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Fibular Autograft Dengan Cancellous Screw Pada Fraktur Neck Femur

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Fibular Autograft Dengan Cancellous Screw Pada Fraktur Neck Femur LAPORAN KASUS FIBULAR AUTOGRAFT DENGAN CANCELLOUS SCREW PADA FRAKTUR NECK FEMUR Oleh dr. Made Bramantya Karna, Sp.OT (K) PROGRAM PENDIDIKAN DOKTER SPESIALIS PROGRAM STUDI SPESIALIS BEDAH ORTHOPAEDI DAN TRAUMATOLOGI UNIVERSITAS UDAYANA DENPASAR 2018 Laporan Kasus IDENTITAS Nama : IKS Jenis Kelamin : Laki-laki Umur : 40 tahun CM : 17001959 Alamat : Sidemen, Karangasem MRS : 13/01/17 ANAMNESIS Pasien datang sadar mengeluhkan sakit pinggul kanannya setelah jatuh 5 jam sebelum MRS. Pasien mengendarai sepeda motor, tiba-tiba kehilangan keseimbangannya kemudian terjatuh dan pinggul kanannya terbentur tanah. Riwayat tidak sadar (-), mual (-), muntah (-). Pasien tersebut dirujuk oleh Ahli Bedah Ortopedi dari Rumah Sakit Badung dengan CF Right Neck Femur. PEMERIKSAAN FISIK Regio Hip Kanan L: Bengkak (-), memar (-), deformitas (+) pemendekan dan rotasi eksternal, daya dipasang skin traction. F: Nyeri tekan (+), nadi a. Dorsalis pedis (+), CRT <2 ", sensasi normal M: Active ROM Hip terbatas karena rasa sakit Active ROM Genu terbatas karena rasa sakit Active ROM Ankle 30/40 Active ROM MTP-IP 0/90 1 PEMERIKSAAN PENUNJANG Foto Pelvis AP (RSUD Badung) Foto Femur Dextra AP/Lateral (RSUD Badung) DIAGNOSIS CF Right Neck Femur Garden Type II PENATALAKSANAAN Analgetik Imobilisasi dengan Skin Traction 5 kg P/ ORIF Screwing cannulated + Strut graft 2 Right Hip X-Ray AP View Post ORIF Screwing + Strut Graft Right Thigh X-Ray AP/Lateral View Post ORIF Screwing + Stut Graft 3 Clinical Picture Post ORIF Screwing + Strut Graft Clinical Picture Post ORIF Screwing + Strut Graft Follow up Foto Pelvis AP (12-9-2017) 4 DISKUSI KASUS Pasien laki-laki usia 40 tahun rujukan dari Ahli Bedah Ortopedi dari Rumah Sakit Badung dengan CF Right Neck Femur, datang sadar mengeluhkan sakit pinggul kanannya setelah jatuh 5 jam sebelum MRS. Pasien mengendarai sepeda motor, tiba-tiba kehilangan keseimbangannya kemudian terjatuh dan pinggul kanannya terbentur tanah. Dari pemeriksaan fisik didapatkan deformitas (+) pemendekan dan rotasi eksternal regio hip kanan, terpasang skin traction, nyeri pada penekanan, ROM hip dan genu kanan aktif terbatas karena rasa sakit, ROM aktif ankle 30/40, dan ROM aktif MTP-IP 0/90. Di RSUD Badung, pasien dilakukan foto X-Ray pelvis AP dan Femur Dextra AP/Lateral. 1. Diagnosis Pasien didiagnosis dengan Close Fracture Right Neck Femur Garden Type II. Klasifikasi Garden pada fraktur neck femur subkapital merupakan klasifikasi yang paling banyak digunakan. Garden menggambarkan bagian tertentu neck femur dan pola trabekula acetabular. Garden mengklasifikasikan fraktur neck femur menjadi 4 tipe. Pada klasifikasi Garden I yaitu fraktur subkapital impaksi valgus, terjadi fraktur yang inkomplit, dengan garis fraktur di sisi lateral tidak menembus korteks sisi medial. Sehingga garis trabekula pada caput femur membentuk sudut dengan garis trabekula pada acetabulum. Pada Garden II dimana fraktur bersifat komplit namun tidak mengalami pergeseran (non displaced), sehingga garis trabekula pada caput femur kolinear dengan garis yang berada di acetabulum dan collum femur di sisi distal dari fraktur. Pada klasifikasi Garden III dimana terjadi fraktur subkapital dengan pergeseran yang tidak komplit (incompletely displaced), caput femur tidak hilang kontak dengan collum femur, namun caput femur dalam posisi varus dan ekstensi, sehingga mengakibatkan angulasi pada garis trabekula. Angulasi yang tercipta memiliki arah berkebalikan dengan Garden I. Yang terakhir Garden IV yaitu fraktur yang mengalami pergeseran komplit (completely displaced) sehingga garis trabekula pada caput femur sejajar dengan garis pada acetabulum akibat caput femur kembali ke posisi netral dalam acetabulum, sedangkan collum femur kehilangan kontak dengan caput femur dan mengalami 5 rotasi eksterna, sehingga garis trabekula pada collum femur tidak kolinear lagi dengan caput femur.1,2 Gambar 1. Klasifikasi Garden berdasarkan derajat pergeseran collum femur terhadap caput femur1 Pada kasus, dari foto Femur Dextra AP/Lat yang dilakukan di RSUD Badung, terlihat adanya fraktur bersifat komplit namun tidak mengalami pergeseran (non displaced), sehingga garis trabekula pada caput femur kolinear dengan garis yang berada di acetabulum dan collum femur di sisi distal dari fraktur dimana hal ini sesuai dengan klasifikasi Garden tipe II. 2. Penatalaksanaan Pasien pada kasus ini diterapi dengan analgetik, imobilisasi dengan Skin Traction 5 kg dan dilakukan ORIF Screwing cannulated + Strut graft. Secara umum, Garden I dan II adalah fraktur yang stabil dan dapat diterapi dengan fiksasi internal (head-preservation), sedangkan Garden III dan VI adalah fraktur yang tidak stabil yang diterapi dengan artroplasti (baik hemi atau artroplasti total). Berbagai tipe suplementasi bone graft telah dianjurkan untuk 6 menurunkan insiden nonunion dan avascular necrosis (AVN). Pemasangan screw cancellous dengan graft tulang dari fibula saat ini sudah menjadi pilihan terapi yang dapat menurunkan angka terjadinya nonunion dan AVN. Prosedur bone graft dengan fiksasi internal telah diteliti pada berbagai kasus dengan patah tulang lama yang belum dilakukan pengobatan4. Berbagai jenis prosedur bone graft mulai dari phemister graft, nonvascularized (graft gril iliaka, graft fibular), cangkokan otot vaskularisasi (Quadratus femoris, Sartorius, Gluteus medius) berbasis graft telah digunakan dalam penatalaksanaan fraktur neck femur namun tidak ada teknik yang menunjukkan lebih baik diantara yang lainnya. Graft fibula ipsilateral autologous memiliki prosedur yang dapat dilakukan dengan mudah dan dapat diterapkan di negara berkembang. Selain itu, kortikal dan tubular tidak hanya akan memberikan kekuatan mekanis seperti screw dalam mempertahankan tetapi juga memberikan stimulus osteogenik di lokasi patahan. Beberapa lubang bor pada graft juga mendorong pertumbuhan tulang. Oleh karena itu, tindakan graft fibula merupakan "cangkok implan biodegradable". Penyambungan fibula ganda dengan atau tanpa cancellous screw telah dilakukan pada fraktur femur yang terabaikan pada pasien dewasa dan menunjukkan hasil yang sangat baik pada banyak penelitian3,5. Muscle pedicle bone grafting dan vascularized fibular grafting merupakan teknik yang unggul namun tergantung pada keterampilan, memakan waktu, mahal dan memerlukan peralatan canggih mikrosurgis yang tidak sealu tersedia di setiap tingkat fasilitas kesehatan.3 Teknik fiksasi ini dilakukan pada beberapa penelitian pada fraktur neck femur yang mengalami pergeseran (displaced) yang termasuk dalam klasifikasi Garden III dan IV.3 Namun, ada pula penelitian yang juga memasukkan pasien dengan Garden tipe II (10%) sebagai sampel dari teknik operasi ini.4 Sebagian besar penelitian yang menggunakan teknik operasi ini dilakukan pada pasien yang berusia dibawah dari 50 tahun.3,4 Prosedur pemasangan screw cancellous dengan graft tulang dari fibula ini dilakukan di ruang operasi dengan pendekatan Moore’s posterior dan Jones’ lateral untuk memaparkan hip. Insisi kapsula dibuat di tengah kapsula anterior dan berhenti 1 cm di garis intertrochanter (Gambar 2). 7 Gambar 2. Insisi kapsula anterior, berhenti 1 cm di garis intertrochanter yang memisahkan lingkaran arteri.3 Jaringan fibrous diantara fragmen dipisahkan dan fraktur direduksi dan difiksasi sementara dengan K-wire yang menembus dasar acetabular. Sebuah screw kemudian dimasukkan tepat dibawah dasar greater trochanter yang memfiksasi fraktur secara aman. Sementara itu, asisten operator melepaskan 10 cm fibula dari sisi yang sama dengan fraktur, tepi interosseous yang tajam dikikis hingga sebagian cavitas medulla terpapar, dan buat 6 lubang pada tempat yang bervariasi di korteks (Gambar 3). Gambar 3. Enam lubang pada tempat yang bervariasi di korteks graft fibula3 Panjang graft fibula yang diperlukan diukur secara langsung di atas head, neck, dan region trochanter. Handerson’s drill digunakan untuk memotong tulang dari korteks trochanter dan neck femur tepat di bawah screw untuk membuat hubungan dengan graft fibula. Graft kemudian dipasang pada tempatnya dan acetabular guide-wire dilepas. Setelah operasi, dilakukan foto X-ray untuk mengevaluasi hasil post operasi (Gambar 4). 8 Gambar 4. Foto X-ray pasca operasi pemasangan screw cancellous dengan graft tulang dari fibula4 3. Follow up Pada kasus, pasien kontrol ke RSUP Sanglah pada tanggal 12 September 2017 dan melakukan foto Pelvis AP. Pada foto, tampak fraktur collum femur dextra, terpasang internal fiksasi screw dan strut graft, aposisi dan kedudukan cukup, callus (+), tulang belum sepenuhnya union. Dari beberapa penelitian didapatkan adanya komplikasi yang dapat terjadi seperti avascular nekrosis, patahnya graft fibula, penetrasi permukaan articular head femur oleh srew maupun graft.3,4 Kaki dipertahankan dalam posisi Thomas splint selama dua minggu, setelah jahitan dilepas dan single spica cast dipasang. Cast ini dilepas saat akhir minggu keenam dan pasien diperbolehkan berjalan dengan penopang tubuh, bertumpu sebagian beban pada ekstremitas yang sakit. Full weight-bearing diperbolehkan umumnya pada akhir bulan ketiga, tetapi dapat lebih lama jika terjadi tanda-tanda AVN atau tanda-tanda union secara radiologis tidak didapatkan.3 9 DAFTAR PUSTAKA 1. Keating J. Femoral Neck Fractures In: Bucholz R, Heckman J, et al. Rockwood and Green’s 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, p. 1563 – 1592 2. Ayush Goel, Frank Gaillard. Neck Femur Fracture. https://radiopaedia.org/articles/femoral-neck-fracture (Diakses 12 Oktober 2017) 3. Sudhir Singh, Dharmendra Kumar, Sanjiv Kumar (2014). Long Term Results of Fresh Femoral Neck Fractures Treated by Cancellous Screw and Fibular Autograft. MOJ Orthop Rheumatol, 1(3): 00020 4. Nagi ON, Gautam VK, Marya SK (1986) Treatment of femoral neck fractures with a cancellous screw and fibular graft. J Bone Joint Surg Br 68(3): 387-391 5. Jaiswal A, Pruthi KK, Goyal RK (2013) Evaluation of osteosynthesis with dual fibular bone grafting for neglected femoral neck fracture. J Clin Orthop Trauma 4(2): 58-69. 10 .
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