Análise da exposição intraoperatória ao raio X e do tempo cirúrgico em diferentes técnicas de fixação das fraturas transtrocanterianas do fêmur

Resumo Objetivo Avaliar e comparar o tempo total do procedimento cirúrgico e a exposição ao raio X no intraoperatório em diferentes técnicas de fixação das fraturas transtrocanterianas do fêmur em pacientes idosos, utilizando técnicas extramedulares e intramedulares baseadas em parafuso de tração cefálico. Métodos Foram avaliados no serviço de ortopedia e traumatologia do nosso hospital 107 pacientes com fraturas transtrocanterianas, sendo 34 do sexo masculino e 73 do sexo feminino, com idade mínima de 61 anos e máxima de 101 anos. As fraturas fixadas, utilizando a técnica com dynamic hip system (DHS, na sigla em inglês) somaram 21 pacientes; em 55 pacientes, foi utilizado o proximal femur nail (PFN, na sigla em inglês) standard; e em 31 idosos, foi optado pelo uso do gama nail standard. Todos os procedimentos foram realizados pelo mesmo cirurgião acompanhado de sua equipe de auxiliares de enfermagem, assim como pelo mesmo técnico de radiologia manuseando o mesmo intensificador de imagens. Foram avaliados o tempo total da cirurgia (em minutos) e a emissão de raios X medida em centigrays. Resultados A fixação das fraturas transtrocanterianas com PFN proporciona um menor tempo cirúrgico com uma diferença estatística significativa (p = 0,013), quando comparada com as demais técnicas utilizadas entre os grupos envolvidos. Foi observada, também, uma menor exposição intraoperatória aos raios X (p = 0,015), a qual foi estatisticamente relevante quando utilizado o DHS como método de fixação comparado com o gama nail e o PFN. Conclusão Apesar do PFN ter o menor tempo de cirurgia, a técnica do DHS se mostrou com menores níveis de exposição dentro da amostra estudada.

Management of Subtrochanteric Femur Fracture Using Proximal Femoral Nail

Injuries to the femur, the longest bone in the body presents a challenging situationto the orthopedic surgeon. The proximal femoral intramedullary devices are useful for the treatmentof isolated pathological lesions in the subtrochanteric region. Biomechanically, the nail can withstandbetween 3to 5 times body weight. Hence the present study was planned to study the managementof these fractures with the proximal femoral nail. Materials and Methods: A total of 44 patientswith proximal femoral fractures of the subtrochanteric region admitted in the department wereincluded in the study. Patients age more than 25 years and diagnosed with subtrochanteric femurfracture were included in the study. Results: The age of the patients was more than 25 years. Therewere 34 males and 10 females included in the study. In the clinical evaluation as per the functionalGrading of the patient as per Kyle’s Criteria excellent and good results were considered satisfactory,whereas fair and poor results were considered unsatisfactory. In this series 92%, satisfactory resultswere obtained. Conclusion: Proximal femur nail (PFN) is an effective device in the management ofcomplex femoral fractures. The use of PFN in such fractures provides various advantages: Closedprocedure, Minimal soft tissue damage. It offers superior stabilization than other currently usedmethods of internal fixation. The use of PFN is technically demanding and needs expertise.Complications can be avoided by proper operative techniques. Early postoperative mobilization andphysiotherapy improve the results of PFN.

Fluoroscopy-assisted percutaneous guide wire puncture for the treatment of intertrochanteric fractures with proximal femur nail anti-rotation

Background: Accurate percutaneous guide wire insertion for the treatment of intertrochanteric fractures with proximal femur nail anti-rotation(PFNA) can be a technical challenge. It is critical for the surgeon to place the implant accurately during the procedure; however, the muscles and soft tissues in the hip often make accurate guide wire insertion difficult, especially in overweight and obese patients.Purposes: The purpose of this study was to evaluate a series of patients who underwent percutaneous guide wire puncture and PFNA fixation to determine the influence of this technique on soft-tissue trauma and accuracy of guide wire placement.Methods: From June 2015 to June 2018,forty-five consecutive patients with a minimally displaced or displaced intertrochanteric fracture were treated with percutaneous guide wire puncture technique and PFNA fixation in two trauma centers. Six patients were lost to follow-up. The remaining thirty-nine patients were followed until union or a minimum of twelve months. There were thirty female and fifteen male patients with a mean age of 78.5 years old. Radiographs were used to evaluate the quality of fracture union. Intraoperative fluoroscopic views of the first puncture attempt were evaluated for the accuracy of percutaneous puncture technique.The number of puncture attempts used was recorded.Incision lengths of nail insertion were measured and recorded.Results: All fractures united. The length of the incisions ranged from 2.0 cm to 3.1 cm,with a mean of 2.5 cm.The angles between the guide wire and the axis of the proximal femur were within 3°in lateral fluoroscopic view,and ranged from 4°to 8°with a mean value of 6.3°in anteroposterior(AP) fluoroscopic views.The number of punctures in every patient were less than 2.Among forty-five patients, forty-three patients(95.6%) were punctured successfully with one pass. No complications were observed.Conclusions: Percutaneous guide wire puncture for the treatment of intertrochanteric fractures with PFNA fixation can lead to excellent outcomes, by virtue of accurate implant placement, less trauma,and fewer complications.Level of Evidence: Therapeutic level IV