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Repositionstechniken in der Marknagelosteosynthese

Reduction techniques in intramedullary nailing osteosynthesis

  • Leitthema
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Zusammenfassung

Die Marknagelung wurde ursprünglich für die Stabilisierung von Schaftfrakturen der langen Röhrenknochen entwickelt. Neue Nageldesigns und multiple Verriegelungsoptionen haben das Spektrum der Marknagelosteosynthese stark erweitert. Die Nagelosteosynthese von Frakturen außerhalb des Isthmus ist technisch anspruchsvoll, da die Fraktur vor Einführung des Marknagels reponiert werden muss. Indirekte Repositionstechniken umfassen die Verwendung eines Extensionstisches, eines großen Distraktors oder eines Fixateurs externe. Die direkte Reposition mithilfe von Repositionszangen, Zugschrauben, Cerclagen oder einer kurzen Platte kann die indirekte Reposition optimieren. Die Wahl des korrekten Eintrittspunkts ist für das optimale Operationsergebnis von überragender Bedeutung. Sie ist von den anatomischen Gegebenheiten und von der Nagelkrümmung abhängig. An der proximalen Tibia ist der optimale Eintrittspunkt direkt hinter der Patellarsehne bei stark gebeugtem Knie, alternativ über einen suprapatellaren Zugang bei leicht gebogenem Knie zu erreichen. Die Einführung des Nagels über den suprapatellaren Zugang ist ohne Stress auf die reponierten Frakturfragmente möglich. Mithilfe von Pollerschrauben wird ein zusätzlicher Isthmus in der Metaphyse erzeugt und damit das Auftreten einer Achsfehlstellung beim Einführen des Nagels verhindert. Nach Einführen des Nagels wird das kurze Frakturfragment mehrfach verriegelt.

Abstract

Intramedullary nailing was originally conceived for the stabilization of shaft fractures of long bones. Due to new nail designs and multiple interlocking possibilities, the spectrum of nailing has significantly increased. Nailing of fractures beyond the isthmus is technically challenging because fractures need to be reduced before the nailing procedure starts. Indirect techniques of reduction include the use of an extension table, a large distractor or an external fixator. Direct reduction with pointed reduction forceps, lag screws, a cerclage wire or a short plate can optimize indirect reduction. The choice of the correct entry portal is of utmost importance for an optimal operative result. The location of the entry portal is dependent on the local anatomy and the bend of the nail. The optimal entry portal at the proximal tibia is directly behind the patellar tendon and accessible with the knee in more than 90° of flexion, alternatively through a suprapatellar approach with a slightly flexed knee joint. Insertion of the nail through the suprapatellar approach is possible without stress on the reduced fracture fragments. Blocking screws create an artificial isthmus in the metaphyseal area and force the guide wire in the desired direction. Blocking screws help to avoid axial malalignment during nail insertion. Interlocking of the nail with screws coming from different directions prevents secondary dislocation.

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Authors and Affiliations

  1. Zentrum für Orthopädie und Unfallchirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland

    P. M. Rommens, R. Kuechle & S.-O. Dietz

  2. Klinik für Unfallchirurgie und Orthopädie 1, Westpfalz-Klinikum Standort I Kaiserslautern, Hellmut-Hartert-Straße 1, 67655, Kaiserslautern, Deutschland

    A. Hofmann

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  1. P. M. Rommens
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  2. R. Kuechle
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  3. A. Hofmann
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  4. S.-O. Dietz
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Correspondence to P. M. Rommens.

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P. M. Rommens, R. Kuechle, A. Hofmann und S.-O. Dietz geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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D. Höntzsch, Tübingen

C. Sommer, Chur

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Rommens, P.M., Kuechle, R., Hofmann, A. et al. Repositionstechniken in der Marknagelosteosynthese. Unfallchirurg 122, 95–102 (2019). https://doi.org/10.1007/s00113-018-0560-1

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  • DOI: https://doi.org/10.1007/s00113-018-0560-1

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