160ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000 - PDF document

160ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000 A HASTE BLOQUEADA“FACULDADE DE MEDICINA DE RIBEIRÃO PRETO”experiência clínica no tratamento das fraturas femoraisfêmur foram tratadas com a haste intramedular bloqueada FMRP,diminuição da permanência hospitalar, excetuando os103 fractures, 67 were cominutive, 12 bifocal (segmental), 4 spiral, 13proximal e 21 distal and unstable rotationaly. From the total of cases,dynamised during evolution. Clinical and radiographic union hadcases with suspected and 3 with established infection that werethat varied from 0.5 centimeter to 4 centimeters with an average of 1.0centimeter. The shortening of less than and equal 2 centimeterswas high. The fracture stabilization had immediately allowed patient’smobilization, early rehabilitation and decreasing hospital stay, exceptin politrauma cases. The FMRP nail had allowed treating these kindoutcomes were matching to those reported with intramedullaryRIBEIRÃO PRETO SCHOOL OF MEDICINE LOCKING NAIL:Clinical Experience in the Femoral Fractures Treatment; CPós-Graduando do Deptº de Cirurgia, Ortopedia e Traumatologia, Faculdade de Medicina de Ribeirão Preto-USPProfessor Titular do Deptº de Cirurgia, Ortopedia e Traumatologia, Faculdade de Medicina de Ribeirão Preto-USP ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000161 processos de travamento de haste intramedular, combinada a focofechado e com a inserção de parafusos que travam o osso à com o uso de haste bloqueadade aplicação, quando 103 cirurgias foram realizadas, e foramem um hospital universitário, onde foi desenvolvida a haste FMRP.conversion for dynamic lock, when necessary.applied to other fractures, where type and localization hinder the use using the locking nail and due to high cost andosteosyntheses were carried out by the author, by orthopedists ofintensifier, special (orthopedic) table, and flexible reamers.CASUISTIC AND METHODSinplants and the instruments used in the investigation are presented.From May, 1987 to December, 1995, 111 pacientes were operated 162ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000 FMRP, no Hospital das Clínicas da Faculdade de Medicina de Das 103 fraturascasos bilaterais. Destes pacientes, 77 eram do sexo masculino e 24 6 (5,50%)pertenciam ao grau I; 9 (8,26%) ao grau II. O grau de cominuiçãoassociadas. Todos foram operados sendo utilizado no tratamento diagrama dofêmur, conforme se(28,16%) e a indicação Arbeitsgemeinschaft für Osteosyntesefragen/ Association for the Study of Internal Fixation). patients with 124 diaphyseal femoral fractures. However, among the classification, 6 (5.50%)To classify the 103 fractures, a AO/ASF group classification femurin 12 (10.26%) because they were segmentar, and in 4 (3.42%) Figura 1 - Classificação das fraturas diafisárias do fêmur deacordo com classificação da AO (23) ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000163 foram operados com a haste intramedular, cuja característica era ainclinação de 60°, e dez distais, que permitem um grau de liberdadedos parafusos de 60° ao longo da fenda da haste e do seu plano dehaste clássica de Küntscher.AO/ASIF, 4,5 mm, para o emprego da implantação da haste bloqueadaFMRP.O bloqueio proximal é realizado inserindo-se dois parafusosguia proximal, o qual orienta o local onde deve ser feito um orifíciona córtex lateral do fêmur, na altura de um dos furos mais distais dadentro do canal medular. Observando-se a haste dentro do canal ecortical lateral do fêmur. inclination, and ten distalholes, giving a freedom degree of 60 for the screws along the grooveof the nail and its plan of symmetry, allowing orientation through theholes in a convergent or divergent direction and, thus, locking the nailin their final 16 mm.at the bottom of the created defect, permits localization of the nailposition of the proximal guide connected to the nail, a perforation ofis placed. The bone cylinder is then placed in its original place, usinga screw that passes through it, through the nail and the medial corticalIn 41 patients, 1.2 mm wall thick nails and in 62 patients, 2.0 mmB) and C) nail proximal and distal portions, respectively, facesrespectively, faces of the femur lateral cortical. 164ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000 do membro inferior. Encorajou-se o paciente a deambular comandador permitindo-se carga parcial de até 20 quilos, medidos emforam submetidos a exame clínico seguido de radiografia. Aavaliação de todos os casos foi feita pessoalmente pelo autor,Todos os pacientes foram acompanhados até à consolidaçãoamplitude articular. Estabeleceu-se como critério radiográfico aThe pacientes operated on with the FMRP locking nail were dividedaccording to pre- and post-operatory care.region. In all cases, the so-called antitelescopable locking nail was used.After surgery, sutures were removed by the 15 day. Load on the to avoid adherence of the quadriceps inposition during almost all the first week, leaving it only for physiotherapy,which was instituted in the fourth day, with isometric contractions ofThe patients were re-evaluated at least 12 months after surgery, inthe orthopedics ambulatory, “Hospital das Clínicas”, Ribeirão Pretoauthor, observing the Thöresen criteriaTo evaluate the fracture consolidation, clinical criteria as absencesurgery, after four weeks, after eight weeks and at periodic intervalsmonths after surgery. Follow-up was effected in the ambulatory usingrelation to complaints, in particular local pain; mobility of the hip and method, shown inTable 1.

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\r\b\t\t\f\t\b"#\t\t\t\f\b\t\n\f\r!\b\t$\b\b\f\r!\f#\t\t\t\f\r\b\b\t\f\t\b"#\t\f\t\n \t\t\f\r&B\b3D\b\f\b!\b\n\b#\t#\t\t\f\t\b"#\t\t\f\b\t\t\b\n\f"\b\t\t\f\r\t\f\t\t\t\b\r\b!8\f\b\b\t$+\b\n\t$#\t\b\t\f\t\b"#\t3B\b\f\b\b\n\b#\t
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\n\b\f\r\n\t\t\f\b\tE\r\t\b\r\b\t\t\b\t\t\f\r\b\b\r\b\bE$\b\t\b*\f#\t\b\t\f\t&'\f\r \r\t!\t"\b\f\t\t$\t\b\b\b\n\t\f\r\b\t\r\t1\f\r\b\t\f\t\f\b\t\t84+\b\b\r\b\b\r\b\f\b\t\b\f#\t\f\b\b\t$E\r\t\t \f\t!\b\f\t\b\t=5\f"#\t\t\t\t\t\b\t\t\r\t1\f\r\b\tF\t\b\b\r\b\t Desalinhamento (graus) Excelente Bom Regular Mau Varo/Valgo
5
10
�10 Ante ou Recurvato
10
15
�15 Rotação/ Interna
10
15
�15 Rotação/Externa 10

15
20
�15 Encurtamento (cm)  1  2  3 �3 Flexão Joelho �120 120
90
0 Deficit Extensão/Joelho  5
10
15
15
Dor nenhuma leve moderada intensa 4\f\b$5*\f\f\f\f\f\f\r\r\f\f\r
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\n\f\r\f\f\n\f\f\r\n\r\t\n$\f\b\n\f\r\n\f!\n �1�R�Q � �D�O�L�J�Q�P�H�Q�W � �G�H�J�U�H�H�V�\f � �(�[�F�H�O�O�H�Q�W � �*�R�R�G � �5�H�J�X�O�D�U � �%�D�G � �9�D�U�X�V � �Y �D�O�J�X�V � �� �q � � �q � �� �q � �!�� �q � �$�Q�W�H��R�U��U�H�F�X�U�Y�H�G � �� �q � �� �q � �� �q � �!�� �q � �5�R�W�D�W�L�R�Q��,�Q�W�H�U�Q�D�O � �� �q � �� �q � �� �q � �!�� �q � �5�R�W�D�W�L�R�Q��H�[�W�H�U�Q�D�O � �� �q �q � �� �q � �� �q � �!�� � �6�K�R�U�W�H�Q�L�Q�J���F�P�\f � �d �� � �d �� � �d �� � �!� � �.�Q�H�H��I�O�H�[�X�U�H � �!��� �q � ��� �q � �� �q � ��� �q � �(�[�W�H�Q�V�L�R�Q��'�H�I�L�F�L�W��.�Q�H�H � �d �� �q � �d �� �q � �d �� � �d �� �q � �3�D�L�Q � �1 �R�P�H � �0 �L�O�G � �0 �R�G�H�U�D�W�H � �L�Q�W�H�Q�V�H � �� �7�D�E�O�H����²��0�H�W�K�R�G��W�R��H�Y�D�O�X�D�W�H��F�R�Q�V�R�O�L�G�D�W�H�G��I�U�D�F�W�X�U�H�V�)�R�Q�W�H���7�+�g�5�(�6�(�1� 166ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000 os afastadores de Hohmann e na junção do colo com o trocânter.protetor de partes moles especial para este fim. Apenas o fragmentohomolateral, fazendo contratração na espinha ilíaca ântero-superior,como se estivesse fazendo teste da gaveta anterior. O fio guia éda abertura do canal distal.A seguir, realiza-se a impactação do fio no osso esponjosoa ponta do segundo fio na ponta do trôcanter maior. O restante docabo do batedor. A haste deve ser introduzida delicadamente atérotação de 90° a 180° na haste com o cabo do batedor podeapós a remoção do fio guia. Neste ponto, a haste deve ter sua as aiding element of reduction. Success in thesedistal metaphysis spongy bone. On the contrary, if it is out of thedistal canal, the progression stop is relatively “soft” and usually thewire protui in the skin., following rombadissection until the focus through the lateral vastus. Using one of theother has penetrated, placing it externally, side by side with the first.second wire is placed in the tip of the greater trochanter. The lenght ofguarantee that the canal has at least 12 mm in straight line and that theThe chosen nail is articulated in a special batedor and it is introduced to 180 rotation in the nail using the batedorThe batedor is disarticulated and the proximal guide is connectedproximal guide touches the tip of the trochanter. It is very important todiaphysis. To avoid this, support is given (campos dobrados) to thewith a special measurer. The proximal guide must not be withdrawn. ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000167 abertura longitudinal voltada para a cortical lateral do fêmur.guia proximal toque a ponta do trocânter. É muito importante manter(campos dobrados) sob a face medial da coxa, antes de encravarguia proximal, enquanto a tração é mantida.pelo parafuso, não havendo mais tendência a encurtamento.parafuso proximal, só que, na hora de sua colocação, introduz-sehaste, observando-se a calibração existente no guia distal.O guia distal é novamente articulado no proximal. O protetor deremovido. A seguir, fixa-se a peça centralizadora da trefina especialnipper and traction can be then liberated, since the nail is firm in thedistal spongy bone and proximally fixed by the screw, with no moreThe same steps are followed to place the second proximal screw,however, in the moment it will be placed, the interconnection elementThe distal guide is articulated in the proximal guide. Two marks areof the thigh distal part, from one mark on the skin to the other. The is opened aligned with the incision and the lateral vastus isOcasionally, it is necessary to cauterize the superior genicularvessels. Afastadores de Hohman are placed, exposing the lateralface of the distal femur.protector.is removed. Afterwards, the special trefina centralizing piece is fixedand screwed in the perforation. With the machine, a “bone cork” (1.5cm diameter cylinder) is then sawed using the trefina. Then, the spongycortical distal bone cylinder is removed through the trefina guideOcasionally, additional curettage is needed at the bottom of thenail inside the femur.When the nail is visualized after remotion of the “bone cork” in theproximally, inclined in relation to the nail long axle, and through one ofresultant flaw. Using an adequate sized screw, the “cork” is againan adequate sized screw.the mini-incision.proximal and distal wounds. The drains remain 24 hours. 168ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000 visualização da haste do interior do fêmur.possível visualizar a porção proximal em AP, o foco fraturário e oRESULTADOSFigura 3 - Fratura cominutiva diafisária 1/3 médio do fêmur, em paciente de 31 anos de idade e acidente automobilístico;In this study, the average time for the surgical procedure wasapproximately 72±43 minutes (minimum 47, maximum 169).RESULTSconsolidation in 7 cases of delay.from 11 to 20 weeks. However, 21 and 26 fractures demanded,respectively, more than 20 weeks and less than 11 weeks, the48 weeks, on average 16.72. Figure 3 shows the evolution of 1 caseFigure 3 – Diaphyseal comminutive fracture 1/3 median of the femur, in a patient aged 31 years, victim of car accident;surgery, presence of callus evidenced; D) one year and four days after surgery with consolidated fracture. ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000169 observou-se que o resultado geral da pesquisaEm se tratando de dor, 55 (53,4%) não tinham dor alguma;Com relação ao uso do membro inferior, 80 (77,7%) tinham it wasexcellent, 15 (14.6%) good, 3 (2.9%) regular, 1 (0.97%) bad, and 3was 1.00 ± 0.99 cm (minimum 0.5 and maximum 4.0). This occurredHowever, 23 patients presented less than 0.6 cm and other 23 moreTechnical errors were observed intra-operatively.Concerning the reduction quality, only 19 (14.71%) did not presentany deviation; 81 (61.76%) presented shortening; 4 (2.94%) were 170ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000 6º (máximo de 10º). Três destes ocorreram no 1/3 proximal33 dias após o acidente e outro fratura do 1/3 distal e 10Quanto à mobilidade do joelho, 93 casos não apresentaramlimitação da flexo-extensão, enquanto 7 casos tiveram(6,8%) suspeitas e 3 (2,91%) estabelecidas. Tanto umameses de evolução com a haste, ao fazer-se a retirada daindicado como opção de tratamento fixador externo. and 3 equal to 10; 4 varus on average 7). In 2 cases in the femur distal 1/3; one in the proximal1/3 and 2 in the middle 1/3 of the diaphysis; 4 (3.68%) varus one less (maximum 15 in only one case); 7 externaltorsions, and 3 internal torsions (more than one option). Varism wasfound in 4, valgism in 4 patients, and 5 antecurvatus in one patient. to 10 and 0 to 40 Only one case presented flexuretreated with drainage, débridement, continuous irrigation andafter 12 months, when the nail was withdrawn and surgical cleaningas the option.Late complications were: in 7 (6.7%) cases, rupture and bendingfall and a second motorcycle accident; 8 (7.77%) cases, rupture or ACTA ORTOP BRAS 8(4) - OUT/DEZ, 2000171 evolução para consolidação sem necessidade de troca; em 6 (4,59%) foi necessário reosteossíntese por motivo da quebrae vergamento da haste e parafusos. Também houve 12 casos de parafusos fora do furo, mas não trouxeram nenhumaFigura 4 - Fratura cominutiva do 1/3 distal do fêmur em paciente de 29 anos de idade, vítima de acidente; A) Pré- operatório;B) pós- operatório de 4 semanas; C) 8 semanas de pós- operatório mostra formação de calo ósseo; D) 28 semanas se observa sinaiFratura do 1/3 distal do fêmur em paciente de 19 anos de idade, vítima de acidente; A) Pré- operatório; B) Pós-operatório Figure 4 – Comminutive fracture of the femur distal 1/3 in a 29 year-old patient victim of accident; A) pre-operatory; B) 4 weeks post-surgery;Figure 5 – Femur distal 1/3 fracture in a 19 year-old patient victim of accident; A) pre-operatory; B) immediate post-operatory