Invloed van osteoporose op de functionele resultaten van distale radiusfracturen
Invloed van osteoporose op de genezing van polsfracturen
Osteoporose en polsfracturen
Osteoporose is een ziekte die gekenmerkt wordt door een gedaalde botdensiteit, met botzwakte als gevolg. De ziekte is sluipend en manifesteert zich meestal symptoomloos. Het is pas wanneer een fractuur optreedt, dat de ziekte symptomatisch wordt.
De ziekte komt voornamelijk voor bij postmenopauzale vrouwen en is sterk gelinkt aan de leeftijd. Ongeveer 6% van de mannen en 21% van de vrouwen tussen de 50 en 84 jaar lijden aan osteoporose. Door de vergrijzing verwacht men dat dit percentage zal blijven stijgen.
Ongeveer 10-12% van alle fracturen zijn polsfracturen. Ze komen typisch voor bij de actieve oudere. Deze groep heeft verzwakte botten, maar is nog steeds mobiel. De meest voorkomende oorzaak van de fractuur, is een val uit staande houding, die opgevangen wordt door de polsen. Het contact met de grond wordt gemaakt met de handpalmen.
Er is reeds veel onderzoek verricht naar de invloed van osteoporose op botsterkte en –metabolisme. Vreemd genoeg zijn er weinig studies die de effecten van osteoporose op de genezing van fracturen beschrijven. Dit ondanks het veelvoudig voorkomen en de hoge kostprijs van fracturen ten gevolge van osteoporose.
Hoe worden polsfracturen behandeld?
Men kan de chirurgische behandelingsopties indelen in gesloten en in open reductie. Reductie betekent de herpositionering van een of meer verschoven botfragmenten, om tot een zo correct mogelijke positie te komen.
Bij de gesloten reductietechnieken wordt er geen incisie gemaakt. Men kan het verschoven bot terugplaatsen door middel van uitwendige druk. Ook kan gebruik gemaakt worden van pinnen en externe fixatoren om de fractuur te fixeren na de reductie.
Bij open reductie wordt voornamelijk gebruik gemaakt van interne fixatie. Hierbij wordt een incisie gemaakt ter hoogte van de pols. Vervolgens wordt de fractuur gereduceerd en wordt er een fractuuroverspannende plaat vastgeschroefd aan het spaakbeen (radius). De meest moderne platen maken gebruik van hoekstabiele schroeven. Deze schroeven zitten vast in de plaat onder een vaste hoek. Hierdoor is de fixatie van de schroef in het bot minder belangrijk. Men vermoedt dat dit een voordeel biedt bij osteoporotische fracturen. Door de verminderde botdensiteit heeft het bot immers een sterk verminderde capaciteit om implantfixatie te behouden.
Er is geen consensus omtrent de optimale behandeling van polsfracturen bij patiënten met osteoporose. Vaak zijn deze fracturen vergruisd en gefragmenteerd. Het is daarom niet eenvoudig om de keuze te maken tussen een conservatieve behandeling (d.i. een behandeling zonder te opereren) en een chirurgische behandeling. De behandelingsopties zijn uiteenlopend en blijven een onderwerp van debat.
Hoe beoordeel je de genezing van fracturen?
De resultaten van een polsfractuur-behandeling worden traditioneel geëvalueerd aan de hand van radiologische parameters en van objectieve fysieke variabelen zoals knijpkracht en polsbewegelijkheid. Deze parameters en variabelen kunnen in een scoringssysteem verwerkt worden. Zo kan men op basis van een enkele eindscore de postoperatieve status van de patiënt op een eenvoudige manier inschatten en vergelijken met andere patiënten.
Men kan eveneens gebruik maken van een subjectieve evaluatie d.m.v. vragenlijsten die de patiënt zelf invult. Deze vragenlijsten beoordelen meestal het uitvoeren van dagdagelijkse taken en het comfort van de patiënt.
Het is moeilijk om de meest gepaste beoordelingswijze van botfracturen te beschrijven. Het beoordelen van het botgenezingsproces is immers zeer subjectief.
Onderzoek
Een literatuurstudie werd uitgevoerd om de invloed van botdensiteit op de genezing van polsfracturen te bepalen. Van de 6 bestudeerde studies toonden slechts 3 een correlatie aan tussen de botdensiteit en de resultaten na behandeling.
Besluit
Er is nog geen consensus over de invloed van osteoporose op de genezing van polsfracturen; er is meer onderzoek noodzakelijk. Er dient opgemerkt, dat de 6 gebruikte onderzoeken samen slechts 350 patiënten omvatten, wat nogal weinig is. Het is ook moeilijk om de studies onderling te vergelijken, omdat de evaluatie vaak op verschillende wijze uitgevoerd werd. Dit benadrukt het belang van uniforme onderzoeksmethoden.
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