髋部骨折--经皮加压钢板固定与髋螺钉固定的探讨

研究表明，经皮加压钢板固定（PCCP）和髋螺钉固定（HS）在治疗髋部骨折相比较的结果各式各样。研究结果推荐PCCP，因为它需求的平均输血量较低，术后疼痛较轻。PCCP和HS两种治疗方法的置人失败率都很低。然而，置入失败和二次手术在PCCP组可能更为常见。额外的随机对照实验可以被用来检验这些结果。     

Percutaneous compression plating versus gamma nail for the treatment of pertrochanteric hip fractures

The objective of this study is to compare percutaneous compression plating (PCCP) device with standard gamma nail (GN). A sample was prospectively followed and compared to a historical cohort: 82 intertrochanteric hip fractures in 81 patients treated with PCCP in 2004 versus 51 hip fractures treated with GN in 2003 (AO type 31A1, 31 A2). The main outcome measures were: surgery times, blood loss (Hb serum level and transfusions), complication, costs, for a 1-year follow-up. The minimally invasive PCCP technique resulted in a lower blood loss and consequently lower transfusion need (statistically significant), fewer implant-related complications and comparable surgery times. Overall surgical costs were lower for a comparable outcome in terms of healing and surgical time.     

股骨转子间骨折经皮加压钢板固定治疗与髋螺钉治疗效果的比较

概 要对于股骨转子间骨折的治疗,经皮加压钢板固定(PCCP)与髋螺钉(HS)的疗效何者更优,目前报道不一.推荐使用PCCP的认为,PCCP不但可以减少输血量,而且术后疼痛发生率低.     

Percutaneous compression plating versus compression hip screw fixation for the treatment of intertrochanteric hip fractures

Percutaneous compression plate (PCCP) devices are used for the fixation of intertrochanteric hip fractures by a minimally invasive technique. One hundred and eight patients who underwent this procedure were retrospectively compared with 155 patients who underwent compression hip screw (CHS) fixation. The general characteristics of the two groups, including age, sex, side of injury and co-morbidities assessed by the ASA score were similar. The operative time was significantly shorter in the PCCP group (67 versus 87 min, p=0.00). Postoperative blood transfusions were not required in 40% of the patients in the PCCP group compared to 24% of the patients in the CHS group (p<0.01). The rate of systemic postoperative complications was lower in the PCCP group (p=0.02) both in univariate and multivariate analyses. A considerable reduction was observed in cardiovascular complications (OR=3.1, p<0.05). Length of hospitalisation, implant failure and mortality rates were not significantly different between the two study groups. We conclude that the PCCP device offers several advantages over CHS device and may improve the current treatment of intertrochanteric hip fractures while maintaining a similar success rate in fracture fixation.     

股骨转子间骨折经皮加压钢板固定与髋螺钉固定的比较

Summary Evidence from four randomized controlled trials suggests a 60％ reduction in 1 year mortality for percutaneous compression plating(PCCP)compared with hip screw(HS)for treatment of pertrochanteric hip fractures.Other outcomes favoring PCCP include lower mean blood transfusion requirements and slightly lower postoperative pain.Both PCCP and HS are associated with low rates of implant failure,however,in the PCCP group implant failure and unplanned reoperations may be more common.Additional randomized controlled trials are recommended to verify these results.4项随机对照研究的证据提示,与髋螺钉(HS)治疗股骨转子间骨折相比,经皮加压钢板固定(PCCP)术后1年的死亡率可以降低60％.另外,PCCP治疗还可以降低输血量,术后疼痛相对轻微.虽然PCCP与HS治疗发生内固定失败的几率均较低,但是相比较而言,PCCP的内固定失败率和再次手术率更高.因此,需要开展大样本随机对照研究(RCT)来进一步明确这些研究结果.     

Minimally invasive percutaneous compression plating versus dynamic hip screw for intertrochanteric fractures: a randomized control trial

Objective：Intertrochanteric femur fracture is a common injury in elderly patients.The dynamic hip screw （DHS） has served as the standard choice for fixation; however it has several drawbacks.Studies of the percutaneous compression plate （PCCP） are still inconclusive in regards to its efficacy and safety.By comparing the two methods,we assessed their clinical therapeutic outcome.Methods：Atotal of 121 elderly patients with intertrochanteric femur fractures （type AO/OTA 31.A 1-A2,Evans type 1） were divided randomly into two groups undergoing either a minimally invasive PCCP procedure or a conventional DHS fixation.Results：The mean operation duration was significantly shorter in the PCCP group （55.2 min versus 88.5 min,P＜0.01）.The blood loss was 156.5 ml±18.3 ml in the PCCP group and 513.2 ml±66.2 ml in the DHS group （P＜0.01）.Among the patients treated with PCCP,3.1％ needed blood transfusions,compared with 44.6％ of those that had DHS surgery （P＜0.01）.The PCCP group displayed less postoperative complications （P＜0.05）.The mean American Society of Anesthesiologists score and Harris hip score in the PCCP group were better than those in the DHS group.There were no significant differences in the mean hospital stay,mortality rates,or fracture healing.Conclusion：Due to several advantages,PCCP has the potential to become the ideal choice for treating intertrochanteric fractures （type AO/OTA 31.A1-A2,Evans type 1）,particularly in the elderly.     

Percutaneous compression plate for pertrochanteric fixation of hip fractures: surgical technique and first results

We have used a minimally invasive technique for fixation of trochanteric fractures since 2003. We use the percuntaneous compression plate described by Gotfried. We describe here the osteosynthsis technique and our special approach which limits operative time. This technique avoids wide opening of the aponeurosis of the tensor fascia lata, major detachment, and section of the vastus lateralis. The plate is inserted via a 2-cm incision over the greater trochanter. Head and shaft screws are inserted via a second incision measuring 3 to 4 cm. Perfect reduction before plate insertion is the key to success. The results of our first twenty cases have demonstrated an uneventful postoperative period and a short operative time of 25 minutes on average. Peri-operative bleeding has been very limited. Radiographic healing was obtained in three months. Weight bearing was possible immediately after fixation in five cases and was delayed in fifteen. There were two early displacements which were analyzed.     

经皮加压钢板和动力髋螺钉治疗老年股骨转子间骨折的疗效比较

目的 比较经皮加压钢板(PCCP)和动力髋螺钉(DHS)治疗老年股骨转子间骨折的疗效.方法 对2007年1月至2010年1月收治的98例老年股骨转子间骨折患者(AO 31.A1-A2)进行回顾性分析,根据内固定方法不同分为PCCP组和DHS组,PCCP组53例,男10例,女43例;平均年龄78.2岁;AO分型:A1型37例,A2型16例.DHS组45例,男7例,女38例;平均年龄75.4岁;AO分型:A1型28例,A2型17例.比较两组患者的手术时间、失血量、骨折愈合时间及末次随访时Harris评分.结果 PCCP组有2例失访,51例患者术后获平均11.6个月(8～24个月)随访;DHS组有3例失访,42例患者术后获平均14.2个月(10～26个月)随访.PCCP组在手术时间、失血量、愈合时间及末次随访时Harris评分明显优于DHS组,差异均有统计学意义(P＜0.05).两组患者术后均末出现感染、骨不连、钢板螺钉断裂、股骨头螺钉切割、松动移位及股骨头坏死等并发症.结论 与DHS比较,PCCP治疗老年股骨转子间骨折具有手术时间短、切口小、剥离肌肉少、出血少、术后疼痛轻及患者能早期活动等优点.

Abstract：

Objective To investigate the clinical outcomes of minimally invasive treatment of elderly patients with intertrochanteric hip fractures with percutaneous compression plate (PCCP) as compared with dynamic hip screw (DHS) .Methods We randomised 98 patients with intertrochanteric fractures (AO31.A1-A2) to surgical treatment with either the PCCP or DHS and followed them post-operatively from January 2007 to January 2010.There were 53 cases in the PCCP group and 45 in the DHS group.The operation time, blood loss, fracture healing time and the last Harris scores were recorded and compared between the 2 groups.Results In the PCCP group 51 cases obtained a mean follow-up of 11.6 months (range, 8 to 24) and 2 were lost to the follow-up.In the DHS group 42 cases obtained a mean follow-up of 14.2 months (range, 10 to 26) and 3 were lost to the follow-up.Shorter operation time and fracture healing time, less blood loss and higher Harris scores were achieved in the PCCP group than in the DHS group.The differences between the 2 groups were statistically significant ( P ＜ 0.05) .Conclusion The minimally invasive PCCP technique can result in a lower blood loss, less post-operative pain, fewer implant-related complications and comparable surgery time than the DHS treatment.     

Percutaneous compression plating of intertrochanteric hip fractures

OBJECTIVE: To present the principles of a surgical technique for percutaneous compression plating of intertrochanteric hip fractures and to report the clinical results of treatment using this method. DESIGN: Retrospective. SETTING: University hospital. PATIENTS: Ninety-eight intertrochanteric hip fractures in ninety-seven patients with a minimum follow-up of twelve months. MAIN OUTCOME MEASURES: Radiographic and clinical evidence of functional outcome and complications including fracture collapse and implant failure. RESULTS: Mean perioperative blood loss was 92.4 milliliters (range 14 to 245 milliliters), and the mean postoperative hospital stay was 8.7 days (range 4 to 20 days). Complications included two minor wound hematomas and one soft tissue infection. Radiographically, one fracture with a varus deformity of 8 degrees and two fractures had minor screw pullout that did not affect the final results. No collapses, screw cutouts, or head penetrations were seen. Three patients required reoperation: one for avascular necrosis after a fracture at the base of the neck and two, after fracture healing, for trochanteric bursitis requiring plate removal. All surviving patients (80 of 98; 82 percent) had uneventful fracture healing with union achieved by six months in all patients. CONCLUSIONS: Use of the percutaneous compression plating for intertrochanteric hip fractures resulted in reduced complications, event-free fracture healing, and improved rehabilitation.     

Percutaneous compression plating for intertrochanteric hip fractures: treatment rationale

Percutaneous compression plating was developed after thorough consideration of each stage in the surgical procedure for intertrochanteric fractures and the ways in which they might be improved. This system represents a minimally invasive method of fracture stabilization and fixation, providing enhanced rotational stability and bone sparing, which reduces both peri- and postoperative complications including cut outs and fracture collapse.     

Osteosynthesis of unstable pertrochanteric femoral fractures with the compression hip screw

Injuries of unstable pertrochanteric fractures of the upper femur represent a contingent with high multi-morbidity at highest average age. The only successful procedures within biologically set boundaries, would be those of an early and weight-bearing resistive osteo-synthesis. Starting in 1979 till the middle of 1982, we treated 70 unstable pertrochanteric fractures out of 350 proximal femur fractures, with this compression hip screw. Because of its underlying bio-mechanical principle, its advantageous operative handling, as well as high durability of the material used, this version of an osteosynthesis showed few complications. We found neither head penetration and pseudoarthrosis, nor did we find any implant bending and breaking so far. Although averaging almost 80 years, 63% of our patients could be released after hospitalization for an average of 39 days, leaving at full mobility. The set goal of an early weight-bearing with elderly patients was fully achieved by means of this version of osteo-synthesis, since dynamic compression of even comminuted fracture zones permitted a statically sound and unhindered possibility at weight-bearing.     

经皮加压钢板和短重建钉治疗股骨转子间骨折的对照研究

目的 比较研究用于微创治疗股骨转子间骨折的同直径双主钉的髓内和髓外设计的两种内固定系统的临床治疗效果.方法 选择2005至2008年同期进行的两组股骨转子间骨折病例,均为AO/OTA分型A1和A2型骨折,其中髓外固定使用经皮加压钢板(percutaneous compression plating,PCCP)36例,髓内固定使用Trigen短重建钉48例,分别进行平均(16.3±3.2)个月随访.随访中临床评估包括术后1周,1、3、6个月和1年的疼痛视觉模拟评分(visual ahalogue scale,VAS)和1年后Harris髋功能评分;放射学评估包括骨折愈合时间、内固定主钉位置及骨折端加压短缩尺度,并记录并发症发生情况.结果 两组病例在手术时间和临床失血量方面差异并无统计学意义.PCCP组早期疼痛的缓解效果优于Trigen短重建钉组,主要表现在术后前3个月内,此后两组疼痛评分差异无统计学意义.PCCP组的骨折愈合时间和Harris评分均优于Trigen短重建钉组,差异有统计学意义.同时,PCCP组显示出更大尺度主钉回退和骨折端加压短缩情况.Trigen短重建钉组术后出现1例大转子劈裂、3例股骨干部骨折,其中1例进行翻修;而PCCP组无内固定周围骨折发生,但存在1例早期主钉切割移位.结论 PCCP和Trigen短重建钉均可满意地用于A1和A2型转子间骨折的微创治疗,其中髓外应用的PCCP具有疼痛缓解早、固定位置好、愈合时间短和并发症少等优点.     

经皮加压钢板与动力髋螺钉治疗股骨转子间骨折的Meta分析

[目的]对经皮加压钢板(PCCP)与动力髋螺钉(DHS)内固定治疗股骨转子间骨折疗效与并发症进行评价。[方法]按照Cochrane系统评价的方法,计算机检索下列数据库:Medline、Pubmed、SPINGER、John Wiley、Science Direct、EBSCO、CNKI、万方数数据库,并采用手工检索等方法收集文献。检索时间为1998年1月~2013年8月。收集所有相关随机对照试验,采用Cochrane协作网提供的软件Revman 5.1进行Meta分析。[结果]经过筛选,共纳入5个临床随机对照试验463例患者。Meta分析显示PCCP组与DHS组在手术时间(95%CI:-26.01~4.05,P=0.15)、住院时间(95%CI:-1.79~1.25,P=0.73)、死亡率(95%CI:0.37~1.02,P=0.06)、置入物相关并发症(95%CI:0.29~1.82,P=0.49)和再手术率(95%CI:0.41~3.05,P=0.83)上无明显统计学差异。但两组患者出血量(95%CI:-173.84~-4.81,P=0.04)和输血量(95%CI:-0.53~-0.07,P=0.01)有明显差异,PCCP组较DHS组明显减少。[结论]PCCP与DHS相比能减少出血和输血量,但在其他方面基本相同。由于病例数的限制,尚需要更多更高质量的临床随机对照试验来评价PCCP的效果。     

Surgical management of pertrochanteric fractures with the dynamic hip screw of the AO type

Since 1981 we have been using the dynamic hip screw (DHS) for surgical treatment of pertrochanteric fractures. After presentation of the implant and the operative technique the postoperative treatment is discussed. Immediate mobilization of the injured leg with weight-bearing is extremely important. Up to the end of 1986 we had used the DHS in 509 patients, whose average age was 75 years. During the hospital stay 31 patients died. Complications in the form of an infection occurred in 11 cases. Technical mistakes during surgery and breakage of the implant were each observed in two cases. After a period of 11 months patients were observed for assessment of the described technique. This examination was possible in 193 patients, showing excellent results presented in this paper. With full weight-bearing DHS ensures constant bony contact of the fracture fragments by means of the sliding mechanism. The advantages of the DHS are (1) relatively simple surgical technique; (2) low rate of complications; and (3) early mobilization without danger of complications resulting from the implant.     

Ender rod versus compression screw fixation of hip fractures

Eighty-seven matched pairs of patients with extracapsular hip fractures were treated with either Ender rod or compression screw and plate fixation. The data obtained both perioperatively and from one to 39 months postoperatively showed no significant differences with respect to infection rate, mortality, length of stay, or ultimate functional status. In the Ender rod group, 66.7% of the patients experienced technical problems, compared with 10.3% of patients in the compression screw group. The Ender technique offered few practical advantages and an unacceptably high level of problems, even when patients with only stable fractures were considered.     

Management of pertrochanteric femoral fractures. Bundle nailing or dynamic hip screw]

In a 8 year period (1981-1988) pertrochanteric fractures treated by elastic round nails (ERN) or dynamic hip screw (DHS) are investigated retrospectively. In spite of the more expense operative technical procedure, complications with DHS are rarer, and hospitalisation shorter, with low mortality.