 2rAior /oi, 2rin i/itarea at?t a -isecAiei /e-iae
c?t :i a ceei aterae 0E,4F,4D,4G,4E,=G1. Se e9it astfe e>2unerea -irect
a focaruui -e fractur, i/2antee fiin- transfor/ate ntr6o ate intern
e>tra/e-uar. 0E,4E1. M$PO 2oate fi siste/ati3at n ; eta2e sau tehnici
0<E,=41.
a) Len-a :i coab. au -escris un abor- atera i/itat a fe/uruui
-easu2ra :i -e-esubtu focaruui -e fractur, cu intro-ucerea 2cior
2e sub 9astu e>tern 0=G1@
b) Osteosinte3a /ini/ in9a3i9 2ercutanat cu 2ci 0Mini/a+ $n9asi9e
Percutaneous Pate Osteos+nthesisHM$PPO1 a fost -e39otat 2entru
trata/entu fracturior e>traarticuare ae fe/uruui 2ro>i/a :i -ista
04E1. Cheia tehnicii M$PPO este utii3area unui i/2ant n -ou 2rAi
ti2 DCS. acesta necesit 2o3iAionarea conco/itent nu/ai n -ou
2anuri, 2ut?n- fi inserat ntr6o /anier 2ercutanat :i sub/uscuar,
utii3?n- un instru/entar s2ecia 04E,=51@
c) Abor-u transarticuar :i osteosinte3a retrogra- cu 2ci
0!ransarticuar A22roach an- Retrogra-e Pate Osteos+nthesis +
!ARPO1 a fost -e39otat -e *rettec :i coaboratorii 0E,4G,=51 2entru
osteosinte3a fracturior co/2e>e intraarticuare ae fe/uruui -ista@
aceast tehnic co/bin o artroto/ie atera 2ara2atear 0care
2er/ite reconstrucAia articuar1 cu fi>area in-irect a 2cii 2e sub
9astu e>tern, n 9e-erea securi3rii con-iior fe/urai a -iafi3@
d) M$PO cu siste/u )ess $n9asi9e Stabii3ation S+ste/ 0)$SS1 M acesta
a fost creat n /o- s2ecia 2entru M$PO a ni9eu fe/uruui -ista
0F,4D,=D1, n 9e-erea asigurrii unei stabiitAi anguare ntre
:uruburi :i 2ac 0BocIe- 2ateNN1.
Acest stu-iu 2ros2ecti9 atrage atenAia asu2ra i/2ortanAei res2ectrii
integritAii Aesuturior /oi a ni9eu focaruui -e fractur@ e e9auea3
re3utatee fracturior co/2e>e subtrohanteriene tratate -e autori 2rin
osteosinte3 /ini/ in9a3i9 cu 2ci.
Material i metod
Jn 2erioa-a iunie <555 M /artie <55D, =G 2acienAi 0<D brbaAi :i 44
fe/ei1 cu fracturi co/2e>e subtrohanteriene au fost trataAi 2rin
osteosinte3 /ini/ in9a3i9 cu. E7OCBP 0figura < A6C, figura = A6G, figura
; A6D1, DCS casic 0figura 7 A6(, figura F A6P :i figura D A6C1, )C6DCS
0figura G A6" :i figura E A6(1 sau )C6CBtP 0figura 45 A6(1. '?rsta /e-ie a
2acienAior a fost -e ;;,7 ani 0cu i/ite ntre << :i G; -e ani1. 4G 2acienAi au
suferit trau/atis/e -e /are intensitate 044 acci-ente -e circuaAie :i D
c-eri -e a nAi/e1, 47 -in ace:tia fiin- 2oitrau/ati3aAi.
Confor/ casificrii ui Seinshei/er 0<G1 otu -e stu-iu a cu2rins <
fracturi ti2 $$B, = ti2 $$C, 7 ti2 $$$A, ; ti2 $$$B, 4; ti2 $' 0co/inuti9e1 :i 45 ti2 '
0subtrohanteriene 6 intertrohanteriene1. F fracturi -eschise au fost
casificate -u2 Gustio 0451. = fracturi ti2 $ :i = ti2 $$.
PacienAii au fost e9auaAi :i resuscitaAi n ser9iciu -e 2ri/ire urgenAe a
S2itauui -e &rgenAe, toAi 2oitrau/ati3aAii necesit?n- internare n ser9iciu
-e tera2ie intensi9. Jn fracturie -eschise s6a 2racticat 2reucrarea
chirurgica a 2gior, 2rofia>ia tetanosuui :i a fost nce2ut antibiotera2ia
2arentera. = 2acienAi au fost o2eraAi n 2ri/ee ore -e a internare, restu
fiin- i/obii3aAi 2?n a inter9enAie cu e>tensie continu transtubero3itar.
Tehnic chirurgical
Panning6u 2reo2erator 02rin trasarea unui te/2ate 2e ra-iografia
antero62osterioar a fe/uruui controatera1 a fost esenAia n
seectarea /ri/ii cores2un3toare a i/2antuui, -eter/inarea e>act a
2unctuui -e intrare a a/ei sau :urubuui, 2o3iAia acestora n cou :i ca2u
fe/ura, 2asarea o2ti/ a :uruburior. Mo/entu o2erator a fost -ecis -e
reechiibrarea 2acienAior, n /e-ie a ; 3ie 0cu i/ite ntre 4 :i D 3ie1.
$nter9enAia s6a 2racticat 2e o /as orto2e-ic, toAi 2acienAii fiin-
2o3iAionaAi n -ecubit -orsa 0fig. 4A1. Du2 re-ucerea orto2e-ic a fracturii
0obAinut -e obicei 2rin si/2 tracAiune1, ungi/ea fe/uruui controatera a
fost co/2arat cu ungi/ea fe/uruui e3at. Du2 2asarea c?/2urior
sterie 0reai3at n a:a fe nc?t s 2er/it e>a/inarea intrao2eratorie a
ungi/ii fe/uruui :i a 2o3iAiei rotuei1, autorii au 2racticat osteosinte3a
/ini/ in9a3i9 cu CBP 0n D ca3uri1, siste/ DCS 0n =5 ca3uri1 2recu/ :i
)C6CBtP M 4 ca3. Sco2u inter9enAiei a fost restabiirea a>uui, ungi/ii :i
rotaAiei /e/bruui inferior.
(oosirea CBP a fost u:urat -e fa2tu c autorii a9eau e>2erienA -e
c?Ai9a ani cu acest i/2ant /onoboc, -estu -e -ifici -e inserat corect n
trei 2anuri si/utan, chiar cu inci3ii argi :i 9i3uai3area fe/uruui. Du2 o
inci3ie a 2iee -e circa F6D c/ 0figura 4B1 n -re2tu regiunii trohanteriene
0continuat cu o inci3ie a fasciei 2?n a 45 c/. 2entru a faciita inserAia
2cii1, au fost inserate 0<41 bro:a -e ante9ersie. bro:a6ghi- :i -ata6ghi-
0figura 4 C1. sub contro R> !' se aege o 2ac -e ungi/e
cores2un3toare 0figura 4 D1. )ungi/ea a/ei este -e circa ;67 c/ fiin-
suficient 2entru ancorarea n /asi9u trohanterian :i u:ur?n- inserAia
/ini/ in9a3i9. Paca aeas este intro-us cu grij 2e sub 9astu e>tern, cu
2ontarea co/inuAiei :i cu a/a n-re2tat s2re chirurg 0figura 4 #1. O inci3ie
secun-ar -e ;67 c/ se 2ractic a ni9eu frag/entuui -ista, n -re2tu
uti/eor guri ae 2cii 0figura 4 (1. Du2 scoaterea -Aii6ghi-, a/a62ac
se ntoarce cu 4G5O 0fiin- /ani2uat 2ro>i/a :i -ista1 iar a/a se
intro-uce a2oi n canau 2re2arat.
(ig. 4. 0A6#1. !ehnica M$PO utii3?n- CBP. 0A1 Po3iAionarea 2acientuui :i re-ucerea
orto2e-ic@ 0B1 $nci3ie -e F 6 D c/ n -re2tu regiunii trohanteriene. 0C1 $ntro-ucerea -Aii
ghi-@ 0D1 Seectarea unei CBP sub contro R>@ 0#1 $ntro-ucerea CBP 2e sub 9astu e>tern cu
a/a n-re2tat s2re chirurg@ 0(1 $nci3ie secun-ar -ista.
(ig. < 0A6C1. M$PO cu CBP n fractur subtrohanterian. A. (ractur subtrohanterian ti2
Seinshei/er '. B. M$PO cu CBP 0as2ect -e faA :i 2rofi1. C. Consoi-area fracturii a =
uni 2osto2 0as2ect -e faA :i 2rofi1
Acest /o/ent ce 2are -ifici 2entru chirurgii obi:nuiAi cu e>2unerea
arg a fe/uruui s6a reai3at fr co/2icaAii, n toate ca3urie. Prin
intro-ucerea unui :urub n frag/entu 2ro>i/a, acesta este stabii3at
suficient, /ai aes c a/a62ac asigur o bun ancorare n /asi9u
trohanterian 0==1.
Du2 restabiirea a>uui, ungi/ii :i rotaAiei /e/bruui inferior 2rin
tehnici cinice :i fuorosco2ice, 2aca a fost fi>at a frag/entu -ista cu =
sau /ai /ute :uruburi 0figura <, =, ;1.
!ehnica M$PO a fost si/2ificat 2rin utii3area n =5 ca3uri a
siste/uui DCS, un i/2ant n -ou 2rAi care a necesitat 2o3iAionarea
corect nu/ai n -ou 2anuri si/utan 0;,4D,4E,=<,=G1. #ta2ee M$PO au
fost ur/toaree. 41 inci3ie 2ro>i/a -e ;6F c/ a 2ieii, continuat cu o
inci3ie a-iAiona -e <6= c/ a fasciei 2entru a faciita inserAia 2cii 0figura
7A1@ <1 intro-ucerea bro:ei fietate sub contro fuorosco2ic@ =1 inserAia
:urubuui con-iian 0figura 7B1 -u2 2rinci2iie a2icrii siste/uui DCS 0<=1@
;1 seectarea unei 2ci sub contro fuorosco2ic 0figura 7C1@ 71 intro-ucerea
2cii 2e sub 9astu e>tern 0figura 7D1@ F1 inci3ie a-iAiona n -re2tu
uti/eor :uruburi ae 2cii 0figura 7#1@ D1 conectarea 2cii a :urubu
con-iian cu 2osibiitatea ajustrii n 2an sagita. 2rin rotaAia i/2antuui.
(ig. =. 0A6G1. 0A1 (ractur subtrohanterian ti2 $' 0Seinshei/er1 cu e>tensie -iafi3ar@ 0B, C1
Osteosinte3 /ini/ in9a3i9 cu CBP@ contro 2osto2erator@ 0D. #1 Caus 2re3ent a < uni
2osto2erator@ 0(, G1 Caus abun-ent a F uni 2osto2erator.
(ig. ;0A6D1. M$PO cu )PC n fractur subtrohanterian.
0A1 (ractur subtrohanterian ti2 Seinshei/er $', cu e>tensie -iafi3ar@ 0B1 M$PO cu CBP,
as2ect 2osto2erator@ 0C1 Caus 2re3ent a = uni 2osto2erator@ 0D1 Caus abun-ent
a 4 an 2osto2erator
(ig. 70A6(1. M$PO cu DCS n fracturi subtrohanteriene 0A1 $nci3ie 2ro>i/a@ 0B1 $ntro-ucerea
:urubuui DCS@ 0C1 Seectarea unei 2ci sub contro RQ@ 0D1 $ntro-ucerea 2cii 2e sub 9astu
e>tern, cu u/ru 2cii n-re2tat s2re chirurg@ 0#1 $nci3ie -ista a-iAiona n -re2tu uti/eor
guri ae 2cii@ 0(1 As2ectu fina a 2gior o2eratorii
Aceast /ane9r este faciitat :i -e tracAiunea 2cii 2rin inci3ia a-iAiona
-ista, care -eter/in 2araeis/u 2cii cu -iafi3a@ G1 fi>area 2cii a
-iafi3 cu ; sau /ai /ute :uruburi 02asate -i9ergent 2entru cre:terea
2uterii -e str?ngere :i a i/itrii inci3iei10figura F, D1.
(ig. F. A6P. 0A1 (ractur subtrohanterian co/2e>@ 0B,C1 M$PO cu DCS, caus inci2ient a <
uni 2.o.@ 0D,#1 consoi-area fracturii a ;,7 uni 2.o.@ 0(,G1 as2ect ra-ioogic a 4 an 2.o.@ 0",$,P1
re3utat funcAiona e>ceent a 4 an 2.o.
(ig. D0A6C1. M$PO cu DCS n fractur subtrohanterian. 0A1 (ractur subtrohanterian
co/2e> cu e>tensie -iafi3ar@ 0B,C1 M$PO cu DCS, cu consoi-area fracturii a F uni
2osto2erator :i /enAinerea a>rii n ciu-a unei 2ci scurte, cu nu/ai < :uruburi -istae
bicorticae :i < unicorticae
(ig. G 0A6"1. B, S.$., G; ani, fractur subtrohanterian st?ng ti2 $$$B Seinshei/er. M$PO cu
)C6DCS. 0A1 as2ect 2reo2erator@ 0B,C1 2rint $O@ 0D1 caus 2re3ent a < uni@ 0#6"1 re3utat
funcAiona e>ceent a < uni 2osto2, n ciu-a 9?rstei :i tareor asociate @ bona9u cac cu
s2rijin tota
(ig. E0A6(1. M$PO cu )C6DCS n fractur etajat 0subtrohanterianR-iafi3 2ro>i/a1. 0A1
(ractur subtrohanterian co/inuti9@ 0B,C1 M$PO cu )C6DCS 2rint $O 0se re/arc as2ectu
-i9ergent a :uruburior -istae :i cee < :uruburi -e cortica -in 2inten M 2araee cu :urubu
DCS, care -au stabiitate /ontajuu@ 0D1 As2ect 2osto2erator, cu a>area frag/enteor
2rinci2ae@ 0#,(1 Consoi-area fracturii a ; uni 2osto2.
(ig. 450A6(1. M$PO cu )C6CBP n fractur subtrohanterian. 0A1 (ractur subtrohanterian
co/2e>@ 0B1 M$PO cu )C6CBP, as2ect 2osto2erator@ 0C,D1 as2ect a 4 un 2osto2, caus
inci2ient n focaru -e fractur 0i/agine -e faA :i 2rofi1@ 0#,(1 Consoi-area fracturii a = uni
2osto2 0i/agine -e faA :i 2rofi1
&n ca3 interesant constituie foosirea ntr6o fractur
subtrohanterian co/2e> a unei )C6CBtP in9ersat 0i/2antu ti2 DCS cu
2ac ung nefiin- -is2onibi n ace /o/ent1, iar 2acientu fiin-
2oitrau/ati3at, cu e3iuni biaterae ae /e/breor inferioare 0figura 45 A6
(1. De re/arcat c i-eea :i utii3area acestei CBtP in9ersate s6a reai3at
naintea a2ariAiei articouui ui Pr+ce PR 0<D1, care foose:te un )$SS
in9ersat ntr6o fractur etajat a fe/uruui 0subtrohanterian :i -iafi3ar1.
Restabilirea axului i rotaiei membrului inferior
Ainierea n 2an fronta s6a obAinut 2rin Btehnica cabuuiC 0E,4F,4D,
4G,4E,<5,<E1. Cu rotua orientat anterior, centru ca2uui fe/ura :i a
ge3nei au fost 9i3uai3ate fuorosco2ic :i /arcate 2e 2iee sau c?/2u
chirurgica. &n cabu -e eectrocauter a fost ntins ntre aceste -ou
2uncte, cu a/2ificatoru -e i/agine centrat 2e genunchi. ProiecAia cabuui
a -eter/inat -e3a>area n 9arus sau 9agus. Ainierea sagita s6a reai3at
foosin- i/aginea fuorosco2ic atera 0E,4E,<51 n ca3u fracturior cu
/icu trohanter intact, rotaAia /e/bruui a fost stabiit foosin- tehnica
Bse/nu for/ei /icuui trohanterC 0E,4E,<51. $/aginea /icuui trohanter a
/e/bruui e3at 0cu genunchiu n e>tensie :i rotua 2asat anterior1 este
co/2arat cu cea a /e/bruui controatera obAinut 2re6 sau intrao2erator,
n aceea:i 2o3iAie. Jn ca3u fracturior cu interesarea /icuui trohanter, a/
reai3at fi>area -ista a 2cii a -iafi3 /enAin?n- o rotaAie a 2icioruui -e
circa 476<5O 0ba3inu fiin- corect 2o3iAionat 2e /asa orto2e-ic1.
ngrijiri postoperatorii
Protocou 2osto2erator a incus ree-ucarea funcAiona ti2
Bcontinuous 2assi9e /otionS 0fig. 441 02entru 2re9enirea a-erenAeor1 :i
/obii3area fr s2rijin sau cu s2rijin 2arAia 0476<5 Ig1 2e /e/bru inferior
o2erat. S2rijinu tota a fost autori3at a a2ariAia ra-ioogic a causuui. )a
2acienAii 2oitrau/ati3aAi. ngrijirie 2osto2eratorii au fost a-a2tate n funcAie
-e e3iunie asociate. Nu s6au utii3at atee sau a2arate ghi2sate.
(ig. 44. Mobii3area 2e *ineteI a
unui 2acient cu fractur
subtrohanterian, o2erat 2rin
tehnica M$PO
!rmrirea postoperatorie
&nghiu cer9ico6-iafi3ar a fost /surat 2e inci-enAa -e faA a
ra-iografiior -e contro efectuate i/e-iat 2osto2erator :i -u2 consoi-are
04E1. AnguaAia atera a fost -eter/inat 2e inci-enAa -e 2rofi a
ra-iografiior -e contro, Ain?n- cont -e corticaee anterioar :i 2osterioar
ae fe/uruui 2ro>i/a 0E,4E,<5,<F1,
PacienAii au a9ut o ur/rire cinic :i ra-ioogic 2e o 2erioa- -e
/ini/ 4< uni 0/e-ie 4F,7 uni1.
Rezultate
Consoi-area fracturior 0-e/onstrat ra-iografie1 s6a obAinut -u2 un
inter9a /e-iu -e 45,< s2t/?ni 0cu i/ite G6<< s2t/?ni1, fr
necesitatea grefrii 2ri/are sau secun-are. S2rijinu tota a fost autori3at n
/e-ie a E,G s2t/?ni 0i/ite F6<5 s2t/?ni1. Nu s6au nregistrat infecAii,
nt?r3ieri n consoi-are, 2seu-artro3e sau -eteriorri i/2ortante ae
/ontajuui. &n 2acient necoo2erant, cu tuburri 2sihice, a c3ut
2osto2erator 2re3ent?n- ru2tura unor :uruburi -istae cu 9arus secun-ar n
focaru fractur 0s6a reinter9enit 2ractic?n-u6se nocuirea :uruburior 2us
cercaj a-iAiona -e siguranA :i corectarea 9arus6uui1. )a ce /ai recent
contro, unghiu cer9ico6-iafi3ar /e-iu a fost 4<7O, cu i/ite ntre 44D :i
4=;O 09aoarea nor/a /e-ie 4<FO T FO, cu i/ite ntre 44D 6 4;5O1@ 7
2acienAi au 2re3entat o -e3a>are n 9arusH9agus /ai /are -e 7O. &n
2acient cu o 9eche fractur su2racon-iian -e fe/ur, 9icios consoi-at, a
2re3entat o /arotaAie e>tern -e <5O. $negaitatea -e ungi/e a /e/breor
a fost n /e-ie 5,D c/ 0cu i/ite ntre 5 :i < c/1, < 2acienAi cu fracturi cu
co/inuAie se9er, 2re3ent?n- aungiri -e 2este 4,7 c/ iar aAi -oi scurtri
-e 2este 4,7 c/. (e>ia /e-ie a :o-uui a fost -e 457O 0cu i/ite ntre G5 :i
4<5O1 iar e>tensia /e-ie a fost 5O 0cu i/ite 5645O1.
Confor/ criteriior ui Neer 0<71, re3utatee funcAionae au fost
e>ceente n <; ca3uri 0figura F "6$1, satisfctoare n 4= ca3uri :i
nesatisfctoare ntr6un ca3.
"iscuii
(racturie subtrohanteriene ri-ic 2robe/e -ificie 2entru orice ti2 -e
fi>are intern 0=51. Aegerea i/2antuui -e2in-e -e ur/torii factori.
configuraAia fracturii, grosi/ea canauui /e-uar :i 2re3enAa ator i/2ante,
situaAia 2rAior /oi. 2oitrau/atis/ee :i scoru -e se9eritate a e3iunior 6
$njur+ Se9erit+ ScoreH$SS 041, e>2erienAa :i 2referinAee chirurgior,
-is2onibiitatea instru/enteor, i/2anteor :i a controuui fuorosco2ic
intrao2erator.
O /are 9arietate -e i/2ante intra/e-uare :i e>tra/e-uare fac
2arte -in arsenau tera2eutic a fi>rii interne n fracturie subtrohanteriene.
$n ca3u fracturior -eschise se9er conta/inate se utii3ea3 fi>area
e>tern@ aceasta este reco/an-at :i n ca3u 2oitrau/atis/eor gra9e
0$SS U ;51. cu con9ersie a fi>area intern n circa 46< s2t/?ni.
Osteosinte3a centro/e-uar cu focar nchis 2rotejea3
9ascuari3aAia frag/enteor fracturate /ai bine -ec?t osteosinte3a cu 2ci,
oferin- :i a9antaje bio/ecanice -eosebite 0;,4<1. #a este 2referat at?t n
osteo2oro3 c?t :i n for/aAiunie tu/orae /etastatice ae regiunii
subtrohanteriene 0;,4<,=51. $/2antarea corect a acestor siste/e
centro/e-euare n fracturie subtrohanteriene nu este si/2, fiin- -e
/ute ori subesti/at 0figura 4<1.
(ig.4<. (ractur subtrohanterian o2erat cu
tij ga//a ung. 'arus se/nificati9 n
focaru -e fractur
Deoarece frag/entu 2ro>i/a 2rinci2a este -e2asat n fe>ie, rotaAie
e>tern :i ab-ucAie, re-ucerea :i -eschi-erea o2ti/ a canauui /e-uar
este -ifici, necesit?n- uneori 2roce-uri a-iAionae 0:uruburi Schan3
foosite ca Bjo+ sticIsC, ce:ti -e re-ucere, cercaje -e s?r/1. Scurtarea :i
-e3a>rie n 9arus sunt -estu -e frec9ente 0;,=51. Kin?n- cont -e
anato/ia fracturii, ti2urie -e i/2ante centro/e-uare 04<1 foosite n
trata/entu acestor fracturi -ificie sunt. tijee centro/e-uare bocate
stan-ar-, tijee -e reconstrucAie 0ti2 Russe 6 !a+or sau tija AO ti2
B&nrea/e- (e/ora Nai ,ith s2ira ba-eC1 sau siste/ee Bstan-ar- sau
ong6shaft intra/e-uar+ hi2 scre,H$M"S 0tijee ga//a sau BPro>i/a
(e/ora NaiHP(N 6 un $M"S -e generaAia a $$6a care re2re3enta 2?n acu/
;67ani i/2antu AO -e 2ri/ aegere n fracturie subtrohanteriene1.
&nii autori au -e/onstrat c tijee ga//a nu asigur o bun fi>are n
fracturie subtrohanteriene nate sau n fracturie instabie cu e>tensie
trohanterian 0;,=51@ n ca3u tijeor scurte 2oate a2are fractura a 9?rfu
i/2antuui, co/2icaAie care nu se nt?ne:te n ca3u tijeor ungi e>tinse n
/etafi3 0441. Di/2otri9, n ca3u fracturior subtrohanteriene cu un
frag/ent 2ro>i/a intact :i /are, trata/entu cu tije bocate a -eter/inat
sc-erea frec9enAei co/2icaAiior 0<4,=5,=E1.
Noi ti2uri -e tije 0cu -esign :i conce2t ino9ator a fi>rii 2ro>i/ae1 :i
cu /o-ificri ae curburii tijei au /buntAit re3utatee n fracturie
subtrohanteriene . B the gi-ing naiS 0D1, tija trohanterian fe/ura cu
Bheica ba-eS 0G1 sau uti/a generaAie -e tije ga//a M Ga//a = 0=;1.
$n ti/2 ce anu/iAi 2acienAi -in seria noastr ar fi 2utut fi trataAi cu un
i/2ant centro/e-uar, /uAi -intre ei 2re3entau fracturi cu frag/ent
2ro>i/a /ic :i e>tensie trohanterian care ar fi fost -ifici -e re-us :i
stabii3at chiar cu o tij -e reconstrucAie sau $M"S -e a $$6a generaAie.
Desigur c n ca3u fi>rii e>tra/e-uare 0co/2arati9 cu cea
centro/e-uar1 s2rijinu tota nu este a-/is n totaitatea ca3urior ceea ce
re2re3int un -e3a9antaj /ai aes 2entru 2acienAii necoo2eranAi sau
9?rstnici 04<1. Cu toate acestea, a>area e>ceent -eter/inat -e 2asarea
corect a 2cior, /2reun cu e>2erienAa obAinut n G ani -e a2icare a
tehnicii M$PO n fracturie fe/uruui :i tibiei ne6au -eter/inat s 2refer/
aceast tehnic.
Jn stu-iu nostru, ca :i n ucrrior ator autori 04E,=51 M$PO a
-e/onstrat c este o tehnic uti n re3o9area fracturior co/2e>e
e>traarticuare ae fe/uruui 2ro>i/a@ ea co/2etea3 cu succes fi>area
bioogic cu /ijoace centro/e-uare 0re3er9at n-eosebi fracturior
-iafi3are1, fiin- 2robabi cea /ai bun aegere n ca3u unor -ifor/itAi
fe/urae sau i/2ante 2ree>istente 04E1.
$n ca-ru tehnicii M$PO, ainierea este asigurat -e 2ci, traiectu -e
fractur nu este abor-at 0Cuntouch techniVueC1, fi>area :i inserAia
:uruburior este i/itat nu/ai a frag/entee 2rinci2ae. $n ti/2 ce CBP
2oate fi utii3at cu succes, tehnica M$PO a fost si/2ificat 2rin foosirea
unui i/2ant n -ou 2rAi ti2 DCS. Acesta este si/iar ca -esign cu CBP,
-ar necesit 2asarea corect a :urubuui nu/ai n -ou 2anuri si/utan
0fronta :i ori3onta1, 2o3iAia 2cii 2ut?n- fi ajustat 2rin rotaAie n 2an
sagita 04E,=5,=<1. Prin utii3area siste/uui DCS n stu-iu nostru, /ri/ea
inci3iei 2entru inserAia 2cii este /ai /ic 0co/2arati9 cu CBP1, iar
tracAiunea /u:chior n ti/2u inserAiei a/ei n canau 2re2arat nu /ai este
necesar. (oosin- un instru/entar s2ecia :i /o-ificri ae ceui casic,
i/2antu ti2 DCS 2oate fi i/2antat ntr6o /anier 2ercutanat :i
sub/uscuar 04E1.
Desigur c a9antajee bio/ecanice incontestabie ae 2cior bocate
0=D1 au -us a reai3area unor i/2ante cu stabiitate anguar 02entru
trata/entu fracturior subtrohanteriene co/2e>e cu e>tensie trohanterian1
ti2 B)CP62ro>i/a fe/ora 2atesS :i Bfe/ora hooI 2atesS 09i-eo;1 cu
:uruburi bocate canuate s2eciae 0figura 4=, 4;, 471
Re3utatee obAinute n cee =G -e fracturi subtrohanteriene
-e/onstrea3 c 2roce-ura M$PO este sigur :i eficient. $ntro-ucerea
atent a 2cii 2e sub 9astu e>tern :i tracAiunie -in ti/2u inter9eAiei 02entru
conectarea 2cii DCS a :urub sau rotirea cu 4G5 gra-e a CBP1 nu au
-eter/inat co/2icaAii 9ascuare sau s?ngerri -atorate e3iunii
2erforanteor. De:i toate fracturie au consoi-at fr necesitatea grefrii
trebuie 2reci3at fa2tu c M$PO nu ei/in 2osibiitatea acesteia -ar re-uce
frec9enAa utii3rii ei co/2arati9 cu tehnicie tra-iAionae 0<E,=4,==1.
Re3utatee bune obAinute cu tehnica M$PO sunt -atorate at?t unei
consoi-ri ra2i-e 2rin conser9area 9ascuari3aAiei c?t :i a unei re3istenAe
crescute a 2cii a obosea 0BstresuC /ecanic care acAionea3 2e unitatea
-e su2rafaA a 2cii este cu at?t /ai sc3ut cu c?t 2orAiunea -e 2ac fr
:uruburi este /ai ung1. Circu/stanAee /ecanice care con-uc a
/buntAirea consoi-rii nu au fost i-entificate cu e>actitate. Oricu/, a/
Bn9AatC -in osteosinte3a centro/e-uar c un anu/it gra- -e instabiitate
fa9ori3ea3 consoi-area. Se 2are c fi>area cu 2ci ungi nu/ai a
frag/entee 2rinci2ae 2ro>i/ae :i -istae 0cu nu/eroase guri neutii3ate
2e o ungi/e a2reciabi a 2cii :i fr :uruburi n focar1 ar susAine
afir/aAia c aceste 2ci /enAin ni9eu B2erfectC -e instabiitate care -uce
a o consoi-are e>ceent 0<E,=5,=4,==1.
(ig.4=. )CP 2ro>i/a fe/ora 2ates.
Pro>i/a 2aca 2re3int < :uruburi -e D,= //
:i un a treiea -e 7 // care acAionea3 ca
su2ort 2entru 2ri/ee <. Jn 2ri/ee < guri
2ro>i/ae 2ot fi 2asate iniAia :uruburi
nebocante care 2ot fi utie n fi>area unei
fracturi subtrohanteriene asociat cu o
fractur -e co fe/ura sau cu o fractur n
2an sagita a /areui trohanter. Wuruburie
-istae 2ot fi nor/ae sau bocate.
0cu 2er/isiunea S+nthes1
(ig.4;. )CP (e/ora hooI 2ates
0cu 2er/isiunea S+nthes1
(ig.47. Wuruburi canuate bocate :i canuate
conice -e D,= // 0st?nga1 :i :uruburi
bocate :i canuate conice -e 7 // 0-rea2ta1
0cu 2er/isiunea S+nthes1
Jn concu3ie, consi-er/ c re3utatee stu-iuui nostru :i -atee -in
iteratur subinia3 a9antajee tehnicii M$PO n fracturie co/2e>e
subtrohanteriene co/2arati9 cu tehnicie tra-iAionae. consoi-are ra2i-
fr necesitatea grefrii. sc-erea frec9enAei co/2icaAiior. Probe/a
2rinci2a a acestei tehnici 2retenAioase o re2re3int -ificutatea restabiirii
intrao2eratorii a a>uui, rotaAiei :i ungi/ii fe/uruui.
Chiar -ac n uti/ii ani tehnica M$PO cu i/2ante casice ce-ea3
arii -e in-icaAii tot /ai argi 2cior /uate bocate sau tijeor bocate -e
uti/ generaAie, costurie /ari ae acestor i/2ante 2erfor/ante i/itea3
foosirea or -e rutin. Desigur c stu-ii ran-o/i3ate co/2arati9e 2e serii
/ari -e 2acienAi 0 M$PO cu 2ci bocate 9ersus osteosinte3
centro/e-uar bocat -e uti/ generaAie1 ar 2utea stabii cu /ai /ut
e>actitate rou actua a osteosinte3ei bioogice cu 2ci n fracturie
subtrohanteriene.
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47@
=;. !agang G. M !he o2erati9e techniVue for the ast generation Ga//a Nai 0!he Ga//a
=1 in )eung *.S., !agang G., Schneter R.0e-s1 M Practice of $ntra/e-uar+ )ocIe-
Nais, S2ringer Berin6"ei-eberg <55F, 4=56D
=7. !o/oia Gh., Soco !., Rogojan R. 6 Casificarea :i trata/entu fracturior
subtrohanteriene@ Re9ista -e Orto2e-ie :i !rau/atoogie 0Bucure:ti1, 4EEG. 9o. G,Nr. 46
<,F=6FG@
=F. 'ecsei 'i/os, "aj-u Stefan, )u> MoniIa, Resinger Christo2h 6 Subtrochanteric
fractures of the fe/ur, in #uro2ean $nstructiona Courses, <557, 9o.D, 4E6<7.
=D. Lagner M, (rigg R 0e-s1 AO Manua of fracture /anage/ent M $nterna (i>ators.
!hie/e Stuttgart 0<55F1
=G. Len-a *., RunIe M., Degreif P., Ru-ig ). 6 Mini/a+ in9asi9e 2ate fi>ation in fe/ora
shaft fractures@ $njur+, 4EED, 9oi. <G, Su22. No. 4, 4=64E.
=E. Liss D.A., (ening C.".. Matta P.M., CarI D. 6 Co//inute- an- rotationa+ unstabe
fractures of the fe/ur treate- ,ith an intererocIing nai. Cin. Ortho2. 4EGF,<4<,=76;D