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The incidence of periprosthetic femoral fractures is increasing due to the growing number of THA all over the world and the older age of the population. This article is a review of the literature and an analysis of our cases; the different surgical treatments were described and evaluated. Attention was paid to the border between synthesis and revision.
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https://doi.org/10.1007/s11639-018-0245-0
Fratture periprotesiche di femore: confine tra
sintesi e revisione
M. Franceschini1,a(B), O. De Bartolomeo1, F. Calabrò2, V. Cerbone2, G.V. Mineo1
1ASST Istituto Ortopedico Gaetano Pini, Piazza Cardinal Ferrari 1, Milano, Italia
2Università degli Studi di Milano, Via F. Sforza, Milano, Italia
amassimo.franceschini@gpini.it
ABSTRACT –PERIPROSTHETIC FEMORAL FRACTURES:THE BORDER BETWEEN SYNTHESIS AND REVISION
The incidence of periprosthetic femoral fractures is increasing due to the growing number of THA all over the world
and the older age of the population. This article is a review of the literature and an analysis of our cases; the different
surgical treatments were described and evaluated. Attention was paid to the border between synthesis and revision.
© Società Italiana Ortopedici Traumatologi Ospedalieri d’Italia 2018
Introduzione
L’incidenza mondiale delle fratture periprotesiche di femore
(PFF) prossimale è in continua crescita dato il grande nu-
mero di protesi d’anca eseguite ogni anno e l’aumento del-
l’età media della popolazione con conseguente osteoporosi e
aumentato rischio di caduta [1].
Nonostante una frattura possa essere intraoperatoria, molto
più di frequente si manifesta in seguito a eventi traumatici
[1].
Il trattamento chirurgico risulta frequentemente complicato
dallo scarso bone stock femorale prossimale o dalle condi-
zioni di salute generale scadenti del paziente. Mentre nei casi
classificati B1 secondo Vancouver una sintesi può risultare
più semplice ed efficace, la revisione è necessaria se l’osso è
di scarsa qualità o in caso di mobilizzazione dell’impianto
[2,3].
L’obiettivo del nostro studio è identificare quali fattori pos-
sono influenzare l’indicazione chirurgica tra osteosintesi e
revisione protesica.
Materiali e metodi
Dalla letteratura abbiamo raccolto i dati epidemiologici re-
lativi alle fratture periprotesiche di femore prossimale e ana-
lizzato le differenze esistenti tra l’osteosintesi e la revisione
protesica.
I criteri di inclusione comprendevano: (1) fratture da B1
a C secondo la classificazione di Vancouver, trattate chi-
rurgicamente tramite osteosintesi e/o revisione; (2) ana-
lisi epidemiologica dei fattori di rischio e/o dei risultati
a breve e lungo termine dei singoli trattamenti (compre-
so il tasso di mortalità); (3) singoli case report. I crite-
ri di esclusione comprendevano: (1) criteri di inclusione
non soddisfatti; (2) fratture oncologiche; (3) infezioni pe-
riprotesiche associate a frattura; (4) trattamento di revisio-
ne e osteosintesi eseguiti durante lo stesso atto chirurgico;
(5) la contemporanea presenza di protesi d’anca e ginocchio
omolaterale.
Inoltre, i pazienti trattati chirurgicamente nel reparto 4adi-
visione del Centro Specialistico Ortopedico Traumatologico,
Gaetano Pini (CTO) dal 2010 ad oggi sono stati rivalutati in
maniera retrospettiva. La nostra casistica comprende esclusi-
vamente pazienti con fratture da B1 a C secondo Vancouver
trattate chirurgicamente con osteosintesi vs revisione; i sin-
goli fallimenti sono stati studiati nel dettaglio con l’obiettivo
di individuarne le cause principali, tra cui eventuali errori di
indicazione chirurgica.
Risultati
Gli studi selezionati mostrano che l’incidenza di fratture pe-
riprotesiche di femore risulta variabile e si aggira intorno a
un valore medio del 4%, maggiore nei pazienti con stelo non
cementato o in caso di precedenti revisioni di protesi d’anca
[46].
I fattori di rischio principali di PFF sono l’età avanzata dei
pazienti, l’osteoporosi, la presenza di comorbidità con alto
rischio di caduta accidentale (patologie neurologiche, della
deambulazione, storia di traumi con esiti, patologie cardio-
vascolari) e, infine, l’osteolisi peri-impianto con conseguen-
te fragilità ossea locale [46].
Fig. 1 - (a,b) Frattura
periprotesica tipo B1 (Rx AP e
assiale). (c,d) Controllo
postopoperatorio
Il tasso di mortalità ha valori differenti a seconda dei diffe-
renti studi e varia dal 2,1 al 27% a 1 anno dall’intervento a
seconda dell’età e delle condizioni cliniche generali; risulta
certo che la sopravvivenza si riduce progressivamente a di-
stanza dall’intervento e che il tasso di mortalità aumenta con
l’età [46].
Ogni studio in letteratura concorda sul fatto che l’alletta-
mento vada ridotto, che il recupero funzionale sia rapido
ed efficace e che l’impianto permetta una guarigione a lun-
go termine. Inoltre, le complicazioni postoperatorie più fre-
quenti sono: le pseudoartrosi asettiche (24% circa), le reci-
dive di frattura con eventuale rottura dei mezzi di sintesi (fi-
Fig. 2 - Fallimento postoperatorio a 6 mesi
no al 24%), le mobilizzazioni asettiche (21%) e le lussazio-
ni ricorrenti (fino al 16%) a cui vanno aggiunte le infezioni
locali, le rigidità post-chirurgiche e la zoppia [4,7,8].
La classificazione di Vancouver è la più utilizzata ed è suffi-
cientemente efficace per l’inquadramento radiografico della
frattura; nonostante tutto, fino al 70% dei pazienti con PFF
presenta una mobilizzazione dello stelo di difficile visualiz-
zazione alle lastre preoperatorie (Fig. 1)[4,5].
Numerosi autori sono concordi nel definire l’osteosintesi il
trattamento ottimale per le fratture di tipo B1, la revisione
quello ottimale per le B2, B3 e C; non è raro trovare casi
di B2 trattate con successo tramite open Reduction Internal
Fixation (ORIF) e, viceversa, B1 fallite nonostante la corretta
indicazione chirurgica (Fig. 2)[47,9,10].
Il numero di protesi parziali e totali di anca eseguite presso la
nostra divisione dal 2010 ad oggi è stato 448 (282 totali, 166
endoprotesi); il numero di fratture periprotesiche femorali
trattate chirurgicamente è stato 13.
Il rapporto M/F è di 2 a 11, l’età media dei pazienti è 81,8
anni. Le informazioni relative ai pazienti da noi operati si
sovrappongonoaidatipresentiinletteratura.
Discussione
Le fratture periprotesiche di femore prossimale sono un
problema sempre più importante del panorama ortopedi-
co internazionale, data l’incidenza in costante aumento e un
numero elevato di pazienti a rischio.
La prevenzione è il primo trattamento, inizia in sala opera-
toria al momento dell’impianto e prosegue con i successivi
controlli a breve e lungo termine. In caso di frattura, l’inter-
vento chirurgico deve favorire una ripresa funzionale rapida,
efficace e duratura, deve garantire una buona stabilità dello
stelo e ridurre il rischio di mortalità perioperatoria.
Classificare le fratture ha permesso di semplificare le scel-
te operatorie; tra le classificazioni esistenti (es. Johansonn,
1981; Beals e Tower, 1996) quella di Vancouver è la più uti-
lizzata: include la sede di frattura, la stabilità dello stelo pro-
tesico e il bone stock femorale prossimale. Le fratture da B1
a C secondo Vancouver necessitano nella maggior parte dei
casi di un intervento chirurgico che può variare dalla sintesi
in caso di B1 alla revisione protesica dello stelo in caso di B2,
B3eC,mailconnenonèsemprecosìbendelineato.
Sia secondo la letteratura, sia analizzando la nostra casistica
risulta evidente che entrino in gioco numerosi altri fattori:
ad esempio, uno stelo che appare mobilizzato alle indagini
radiografiche preoperatorie (Rx e, eventualmente, TC) può
risultare stabile a sufficienza in sala, dirottando la decisione
chirurgica verso una sintesi. Le condizioni cliniche generali
scadenti (età, eventuali patologie cardiovascolari, demenza
senile, deambulazione scarsa o nulla, patologie neurologiche
associate, esiti di traumi, aumentato rischio settico) e la scar-
sa compliance dei pazienti spingono il chirurgo a eseguire
l’intervento meno invasivo possibile. Viceversa la relativa-
mente giovane età, le buone condizioni cliniche generali e
un buon bone stock complessivo permettono una revisione
di stelo, nei casi in cui è indicata, con minor probabilità di
complicazioni. Infine, non sono rari i casi di fallimento della
sintesi pur in caso di fratture tipo B1 (Fig. 3).
Complessivamente risulta difficile avere una visione univo-
ca; l’unica certezza è che il trattamento chirurgico debba ga-
rantire sia la sopravvivenza a lungo termine dell’impianto sia
la migliore qualità di vita possibile al paziente.
Conclusione
Il trattamento delle fratture periprotesiche di femore prossi-
male risulta ancora argomento di dibattito. Non esiste un
confine netto tra sintesi e revisione nei casi dubbi; men-
tre la classificazione di Vancouver permette un ottimo in-
quadramento radiografico, a nostro parere non risulta com-
Fig. 3 - Revisione di stelo
pleta nell’indirizzare verso un’indicazione chirurgica. I pa-
zienti in condizioni generali precarie, con difficoltà della
deambulazione (ad esempio per esiti di traumi o patologie
neurologiche degenerative) e ad alto rischio di complicazio-
ni perioperatorie sono più indicati per un intervento con-
servativo, quando possibile in base alla qualità dell’osso e
al pattern fratturativo. L’obiettivo primario resta garantire
la sopravvivenza del paziente con la miglior qualità di vita
possibile.
CONFLITTO DI INTERESSE Gli autori G.V. Mineo, M. Franceschini, O.
De Bartolomeo, F. Calabrò e V. Cerbone dichiarano di non avere alcun
conflitto di interesse.
CONSENSO INFORMATO E CONFORMITÀ AGLI STANDARD ETICI Tu t t e
le procedure descritte nello studio e che hanno coinvolto esseri umani
sono state attuate in conformità alle norme etiche stabilite dalla di-
chiarazione di Helsinki del 1975 e successive modifiche. Il consenso
informato è stato ottenuto da tutti i pazienti dello studio.
HUMAN AND ANIMAL RIGHTS Per questo tipo di studio non è richie-
sto l’inserimento di alcuna dichiarazione relativa agli studi effettuati su
esseri umani e animali.
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