股骨转子周围骨折的髓内钉固定

目的探讨带锁髓内钉固定在股骨转子周围骨折中的应用价值以及相关并发症的防治。方法回顾分析了自1993年12月至2001年9月间作者收治的180例(181髋)经髓内钉治疗的转子周围骨折,其中应用亚太型Gamma钉96例(97髋)、股骨重建钉54例、股骨近端钉(PFN)30例。结果平均手术时间65分钟,术中术后输血患者仅占15.6%;平均随访时间为16个月,96%的骨折获得愈合,平均愈合时间为3.5个月;按黄公怡评价标准,髋关节功能优良率为90.2%;发生9种类型的并发症。结论髓内钉固定在治疗股骨转子间骨折中具有较大的临床价值,但仍存在一定的并发症,应引起足够重视。     

Gamma钉治疗股骨转子周围骨折

目的总结Gamma钉治疗股骨转子周围骨折临床经验.方法对Gamma钉治疗的79例股骨转子周围骨折患者进行回顾性分析.结果79例经12～50（25．3±9．2）个月随访．骨折临床愈合时间为（12．98±1．26）周。根据Merle Daublgne髋关节功能评分标准：优28例,良36例．中12例．差3例．优良率为81．0％,结论Gamma钉治疗股骨转子周围骨折具有切口暴露小、固定强度牢靠、创伤小等优点．是一种治疗股骨转子周围骨折行之有效的内固定方法.     

股骨重建钉治疗股骨干骨折合并同侧股骨转子周围骨折的疗效分析

[目的]探讨股骨干骨折合并同侧股骨转子周围骨折的股骨重建钉(RIN)内固定手术治疗方法并评估其临床效果。[方法]对2002年9月～2009年1月通过RIN手术治疗的累及同侧股骨转子周围部的37例股骨干骨折患者的治疗结果进行分析。男32例,女5例,年龄24～69岁,平均36岁。高能量损伤33例(交通事故伤26例,高处坠落伤7例),低能量损伤4例(均为运动中跌倒摔伤)。股骨干骨折发生在上1?3段13例,中1?3段18例,下1?3段6例,其中开放骨折6例(GustiloⅠ型1例,Ⅱ型5例)。股骨颈骨折按照Garden分类,Ⅱ型19例,Ⅲ型9例,Ⅳ型2例。转子间骨折按AO分类,A1.1型3例,A2.1型1例。转子下骨折按照Seinsheimer分型,Ⅰ型1例,ⅡA型2例。受伤至手术时间为4h～13d(平均3.7d)。术后进行渐进式的功能锻炼。[结果]所有患者得到14～38个月(平均24个月)随访。术后均获得骨性愈合,骨折平均愈合时间:股骨干13周,股骨颈14周,转子间12.6周,转子下15.5周。发生股骨头坏死1例。无感染、内固定断裂和松动、髋内翻及畸形愈合等并发症发生。根据Harris评分:优(91～100分)21例,良(81～90分)11例,可(71～80分)4例,差(≤70分)1例,优良率86.5%。[结论]RIN治疗股骨干骨折合并同侧转子周围骨折具有创伤小、固定可靠、骨愈合率高、并发症少和疗效好等优点,较其他方法可减少内固定数目。精心选择适应证、规范的手术操作和积极的术后康复锻炼是治疗成功的关键。     

The Gamma nail for peritrochanteric fractures.

The Gamma nail was designed to treat unstable intertrochanteric and subtrochanteric fractures. The device was developed after cadaver studies and has been used clinically since February 1985 in a total of 421 patients. The results in 123 patients treated by the third version of this design are reported. The Gamma nail transmits weight closer to the calcar than does the dynamic hip screw and it has greater mechanical strength. A semi-closed operative technique is used, with an average duration of operation of 35 minutes and little blood loss. Distal locking screws can be used to maintain rotational stability, and can be inserted without the use of an image intensifier. Results showed satisfactory fracture union with little loss of position, even in comminuted fractures. Operative complications were few, but included fractures of the base of the greater trochanter. The most important postoperative complication, seen in one case, was fracture of the shaft of the femur at the distal end of the nail, but this healed well after re-nailing.     

带锁髓内钉治疗股骨干骨折合并股骨颈及转子间骨折或转子下粉碎骨折

目的应用带锁髓内钉治疗股骨干骨折合并同侧股骨颈骨折及转子间骨折或转子下粉碎骨折。方法在1996年7月～1998年11月收治的16例复杂股骨骨折中,股骨干骨折合并同侧股骨颈骨折3例,合并转手间骨折4例,转子下粉碎骨折9例。其中10例应用国产加长型Gamma钉,6例使用Russell－Taylor股骨重建钉固定。结果所有病例随访6～22个月,平均11个月。除1例股骨干骨折合并同侧股骨颈骨折患者术后7个月出现股骨头坏死外,其余15例骨折均愈合,平均愈合时间5．5个月,患肢关节功能优良。经此方法治疗后可早期活动关节及功能锻炼、手术创伤小、切口小、固定可靠、骨折愈合率高。结论　　对股骨干骨折合并同侧股骨颈骨折及转手间骨折或转子下粉碎骨折的治疗,带锁髓内钉具有明显优势。     

The treatment of proximal femoral fractures using the interlocking nail

The good result hoped for with interlocking nailing of the proximal part of the femoral shaft is only possible when precise diagnosis is of the fracture form is made with reference to informative X-rays and a meticulous operative technique is observed. Therefore, positioning of the patient on an extension table, the repositioning of the bone, the choice of the insertion point for the nail, and careful drilling are of the utmost important. All follow-up examinations conducted in 42 patients, we found good or very good results in 32 cases, satisfactory results in 7, and poor results in 3.     

Gamma3 型髓内钉治疗股骨转子间骨折手术并发症的原因分析

 目的 分析 Gamma3 型髓内钉治疗股骨转子间骨折术后发生并发症的原因。方法 回顾性分析 2006 年 5 月至 2011 年 7 月应用 Gamma3 型髓内钉治疗股骨转子间骨折 186 例患者资料,其中 24 例出现手术并发症,男 19 例,女 5 例;年龄 42～81 岁,平均（69.00±3.27）岁。根据 AO/OTA 分型：A1 型 8 例,A2.1 型 1 例,A3 型 15 例;稳定性骨折 9 例,占 37.5%（9/24）;不稳定性骨折 15 例,占 62.5%（15/24）;均为新鲜骨折,排除病理性骨折。手术均采用闭合复位的方式进行固定,内固定器材为史赛克公司生产的短 Gamma3 型髓内钉。入院至手术时间为 3～12 d,平均 6 d;术后 3～16 d 出院。根据术中、术后随访的 X 线片及 Harris 功能评价标准对术后疗效进行评价,总结 Gamma3 型髓内钉在股骨转子间骨折应用中的并发症。结果 24 例患者手术时间为 45～160 min,平均 80 min;失血量为 300～800 ml,平均 600 ml;下地时间为术后 35～106 d。Harris 评分为 75～92 分,平均 81 分。24 例患者术后发生并发症的原因：1 例因未安装保护套筒而导致防旋钉进入大腿内侧肌间隙;3 例在闭合复位时进钉点偏外,扩髓时造成股骨外侧壁缺失;5 例因插入主钉前扩髓不充分而导致进钉时股骨干近端劈裂;6 例反转子间粉碎骨折,小转子嵌入骨折断端,致非解剖复位下置钉,对位欠佳;2 例难复型骨折术后出现再移位;3 例股骨外侧壁骨折,术后骨折移位;3 例骨折粉碎严重、大小转子分离移位明显者选用短 Gamma3 钉固定,术后发生拉力钉切出;1 例股骨干远端锁钉处再骨折。结论 对于 AO 分型中某些特殊类型的骨折,闭合复位短 Gamma3 钉固定具有较高并发症发生率,这多由复位方法、适应证选择不当以及非规范化使用器械造成,因此应明确长、短不同 Gamma 钉的适用范围及复位方法,尽量规避并发症发生。     

Early experience with closed interlocking medullary nailing of the femur

We report on the first 14 patients treated with the Grosse Kempf femoral locking nail in our hospital. As with simple closed nailing of the femur attention to detail in the operating theatre is important. To date there have been only a few minor complications with the procedure, apart from one non-union. It allows stabilization of complicated fractures of the femoral shaft particularly in patients with multiple and often bilateral injuries caused by high velocity. It is concluded that it is an excellent procedure for complicated unstable fractures of the femoral shaft which would otherwise be treated on traction, and that the procedure can be safely performed in any centre where closed intramedullary nailing is commonly practised.     

Long proximal femoral nail in ipsilateral fractures proximal femur and shaft of femur

Background:

Ipsilateral fractures of the proximal femur and femoral shaft are extremely uncommon injuries which occur in young adults who sustain a high energy trauma. A variety of management modalities have been tried to treat this complex fracture pattern ranging from conservative approach to recently introduced reconstruction nails. All these approaches have their own difficulties. We studied the outcome of long proximal femoral nail (LPFN) in the management of concomitant ipsilateral fracture of the proximal femur and femoral shaft.

Materials and Methods:

We analysed the prospective data of 36 consecutive patients who had sustained a high energy trauma (30 closed fractures and 6 open shaft fractures) who had concomitant ipsilateral fractures of the femoral shaft associated with proximal femur fractures treated with LPFN between December 2005 and December 2011. The mean age was 39 years (range 28-64 years). Twenty nine males and seven females were enrolled for this study.

Results:

The patients were followed up at three, six, twelve, and eighteen months. The mean healing time for the neck fractures was 4.8 months and for the shaft fractures was 6.2 months. The greater trochanter was splintered and widened in two cases which eventually consolidated. Two patients had superficial infection, two patients had lateral migration of the screws with coxa vara which was due to severe osteoporosis detected during the followup. We had two cases of nonunion of shaft fracture and one case of nonunion of neck fracture. Two cases of avascular necrosis of femoral head were detected after 2 years of followup. No cases of implant failure were noted. Limb shortening of less than 2 cms was noted in four of our patients. The functional assessment system of Friedman and Wyman was used for evaluating the results. In our series 59.9% (n = 23) were rated as good, 30.6% (n = 11) as fair, and 5.5% (n = 2) as poor.

Conclusion:

Long PFN is a reliable option for concomitant ipsilateral diaphyseal and proximal femur fractures.     

Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail

One hundred twelve comminuted or rotationally unstable fractures of the femur were treated with the Grosse-Kempf interlocking nail. Two-thirds of the fractures had comminution involving more than 50% of the cortex. Of the 112 nailings, 82 were static and 30 dynamic. Clinical and radiographic fracture union occurred in 98% of cases; there were two nonunions. There were no instances of deep wound infection or osteomyelitis. Only two patients had a change of limb length greater than 1 cm. Angulation in any plane greater than 10 degrees was noted in three patients (2.5%). External rotation deformities occurred in eight patients (7.0%). The interlocking nail has expanded the indications for the use of closed intramedullary nailing in the treatment of complex fractures of the femur. The incidence of infection and nonunion is remarkably low. Immediate stability of the fracture allows for immediate mobilization of the patient, early rehabilitation of the limb, and a shorter hospital stay.     

两种股骨近端髓内钉治疗老年粗隆部骨折的比较分析

目的:比较两种股骨近端髓内钉PFNA和PFN治疗老年粗隆部骨折的疗效.方法:2005年12月-2006年9月收治的14例70岁以上粗隆部骨折患者随机分别使用PFNA(PFNA组)、PFN(PFN组)治疗,比较两组手术完成时间、术后下地负重行走时间、术后非手术区并发症情况及术后4个月X线复查情况.结果:PFNA组手术时间31～62 min,平均(46.29±10.98)min,较PFN组手术时间[67～113 min,平均(88.29±17.25)min明显缩短.PFNA组下地负重行走时间为术后3～5 d,平均(3.57±0.79)d,PFN组为5～20 d,平均(9.71±16.73)d.PFN组术后2例出现并发症,分别为患肢髂外静脉栓塞和股静脉栓塞;术后4个月1例X线片显示股骨颈切割征象.结论:对于粗隆部骨折的老年患者,PFNA内固定系统在缩短手术时间、减少卧床时间、减少术后并发症方面优于PFN,在减少股骨颈切割方面是否存在优势还需进一步观察.     

A review of fractures in the proximal femur treated with the Zickel nail.

The Zickel intramedullary fixation device was used to treat 26 patients with subtrochanteric or impending subtrochanteric fractures. The use of this device has advantages over traditional traction methods as well as nail plate fixation. Twenty-two patients were ambulatory within one month following surgery. Healing of the fracture by roentenogram required an average of 4.9 months and had a high union rate, 17 out of 18 patients was apparent with the use of the Zickel device. There is no classification of fractures at present which has a prognostic value when intramedullary fixation is used. Traumatic and pathologic fractures were treated with similar results. There was no appliance failure in this series.     

Minimal invasive treatment of proximal femur fractures with the long gamma nail: indication, technique, results

BACKGROUND: The surgical treatment of complex unstable proximal femur fractures from the trochanteric region to the middle shaft area is difficult and often highly invasive, especially in older patients with osteoporotic bones. METHODS: In 1993, we began to treat all unstable proximal femur fractures from the trochanteric region to the middle third of the shaft with the long gamma nail (LGN) and allowed the patients immediate full weightbearing after surgery. Perioperative, postoperative, and follow-up data were analyzed. RESULTS: During a 3-year period, we treated 37 patients with unstable proximal femur fractures with the LGN. Five of the patients had sustained pathological fractures, and four patients had sustained multiple trauma. The 37 operations were performed by 22 different surgeons with varying degrees of experience. The LGN implantations through maximal 40-mm skin incisions were performed in a mean skin-to-skin operation time of 125 minutes (range, 65-200 minutes) without any further complications. Thirty-one of the 37 patients were allowed immediate full weightbearing after the second postoperative day. The six patients who were not allowed full weightbearing were the ones who had multiple trauma (4) and those who were unable to walk before surgery (2). Three postoperative complications were as follows: one deep infection 4 months after surgery, one superficial infection 3 weeks after surgery, and one deep vein thrombosis 2 weeks after discharge. All three complications occurred in the group of patients who had sustained only one trauma. All traumatic fractures (n = 32) healed without any bone grafting, which means a union rate of 100%. Although immediate full weightbearing was allowed, there were no implant dislocations, implant failures, or other problems. The 30-day mortality was 0%. The follow-up examinations after a mean time of 6 months were very satisfying. All traumatic fractures were healed. The patients had symmetrical functional findings to the opposite side or before surgery, respectively, except for two patients with a leg shortening of 2 cm, two patients with an external malrotation of 10 degrees, and one patient with a hip extension deficit of 10 degrees after a pathological fracture. CONCLUSION: The LGN is, after appropriate introduction and training, a safe and easy implant for the treatment of complex proximal femur fractures from the trochanteric region to the middle shaft area. The minimal invasive technique with low risks and minimal complications and the possibility of immediate full weightbearing sets a new standard, especially for older patients with osteoporotic bones.     

逆行交锁髓内钉治疗股骨远端骨折

目的 总结逆行交锁髓内钉内固定结合CPM治疗股骨远端骨折的临床效果。方法 采用逆行交锁髓内钉内固定治疗30例股骨远端骨折，术后早期进行伤肢CPM锻炼。结果 30例随访6～18个月，平均10个月，骨折住6～8个月内愈合，膝关节功能恢复良好．优良率93％。结论 逆行交锁髓内钉内固定治疗股骨远端骨折具有稳定性高、固定牢靠、操作简单安全的特点：术后早期可进行伤肢CPM锻炼，骨折愈合快，并发症少，是一种治疗股骨远端骨折比较理想的方法，     

Complex fractures of the femur: treatment with a long gamma nail: short- and medium-term experience

The introduction of the gamma nail and of the long gamma nail, associating the principle of intramedullary nailing and of the sliding screw-plate, has led to good results in the treatment of complex fractures such as per-sub-trochanteric fractures and associated fractures of the femoral neck-diaphysis. In this study, our experience with the long gamma nail (Long Gamma Nail Howmedica) is presented. Of the 43 patients treated between 1993 and 1998, 21 (49%) with a mean follow-up of 2.5 years (1-5 years) were reviewed. Clinical and a radiographic evaluations were obtained for each of the patients. This study showed that there was a high incidence of poor consolidation (dysmetria in 10 patients, torsion deficit in 7, consolidation in varus of the femoral neck in 1 patient) particularly in associated fractures of the femoral neck and diaphysis, accompanied, however, by good functional recovery (only 3 patients with modification in the angle of progression of the foot) and by the satisfaction of the patients questioned. Thus, indications for the use of this device in proximal fractures of the femur, particularly in elderly patients and in high-energy traumas, are demonstrated.     

Finite element study of the proximal femur with retained trochanteric gamma nail and after removal of nail

This study aims to evaluate the stress and strain distributions in the healed proximal femur after fixation with a trochanteric gamma nail (TGN) and after TGN removal, using the finite element method. The stress distributions in the proximal femur with retained TGN and after TGN removal were very similar. The strain and the strain energy density in the femoral neck region with retained TGN were much higher than in the lag screw hole at the subtrochanter and the distal locking screw hole at the proximal femur, and even higher after TGN removal. Stair climbing resulted in higher strain and higher strain energy density at the femoral neck than normal walking. The conclusion can be drawn that removal of the TGN may result in high risk of femoral neck fracture.     

交锁髓内钉治疗骨质疏松性肱骨近端并同侧肱骨干骨折的临床研究

目的 探讨应用交锁髓内钉治疗肱骨近端合并同侧肱骨干骨折的疗效.方法 2008年2月至2009年1月采用肱骨髓内钉治疗肱骨近端合并同侧肱骨干骨折患者13例,男5例,女8例;年龄为65～78岁,平均年龄68.6岁;按照A0分类肱骨近端骨折均为A1型(关节外骨折,两部分,外科颈型),肱骨干骨折分为A1型3例,A2型4例,A3型2例,B2型3例,B3型1例.结果 8例患者成功行闭合复位固定术,术中出血<50 ml,手术时间平均85.0 min(60～125 min).其余5例行有限切开复位内固定术,术中出血量平均157.3 ml(100～250 ml),手术时间平均105.0 min(95～150 min).所有患者平均随访12.1月(9～18月).12例骨折愈合,平均骨愈合时间3.5月(3～5月),1例患者为多发性骨髓瘤致肱骨多发性病理性骨折,骨折未愈合.末次随访VAS评分平均为30.8分(18～70分),肩关节功能OSS评分平均为20.7分(16～31分),肘关节功能HSS评分平均为91.5分(68～95分),优良率92.3%.结论 肱骨髓内钉是治疗肱骨近端合并同侧肱骨干骨折一种可供选择的有效内固定方法.     

Employing a modified gamma nail for the treatment of proximal femoral fractures

A modified custom-designed long gamma nail (LGN10) and the long gamma nail (LGN11) were evaluated in a prospective trial for operative treatment of proximal femoral fractures. Between May 1998 and January 2000, 50 patients (mean age 79 years) were alternately treated with LGN10 or LGN11. The femoral antecurvature varied from 6 degrees to 10 degrees, with a maximum of 14 degrees, as evidenced by lateral radiograms. The need for intramedullary reaming in LGN10 cases was significantly less ( p=0.046). Other significant differences between the two study groups were not observed. One cranial cut out of the lag screw in the LGN10 group was observed. Other complications were not recorded during hospital treatment. Follow-up results are not yet complete. Using LGN10 seems to reduce intramedullary damage to the femur and make insertion of the nail easier.     

A biomechanical study comparing proximal femur nail and proximal femur locking compression plate in fixation of reverse oblique proximal femur fractures

BackgroundThe reverse oblique trochanteric fractures are common fractures and its treatment poses a challenge. The purpose of this study was to compare the biomechanical parameters of the construct using proximal femoral nail (PFN) and proximal femoral locking compression plates (PFLCP) in these fractures using cadaveric specimens.Materials and MethodsTwenty freshly harvested cadaveric femoral specimens were randomly assigned to two groups after measuring bone mineral density, ten of which were implanted with PFN and the other ten with PFLCP. The constructs were made unstable to simulate reverse oblique trochanteric fracture (AO type 31A3.3) by removing a standard size posteromedial wedge. These constructs were tested in a computer controlled cyclic compressive loading with 200 kg at a frequency of 1 cycle/s (1 Hz) and test was observed for 50,000 cycles or until implant failure, whichever occurred earlier. Peak displacements were measured and analysis was done to determine axial stiffness and subsidence in axial loading.ResultsAll the specimens in PFN group completed 50,000 cycles and in PFLCP group, seven specimens completed 50,000 cycles. Average subsidence in PFN group was 1.24 ± 0.22 mm and in PFLCP group was 1.48 ± 0.38 mm. The average stiffness of PFN group (72.6 ± 6.8 N/mm) was significantly higher than of PFLCP group (62.4 ± 4.9 N/mm) (P = 0.04). The average number of cycles sustained by PFLCP was 46634 and for PFN group was 50,000 (P = 0.06).ConclusionThe PFN is biomechanically superior to PFLCP in terms of axial stiffness, subsidence and number of specimens failed for the fixation of reverse oblique trochanteric fractures of femur.