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Mechanische Einflussfaktoren der Marknagelung auf die femorale Antetorsion

Optobiomechanische Messungen

Femoral nail osteosynthesis

Mechanical factors influencing the femoral antetorsion

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Zusammenfassung

Einleitung

Die Marknagelung ist ein Standardverfahren bei der Versorgung von Femurschaftfrakturen. Ein bisher ungelöstes Problem stellt die hohe Inzidenz der Torsionsfehler dar. Trotz dieser Kenntnis und intraoperativer Vorsicht scheint das Problem nur unbefriedigend gelöst zu sein. Ziel der Arbeit war, die mechanischen Einflüsse des Marknagels während und nach der Verriegelung bei Femurschaftfrakturen auf den femoralen Antetorsionswinkel zu evaluieren.

Material und Methoden

Zur Testung wurde ein mechanisches Gerät entwickelt, mit dem ein definiertes Drehmoment auf das distale Fragment ausgeübt werden konnte. Als optisches Messsystem für die Bestimmung des ATW wurde ein Navigationssystem verwendet. In der 1. Studie wurde der Einfluss der Verriegelung auf die Antetorsion ermittelt. Es erfolgten distale Verriegelungen nach konventioneller Methode (ohne Zielgerät) und unter Verwendung eines Navigationssystems. Die Bewegung des distalen Fragments (Antetorsion, AT) wurde mittels Navigation dokumentiert. In der 2. Studie wurde der Einfluss der Rotationsinstabilität auf die AT nach mechanischer Belastung <4 Nm ermittelt. Dazu wurde die Restrotation des distalen Femurfragments (AT) unter Belastung bestimmt.

Ergebnisse

Die durchschnittliche Restrotation des distalen Fragments um den Nagel betrug bei der konventionellen Freihandbohrung 5,8°. Bei der navigierten Verriegelung resultierte eine Restrotation um durchschnittlich 2°, mit einem signifikanten Unterschied gegenüber der konventionellen Freihandbohrung. Testungen der Rotationsinstabilität unter Belastung zeigten eine Restrotation von durchschnittlich 15,7° des distalen Fragments. Auch nach komplett statischer Verriegelung des Nagels verblieb eine Restrotation von durchschnittlich 14,2°.

Diskussion

Es gelang der Nachweis, dass sowohl die mechanische Stabilität des Nagels als auch der Verriegelungsvorgang an sich einen relevanten Einfluss auf die femorale AT haben. Potentielle klinische Fehlerquellen zur korrekten Einstellung der femoralen AT ergeben sich demnach bei der Verriegelung selbst sowie bei forcierter Rotation des Beins nach Marknagelosteosynthese. In der Summation aller potentiellen Fehlerquellen bei der Marknagelosteosynthese können diese einen essentiellen Einfluss haben.

Abstract

Introduction

Antegrade or retrograde intramedullary nailing is a common and well established procedure for the treatment of femoral shaft fractures. One drawback of this technique is the high incidence of clinically relevant malalignment. Despite intra-operative and radiological improvements this problem has not yet been solved efficiently. The aim of this study was the evaluation of the mechanical influence on the antetorsion angle of intramedullary nails during and after interlocking in femoral shaft fractures.

Material and methods

A mechanical instrument was developed allowing a defined torque to be administered to the distal femur fragment. As an optical measurement system for the assessment of the antetorsion angle, a navigation system was applied. Initially the influence of the interlocking mechanism of the nail on the antetorsion deviation was investigated. The distal interlocking hole was fixed free handed or by using a navigation system. The multidirectional movement of the distal femur fragment was documented. Furthermore, the influence of the rotational stability on the antetorsion angle after mechanical stress of 4 NM was investigated by measuring the remainding rotational capacity of the distal femur fragment.

Results

The average remaining rotational capacity of the distal femur fragment was 5.8° after locking the nail by hand. The navigated locking resulted in a deviation of only 2°, a significant difference compared to the free-hand procedure. The rotational stability under stress showed an average of 15.4° deviation of the distal fragment. Even after complete interlocking of the intramedularry nail a 14.2° rotational deviation was observed.

Discussion

It could be shown that mechanical stability as well as the interlocking itself of femoral nails have a relevant impact on the antetorsional angle of the femur. Potential sources of error of the femoral antetorsion angle can be caused by the interlocking process as well as by forced rotation of the femur after interlocking. Clinical studies are needed to improve our findings, while the observed effects might have an essential influence on the incidence of femoral malalignment after osteosynthesis by intramedullary nailing of the femur.

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Authors and Affiliations

  1. Unfallchirurgische Klinik, Medizinische Hochschule, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland

    M. Citak, D. Kendoff, M. Citak, M. Oszwald, C. Krettek & T. Hüfner

  2. Orthopaedic Department, Hospital for Special Surgery, New York, USA

    D. Kendoff, M. Citak & M.J. Gardner

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  1. M. Citak
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  2. D. Kendoff
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  3. M. Citak
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  4. M.J. Gardner
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  5. M. Oszwald
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  6. C. Krettek
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  7. T. Hüfner
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Correspondence to M. Citak.

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Citak, M., Kendoff, D., Citak, M. et al. Mechanische Einflussfaktoren der Marknagelung auf die femorale Antetorsion. Unfallchirurg 111, 240–246 (2008). https://doi.org/10.1007/s00113-008-1435-7

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