Intramedullaire osteosynthese van het femur

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Intramedullaire osteosynthese van het femur

Citation for published version (APA):

Stapert, J. W. J. L. (1983). Intramedullaire osteosynthese van het femur. Rijksuniversiteit Limburg.

https://doi.org/10.26481/dis.19830916js

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Published: 01/01/1983

DOI:

10.26481/dis.19830916js

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k z e s t u d i e h e e f t a l s doe1 d e u a a r d e a a n t e geven v a n d e i n t r a m e d z e l l a i r e o s t e o s y n t h e s e b i j d e b e h a n d e l i n g v a n femurschachtf r a c t u r a n . Een z o r g v u l - d i g e a n a l y s e van d e i n d i c a t i e s t e l l i n g e n b e h a n d e P i n g s r e s f i l t a t e n v a n 139 b e h a n d e l d e p a t i g a t e n met 1 4 3 f e m u r s c h e c h t f r a c t u r e n , I n een p e r i o d e van t l e n j a a r , h e e f t g e l e i d t o t p r o t o c o l l a i r g c n e e s k u n d i g e a n n b e v e l i n g e n voor d e b e h a n d e l i n g van p a t i k i n t e n met een f e m u r s c h a r h t f r a c t u u r .

I n h o o f d s t u k 2 wordt e e n e v e r z i c h t gegeven van d e h i s t o r l e van d e o p e r a - t i e v e en n f e t o p e r a t i e v e b e h a n d e l i n g v a n f e r m u r s c h a c h t f r a c t u r e n .

I n h o o f d s t u k 3 wordt d e a n a t o n i e v a n h e t bovenbeen besproken. De femur- s c h a c h t wordt g e d e f i n i z e r d a l s d a t d e e l v a n h e t femur, d a t g e l e g e n i s t u s s e n d e o n d e r b e g r e n z i n g wan d e t t o c h a n t e r minor en e e n l i j n g e t r o k k e n l o o d r e c h t op d e l e n g t e - a s van h e t femur, 6 cm boven h e t kncniegeuricht.

I n h o o f d s t u k 4 wordt i n g e g a a n op d e v e r s c h i l l e n d e t h e o r i e s n o v e r botaan- maak. De i n v l o e d v a n opboren wan rle m e r g h o l t e , h e t a a n b r e n g e n van c e r e l a - g e d r a d e n en d e mechanische s t a b d l i t e b t op da bataanmaak worden b e s p r o k e n . Een t o e l i c h t i n g wordt gegeven op d e w i j z e waarop b i j g s b r u b k vat1 d e K h t - s c h e r p e n , d s Kaessmannpen en d e Kaessmannpen i n c o m b i n a t i e n e t c e r c l o g e , m e c h a n i s c h e s t a b i l i t e i t wordt b e r e i k t .

I n h o o f d s t u k 5 wordt d e i n d i c a t i e s t e l l i n g t o t , d e t e c h n i e k van d e d r l e t y p e n i n t r a m e d u l l a i r e o s t e o s y n t h e s e , e v e n a l e d e n a b e h a n d e l i n g b e s c h r e v e n . De i n d i c a t i e s t e l l i n g wordt g e s y s t e m a t i s e r r d door i n v o e r i n g v a n h e t b e g r i p p o t e n t i z l e i s t h m u s . Be p o t e n t i s l e i s t h u s i s d a t deeE v a n de f e m u r s c h a c h t , v a a r n a opboren van d e m e r g h o l t e voldoende s t e v i g c o r t i c a a l b o t o v e r b l i j f t om met e l a s t i s c h e inklemming v a n een Kiintscherpen s t a b i l i t e f t t e k r i j g e n .

& l l e e n b i j dwarse e n k o r t e s c h u i n e f r a c t u r e n i n deze p o t e n t i g l e i s t h m u s , i s met e e n Ktintscherpen voldoende s t a b i l i t e i t t e v e r k r i j g e n . F r a c t u r e n d i e n i e t a a n d e z e voarwaarden v o l d o e n , moeten met e e n a n d e r e o p a r a t i e t e c h n i e k b e h a n d e l d worden. In M a a s t r i c h t worden h i e s v o o r d e Kaessrnannpen e n d e ffiessmannpen i n c o m b i n a t i e met c e r c l a g e g e b r u i k t .

Het t i j d s t i p van d e o p e r a t i e d s a f h a n k e l f j k v a n d e b e g e l e i d e n d e l e t s e l s en d e t o e s t a n d van d e weke d r l e n . H u l t i t r a u m a p a t f e n t e n e n p a t f z n t e n met een e r n s t i g weke d e l e n l e t s e l worden a c u u t g e o p e r e e r d . Om dp? vuscul a r i s a L l e van h e t g e f r a c i u r e e r d e b o t te l a t e n h e r s t e l l e n , wordcn p a t i g n t e n met ge- s l o t e n g e i s o l e e r d e 2 e t s e l s i n p r i n c i p e na t i e n dagen g e o p e r e e r d .

I n h o o f d s t u k 6 wosden b e g e l e i d e n d e l e t s e l s i n g e d e a l d , waarbY.j g e b r u i k wordt gcmaakt v a n d e I n j u r y S e v e r i t y Scare ( I . S . S . ) . Gebruik makend van d e z e I.S.S. kunnen p a t l E n t a n a f l i a n k e l t j k van d e e r n s r van h e t trnunza, i n c a t e g o r i e g n worden i n g e d e e l d . Van d e b e s t u d e e r d e p a t i e n t e n h e e f t 27% a l e e n i g L e r s e l e e n f e m u r s c h a c h t f r a c t w u r .

I n h o o f d s t u k 7 wordt e e n a n a l y s e gegeven van h e t p a t l z n t e n b e s t a n d . De ge- m i d d e l d e l e e f t i j d v a n 101 iuannen e n 38 vrouwen b e d r a a g t 3 3 , s j a a r . BiJ 7,9% wan d e p a t i e n t e n komen p r e - e x i s t e n t e z i e k t e n v o a r . Een v e r k e c r s o n g e - v a l i s i n 81% v a n d e g e v a l l e n d e o o r z a a k v a n d e f e m u r s c h a c l ~ t f r a c t u u r . Het i n t e r v a l t u s s e n o n g e v a l e n na-onderzoek b e d s a a g t gemiddeld 5 , 5 j a a r . Mct e e n Kiintscherpen z i j n 80 f r a c t u r e n , 3 2 f r a c t u r e n met een k e s e m a n n p e n en,

31 f r a c t u r e n met Kaessmannpen e n c e r c l a g e behandeld. De opnainedvur be- d r a a g : gemfddeld 6 3 dagen. De t i j d s d u u r t o t r8negenologiftclie conaoll.de t i e b e d r a a g t v o o r d e KGntschergroep 1&,9 u e k s n , voos d e 3taes8noanngroep 19,6

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weken e n woar d e b e s m a n n l c e s c l a g e g r o e p 1 2 , l weken ( t a b e l 22).

E r n s t i g e c o m p l i c a t i e r ~ , s o a r s i n f e c t i e , g e s t o o r d e c o n s o l i d a t i e en e r n s t i g v e r l i e s v a n f u n c t i e b m e n s l e c h t s b i j 7 % van d e p a t i g a t e n .roo+. Toch maakt ihet merendeel van d e p a t i z n t r n ( 7 3 2 ) minder b e l a n g r i j k e c o m p l i c a t i e s d o o r 0 5 h o d t gerknge k l a c h t e n ( t a b e l l r 4 ) .

SZechta 27% van be p a t i z n t a n h e e f t h e t g e n e s i n g s p r o c e s v a n e e n femur- e c h a c h t f r a c t u u r d o o r g a e a k t zonder c o m p l k c a t i e s of b l i j v e n d e k l a c h t e n . B i j d e a n a t o m i s c h e a f w i j k i n g e n v o m t de r o t a t i e d e f o w i t e l t , d i e bij 4 7 % van d e p e t i l n t e n wordt gevondcn, h e r g r o o t s t e probleem.

I n h o o f d s t u k 8 wordt e e n o v e r z i c h t gegeven van d e b e h a n d e l i n g s r e s u l t a t e n van 25 p a t l z n t e n d i e n i e t o p e r a t i e f z l j n behandeld. 14 P a t i z n t e n z i j n con- s e r v a t i e f behandeld met d r a a d e x t e n s i e op Braunse s l e d e , e l f p a t f E n t e n z i j n vaoeg f u n c t i o n e e l b e b n d e l d met P e r k i n s t r a c t i e e n "'thigh l a c e r " . De opoaareduur b e d r a a g t v o o r d e c o n s e s v a t i e f behandelde p a t i s m t e n gemiddeld 87 d a g e n , voor d e mat P e r k i n s t r a c t i e behendelde p a t i i n t e n 56 dagen. Gemiddeld v e r l a p e n 18,7 wekcn t o t a 8 n t g e n o l o g i s c h e c o n s o l i d a t i e i n d e r o n s e r v a t l e f behandelde g r a e p e n L3,4 weken b i j d e met P e r k i n s t r a c t i e behandelde par4Znten ( t a b e l 4 7 ) .

B i j d e c o m p l i c a t i a d van d e n i e t o p e r a t i e f behandelde p a t i g n t e n w r d t 66n p a t i g n t g e a i e n met e e n d i e p e i n f e c t i e , t e r w i j l i n h e t t o t a a l v i e r p a t i s n - t e n e e n r e f r a c t u u r hebben opgelopen. Een c o r r i g e r e n d e o s t e o t o r n i e w a s a c h t e r a f n o o d z a k e l i j k h i 3 twee p a t i E n t e n u i t d e c o n s e r v a t i e f behandelde g r o e p e n b i J &En p a t i s n t u i t d e met P e r k i n s t r a c t i e behandelde g r o e p ( t a b c l 53).

I n h o o f d s t u k 9 warden d e voor- e n n a d e l e n van d e t o e g e p a s t e b e h a n d e l i n g s - mcthoden van p a t i h t e n m e t f e m u r s c h a c h t f r a c t u r e n , besproken. Een t o e l i c h - t i n g wordt gegeven o v e r h e t voorkomen van problemen met b e g e l e i d e n d e l e t s e l s , p r e - e x f s h e n t e z i e k t e n , G n d i c a t i e a t e l l i n g , p r e - o p e r a t i e v e voorbe- r e i d i n g , o p e r a t i e t e c h n i e k e n n a b e h a n d e l i n g .

I n h o o f d s t u k 10 wordt v o o r u i t l o p e n d op p r o s p e c t i e f onderzoek e e n v e r a n t - woording a f g e l e g d vooot d e o p s t e l l i n g van een b e h a n d e l i n g s p r o t o c o l , d a t v o o r d i t d o e 1 g e h a n t e e r d z a l wosden ( f i g u u r 2 2 ) .

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The i d e a b e h i n d t h i s s t u d y was t o a s s e s s t h e v a l u e O F i ~ l t r m e d d l a r y o s t e o s g n t h e s i s i n t h e t r e a t m e n t o f f e m o r a l s h a f t f r a c t u r e s .

A c a r e f u l a n a l y s i s of t h e i n d i c a t i o n s f o r o s t e o s y m t h e s i s and t h e r e s u l t s o f t h e t r e a t m e n t of 139 p a t i e n t s w i t h 1 4 3 f r a c t u r e s , w i t h i n a p e r i o d of t e n y e a r s , l e d t o f o r m a l m e d i c a l recommendations f o r t h e t r e a t m e n t o f p a t i e n t s w i t h f r a c t u r e s of t h e f e m o r a l s h a f t .

I n c h a p t e r 2 , a b r i e f r e v i e w i s g i v e n of t h e h i s t o r y of o p e r a t i v e a n d n a n - o p e r a t i v e t r e a t m e n t of t h e f e m o r a l s h a f t f r a c t u r e .

I n c h a p t e r 3 , t h e anatomy of t h e femur i s d i s c u s s e d . The f e m o r a l s h a f t i s d e f i n e d a s t h e segment of t h e femur which i s s i t u a k e d between t h e lower l i m i t a t i o n of t h e t r o c h a n t e r minor and a l i n e r u l e d p e r p e n d l c u l a r an t h e l o n g i t u d e 3 x 1 5 , 6 C ~ Sabove t h e k n e e - j o i n t .

I n c h a p t e r 4 , d i f f e r e n t t h e o r i e s of bone formation a r e d i s c u s s e d . The i n - f l u e n c e of reaming of t h e m e d u l l a r y c a v i t y , t h e u s e of e n c i r c l i n g w i r e l o o p s f o r t h e f i x a t i o n of bone f r a g m e n t s and of m e c h a n i c a l s t a b i P i L y on new bone f o r m a t i o n i s d i s c u s s e d .

Tkra way i n which m e c h a n i c a l stability i s a c h i e v e d by u s i n g t h e Klintscher- n a i l , t h e Kaessrnannnail and t h e Kaessmanna~ail i n c o m b i n a t i o n w i t h e n c i r - c l i n g w i r e l o o p s i s e x p l a i n e d .

I n c h a p t e r 5 , t h e i n d i c a t i o n s f o r o p e r a t i o n , t h e t e c h n i q u e of t h e t h r e e t y p e s o f i n t r a m e d u l l a r y o s t e o s y n t h e s i s , n s w e l l a s t h e follow-up treatment.

a r e d e s c r i b e d . The c h o i c e of method f o r i n t r a m e d u l l a r y f i x a t i o n i s d e l i n e d b y a d d i n g t h e c o n c e p t " p o t e n t i a l isthmus".

The p o t e n t i a l i s t h m u s i s d e f i n e d a s t h e seglnclit of t h e femoral s h a f t w h e r e , a f t e r reaming of t h e m e d u l l a r y c a v i t y , s u f f i c l e n t s t r o n g c o r t i c a l bone r e m a i n s t o a c h i e v e s t a b i l i t y by e l a s t i c impingement of a RGntschet- n a i l . Only i n t r a n s v e r s e o r s h o r t o b l i q u e f r a c t u r e s l o c a t e d i n t h i s poten- t i a l i s t h m u s , s u f f i c i e n t s t a b i l i t y i s a c h i e v e d w i t h a K i i n t s c h e r n a i l . For f r a c t u r e s n o t w i t h i n t h e l i m i t of t h e p o t e n t i a l i s t l m u s , a d i f f e r e n t method of o s t e o s y n t h e s i s has t o be used. In t h e s e c a s e s t h e Kaessmaimall a n d t h e Kaessmannnail i n c o m b i n a t i o n w i t h e n c i r c l i n g w i r e l o o p s a r e used i n X i a s t r i c h t .

The, moment of o p e r a t i o n Ps dependent on t h e a a s o c i a t c d i n j u r i e s and t h e f i o f t t i s s u e damage.

Multi-trauma p a t i e n t s and p a t i e n t s w i t h s e r l r r u s ? o f L t i s s u e damage arc?

o p e r a t e d upon a c u t e l y . I n p a t i e n t s w i t h i s o l a t e d t n j r ~ r i c e t h e o s t e o s y n - t h e s i s i s d e l a y e d for t e n d a y s .

I n c h a p t e r 6 , t h e associated i n j u r t e s a r c d e s c r i b e d w i t h t h e ufic o f ithc I n j u r y S e v e r i t y S c o r e (1.5.5.). I n 2 7 p e r c e n t of t h e p a t i e n t a , t h e f e m o r a l s h a f t f r a c t u r e i s t h e i r o n l y i n j u r y .

I n c h a p t e r 7, a n a n a l y s i s i s g i v e n of t h e p a t i e n t s e x a a i n e d . ?'he a v e r a g e a g e i s 33.5 y e a r s . 38 Women and 101 men a r e d e s c r i b e d . Zn 7 . 9 p e r c e n t o f t h e p a t i e n t s , p r e - e x i s t i n g d i s e a s e s e x i s t . I n 8 1 p e r c e n t of t h e cacses, a t r a f f i c a c c i d e n t I s t h e c a u s e of t h e f e m o r a l s h a f t f r a c t u r e .

The a v e r a g e i n t e r v a l between a c c i d e n t and t h e e x a m i n a t i o n f o r f0110w-up amounts t o 6.5 y e a r s .

80 F r a c t u r e s were s t a b i l i z e d by means of a KGntschernaL1, 32 f s s c t u c e e by means of a h e s s m a n n n a i l , and 31 f r a c t u r e s were o p e r a t e d by means of a

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