Proximale Femurfrakturen

Zusammenfassung

Proximale Femurfrakturen gehören zu den häufigsten Osteoporose-assoziierten Fragilitätsfrakturen des älteren Menschen und zeigen durch den demographischen Wandel steigende Inzidenzen. Die Behandlung von Patienten mit proximalen Femurfrakturen ist komplex. Das orthogeriatrische Co-Management bezeichnet dabei die inter- und multidisziplinäre Zusammenarbeit aller involvierten Fachrichtungen und Berufsgruppen. Im Fokus liegt die Wiederherstellung der bestmöglichen Mobilität und Funktionalität als primäres Behandlungsziel. Chirurgisch existieren verschiedene moderne Osteosyntheseverfahren, welche insbesondere bei Patienten mit pertrochantären Femurfrakturen eingesetzt werden können. Aufseiten der Schenkelhalsfrakturen ist in aller Regel ein endoprothetischer Gelenkersatz nötig. In beiden Fällen soll nach der Operation eine unmittelbare Mobilisation unter Vollbelastung der operierten Extremität beginnen. Essenziell ist zudem die geriatrische Mitbehandlung der Patienten. Diese soll durch Fachärzte mit geriatrischer Kompetenz gewährleistet werden. Wesentliche Vorgaben der akutstationären Versorgung von Patienten mit proximalen Femurfrakturen werden durch eine Richtlinie des Gemeinsamen Bundesausschuss (G-BA) geregelt, welche zum 01.01.2021 in Kraft getreten ist. Der vorliegende Artikel soll einen Überblick über die wichtigsten Aspekte zur Klinik, Diagnostik und Therapie der proximalen Femurfrakturen geben.

Abstract

With demographic change and aging society osteoporotic fragility fractures are showing increasing incidences. Proximal femur fractures are among the most common osteoporosis-related fragility fractures in the elderly population. The treatment of patients with proximal femur fractures is complex. To cope with the emerging challenges, orthogeriatric co-management, which refers to the interdisciplinary and multidisciplinary collaboration of all specialties involved, was introduced. The primary therapy goal is to restore the best possible mobility and functionality. There is a wide range of surgical treatment options. Modern osteosynthesis procedures are particularly applicable for trochanteric fractures. In case of femoral neck fractures, endoprosthetic joint replacement is usually necessary. Postoperative mobilization should involve full weight-bearing of the operated limb. Further, specialized geriatricians should take part in perioperative care of orthogeriatric patients. The Federal Joint Committee (G-BA) determined specific requirements for the treatment of patients with proximal femur fractures that must be met by hospitals in Germany. This article gives an overview of the most important clinical aspects, diagnostics and treatment of proximal femur fractures.

Schlüsselwörter

Orthogeriatrie - Alterstraumatologie - Hüftfraktur - Schenkelhalsfraktur - pertrochantäre Oberschenkelfraktur

Keywords

orthogeriatrics - hip fracture - femoral neck fracture - trochanteric fracture

• References

• 1 Friedman SM, Mendelson DA. Epidemiology of fragility fractures. Clin Geriatr Med 2014; 30: 175-181
• 2 Rupp M, Walter N, Pfeifer C, Lang S, Kerschbaum M, Krutsch W. et al. The Incidence of Fractures Among the Adult Population of Germany-an Analysis From 2009 through 2019. Dtsch Arztebl Int. 2021; 118: 665-669
• 3 Schulz C, Konig HH, Rapp K, Becker C, Rothenbacher D, Buchele G. Analysis of mortality after hip fracture on patient, hospital, and regional level in Germany. Osteoporos Int 2020; 31: 897-904
• 4 Sing CW, Lin TC, Bartholomew S, Bell JS, Bennett C, Beyene K. et al. Global Epidemiology of Hip Fractures: Secular Trends in Incidence Rate, Post-Fracture Treatment, and All-Cause Mortality. J Bone Miner Res 2023; 38: 1064-75
• 5 Hernlund E, Svedbom A, Ivergard M, Compston J, Cooper C, Stenmark J. et al. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 2013; 8: 136
• 6 Kanis JA, Norton N, Harvey NC, Jacobson T, Johansson H, Lorentzon M. et al. SCOPE 2021: a new scorecard for osteoporosis in Europe. Arch Osteoporos 2021; 16: 82
• 7 Lai SW. Risk factors for hip fracture. Osteoporos Int 2021; 32: 2599
• 8 Park HY, Kim S, Sohn HS, Kwon JW. The Association between Polypharmacy and Hip Fracture in Osteoporotic Women: A Nested Case-Control Study in South Korea. Clin Drug Investig 2019; 39: 63-71
• 9 Zakarias JK, Norgaard A, Jensen-Dahm C, Gasse C, Laursen TM, Palm H. et al. Risk of hospitalization and hip fracture associated with psychotropic polypharmacy in patients with dementia: A nationwide register-based study. Int J Geriatr Psychiatry 2021; 36: 1691-1698
• 10 Kose E, Hirai T, Seki T. Anticholinergic drugs use and risk of hip fracture in geriatric patients. Geriatr Gerontol Int 2018; 18: 1340-1344
• 11 Lim SK, Beom J, Lee SY, Kim BR, Chun SW, Lim JY. et al. Association between sarcopenia and fall characteristics in older adults with fragility hip fracture. Injury. 2020; 51: 2640-2647
• 12 Mazzucchelli R, Crespi-Villarias N, Perez-Fernandez E, Durban Reguera ML, Guzon Illescas O, Quiros J. et al. Weather conditions and their effect on seasonality of incident osteoporotic hip fracture. Arch Osteoporos 2018; 13: 28
• 13 Johansen A, Grose C, Havelock W. Hip fractures in the winter – Using the National Hip Fracture Database to examine seasonal variation in incidence and mortality. Injury. 2020; 51: 1011-1014
• 14 Koseki H, Sunagawa S, Noguchi C, Yonekura A, Matsumura U, Watanabe K. et al. Incidence of and risk factors for hip fracture in Nagasaki, Japan from 2005 to 2014. Arch Osteoporos. 2021; 16: 111
• 15 McCusker J, Bellavance F, Cardin S, Trepanier S, Verdon J, Ardman O. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc 1999; 47: 1229-1237
• 16 Liener UC, Becker C, Rapp K. Weißbuch Alterstraumatologie. Kohlhammer Verlag; 2018
• 17 Knauf T, Buecking B, Geiger L, Hack J, Schwenzfeur R, Knobe M. et al. The Predictive Value of the "Identification of Seniors at Risk" Score on Mortality, Length of Stay, Mobility and the Destination of Discharge of Geriatric Hip Fracture Patients. Clin Interv Aging 2022; 17: 309-316
• 18 Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The Confusion Assessment Method: a systematic review of current usage. J Am Geriatr Soc 2008; 56: 823-830
• 19 Knobe M, Gradl G, Ladenburger A, Tarkin IS, Pape HC. Unstable intertrochanteric femur fractures: is there a consensus on definition and treatment in Germany?. Clin Orthop Relat Res 2013; 471: 2831-2840
• 20 Kammerlander C, Doshi H, Gebhard F, Scola A, Meier C, Linhart W. et al. Long-term results of the augmented PFNA: a prospective multicenter trial. Arch Orthop Trauma Surg 2014; 134: 343-349
• 21 Sermon A, Boner V, Boger A, Schwieger K, Boonen S, Broos PL. et al. Potential of polymethylmethacrylate cement-augmented helical proximal femoral nail antirotation blades to improve implant stability – a biomechanical investigation in human cadaveric femoral heads. J Trauma Acute Care Surg 2012; 72: E54-E59
• 22 Schuetze K, Ehinger S, Eickhoff A, Dehner C, Gebhard F, Richter PH. Cement augmentation of the proximal femur nail antirotation: is it safe?. Arch Orthop Trauma Surg 2021; 141: 803-11
• 23 Keppler AM, Pfeufer D, Kau F, Linhart C, Zeckey C, Neuerburg C. et al. Cement augmentation of the Proximal Femur Nail Antirotation (PFNA) is associated with enhanced weight-bearing in older adults. Injury. 2021; 52: 3042-3046
• 24 Lewis SR, Macey R, Gill JR, Parker MJ, Griffin XL. Cephalomedullary nails versus extramedullary implants for extracapsular hip fractures in older adults. Cochrane Database Syst Rev 2022; 1: CD000093
• 25 Schemitsch EH, Nowak LL, Schulz AP, Brink O, Poolman RW, Mehta S. et al. Intramedullary Nailing vs Sliding Hip Screw in Trochanteric Fracture Management: The INSITE Randomized Clinical Trial. JAMA Netw Open 2023; 6: e2317164
• 26 Katsuyama Y, Okuda Y, Kanamura H, Sasaki K, Saito T, Nakamura S. Surgical versus conservative treatment of greater trochanteric fractures with occult intertrochanteric fractures: Retrospective cohort study. Injury. 2023; 54: 111055
• 27 Okike K, Udogwu UN, Isaac M, Sprague S, Swiontkowski MF, Bhandari M. et al. Not All Garden-I and II Femoral Neck Fractures in the Elderly Should Be Fixed: Effect of Posterior Tilt on Rates of Subsequent Arthroplasty. J Bone Joint Surg Am 2019; 101: 1852-1859
• 28 Rogmark C, Leonardsson O. Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients. Bone Joint J 2016; 98-B: 291-297
• 29 Migliorini F, Trivellas A, Driessen A, Quack V, El Mansy Y, Schenker H. et al. Hemiarthroplasty versus total arthroplasty for displaced femoral neck fractures in the elderly: meta-analysis of randomized clinical trials. Arch Orthop Trauma Surg 2020; 140: 1695-704.
• 30 Ekhtiari S, Gormley J, Axelrod DE, Devji T, Bhandari M, Guyatt GH. Total Hip Arthroplasty Versus Hemiarthroplasty for Displaced Femoral Neck Fracture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Bone Joint Surg Am 2020; 102: 1638-45.
• 31 Mendelson DA, Friedman SM. Principles of comanagement and the geriatric fracture center. Clin Geriatr Med 2014; 30: 183-189