Management of pertrochanteric fractures in high-risk patients with an external fixation

In 44 surgical high-risk patients (ASA grade 3 or 4) pertrochanteric fractures were treated with a newly developed external fixator; all fractures healed within 14 weeks. Seven patients had a superficial pin tract infection and in 12 patients the fracture united with a shortening of 18 (5-30) mm. No implant failures or limitation of knee movements were recorded. Nine patients died during the first 6 months. The "pertrochanteric fixator" is a valuable alternative for treating high-risk, elderly patients.     

老年不稳定性股骨转子骨折髓内固定的治疗策略

目的探讨应用股骨近端髓内钉（proximal femoral nail，PFN）治疗老年不稳定性股骨转子骨折的手术方法及术后功能锻炼策略。方法采用PFN治疗老年不稳定性股骨转子骨折77例79侧，男29例29侧，女48例50侧。年龄60—95岁，平均73．6岁。根据AO／ASIF骨折分型：A2型56例58侧，A3型21例21侧。术后早期功能锻炼。对骨折复位情况、内固定效果、髋关节功能、术中及术后并发症等进行统计。结果术中复位效果优良率100％，手术操作优良率81％～84．5％。术后3～6个月时骨折均愈合。随访1～2年，髋关节功能恢复良好，无复位丢失、内固定失败等。结论PFN能提供可靠的内固定，用于老年不稳定性股骨转子骨折的治疗临床效果良好。     

股骨近端防旋髓内固定治疗高龄股骨转子周围骨折

目的探讨应用股骨近端防旋髓内固定(PFNA或Gamma3)治疗高龄股骨转子周围骨折的疗效。方法对65例高龄股骨转子周围骨折患者经详细术前评估后,在透视下行骨折闭合复位,采用PFNA或Gamma3行内固定。术后第2天开始功能锻炼。随访时对骨折复位情况、内固定效果、髋关节功能及并发症等进行分析。结果 65例患者术中、术后复位效果评估:PFNA组优12例,良5例,差4例,优良率81%;Gamma3组优25例,良11例,差8例,优良率81.8%。51例获得完整随访,时间6～12个月,术后24周时HSS评分为58～85(63.5±16.5)分。Gamma3组术后发生深静脉血栓2例,PFNA组发生深部感染1例,均经治疗后痊愈;术后4周内PFNA组2例发生螺旋刀片股骨头内切出,二次取出内固定;无神经损伤及骨不愈合等发生。结论对高龄股骨转子周围骨折患者采用PFNA或Gamma3髓内固定治疗均可获得较好的临床疗效。     

Secondary fractures associated with external fixation in pediatric femur fractures.

Sixty-six femur fractures sustained by children ages 4-14 years and treated with external fixation were reviewed retrospectively to assess factors influencing the incidence of refracture. The total rate of secondary fracture was 12% (eight patients) including five recurrent fractures at the original fracture site and three fractures through the pin sites. After removal of the external fixator, five patients refractured at the original fracture site and one patient fractured through a pin tract. Two patients fractured at pin sites while the fixator was still in place. Multivariate linear-regression analysis showed no correlation between the incidence of refracture and fracture pattern, percentage of bone fragment contact after fixator application, type of external fixator, or dynamization. A statistically significant association (p < 0.05) was found between the number of cortices demonstrating bridging callus [on both anteroposterior (AP) and lateral views] at the time of fixator removal and the rate of refracture. Fractures showing fewer than three cortices of bridging callus had a three (33%) in nine rate of refracture, whereas fractures with three or four cortices of bridging callus had a two (4%) of 57 rate of refracture.     

Complex femur fractures in children: treatment with external fixation

External fixation was used to treat complex femur fractures in 10 children. These injuries were associated with head trauma, cerebral palsy, epidermolysis bullosa, open wounds, and failed casting. The duration of external fixation averaged 8 weeks, and the mean follow-up was 5 years 8 months. At follow-up, one patient had 2.6 cm of residual shortening, and two had overgrowth. Complications included one refracture. Three children developed superficial pin site drainage. Although most femur fractures can be treated with traction or casting, external fixation may simplify overall care in children with multiple injuries and is effective in controlling unacceptable femoral shortening and angulation.     

Rates of refracture associated with external fixation in pediatric femur fractures

We conducted a small retrospective study of rates of early complications associated with external fixation of pediatric femur fractures and compared rates at our institution with those reported in the literature. In our series of 22 patients, early complications included 12 pin-track infections (54.5%), 2 cases of loss of reduction (9.1%), 1 pin-track abscess (4.5%), and 1 refracture (4.5%). Overall rates (ours combined with those reported by other investigators) were 4.7% (34/719) for refractures and 33.1% (224/677) for pin-track infections. Factors that correlated with refractures were open fracture, bilateral fracture, and longer time in fixator. Factors with inconclusive correlations were fracture pattern, dynamization status, fixator type, pin size, and number of pins.     

Condylo-cephalic nail fixation for trochanteric fractures of the femur (author's transl)

Condylo-cephalic nailing which has been developed by Ender is described. Three elastic pins are inserted at the proximal part of the medial femoral condyle and passed through the femur across the fracture into the head of the femur. The operative procedure is very simple and not hazardous to elderly patients. A special advantage is early weight-bearing. One hundred and three patients with intertrochanteric and subtrochanteric fracture were treated by this method. The average age was seventy-six years. Our own experiments have shown that this method can allow immediate weight-bearing.     

Intramedullary hip screw fixation of reverse oblique and transverse trochanteric femur fractures

Introduction  Reverse oblique and transverse trochanteric femur fractures (31A3) are relatively rare. They are associated with a high failure rate, particularly in cases where extramedullary implants are used. This study investigated a second-generation intramedullary nail in this specific fracture type. Methods  Flinders Medical Centre is a level 1 trauma centre and the largest user of the Intramedullary Hip Screw (IMHS, Smith and Nephew, Memphis, USA) in the Southern Hemisphere. Two hundred and forty-eight IMHS cases completed between September 2003 and August 2005 were retrospectively analysed. All fractures were classified using the AO/ASIF system (Muller et al., The comprehensive classification of fractures of the long bones, Springer, Berlin, 1990) and 31A3.1, 2, 3 fractures were selected. The case notes and radiology were reviewed over a 1-year follow-up. Results  Twenty-six cases were classified as 31A3 fractures. Thirty-eight percent of the cases received a long stem IMHS. Mean patient age was 81.9 years with a 1-year mortality of 11.5%. Two of the 26 cases (7.7%) had surgical complications, including one cut-out (associated with a tip-apex distance of 40.9 mm) and one loss of reduction. Both cases required re-operation. There were no femoral shaft fractures or non-unions in this series. Conclusions  This second-generation intramedullary implant, the IMHS, performed well in this often difficult to fix fracture. The complication rate is considerably less than the rate published for extramedullary implants and is comparable to previous studies using a range of intramedullary techniques.     

经皮螺纹针骨水泥球结状外固定治疗股骨转子间骨折

1998年1月～2004年6月,我院采用经皮螺纹针骨水泥球结状固定治疗股骨转子间骨折患者36例,取得了较好的疗效。1材料与方法1.1病例资料本组36例,男28例,女8例,年龄52～82岁。按Evan法分类:Ⅰ型5例,Ⅱ型6例,ⅢA型25例。其中22例并存有心血管、肺、脑血管意外后遗症等疾病。均为新鲜骨折。1.2治疗方法入院后先予以胫骨结节骨牵引3～7d。根据患者全身检查结果积极有效地控制并存症。复位满意后维持牵引,于C臂X线机监视下进行手术。采用局麻,先于透视下选择进针点并确定股骨头中心,尽量采用强斜位路线,沿压力骨小梁进入,平行穿入2枚或3枚φ4mm螺…     

X线透视导航在股骨转子间骨折髓内固定中的应用

目的探索在X线透视导航下使用Gamma钉治疗股骨转子间骨折的方法。同时,对依据导航特性设计的新型Gamma-3和以往使用的Gamma-AP内固定系统进行比较。方法66例股骨转子间骨折患者在导航下行Gamma钉植入(40例使用Gamma-AP,26例使用Gamma-3),由同一观察者记录各种术中数据。结果Gamma-3治疗组较Gamma-AP组手术时间短(平均32min),切口小(平均5cm),操作中X线照射时间短(7min),且拉力螺钉位置好(顶轴距17.9mm)。结论使用导航系统微创置入Gamma钉不仅进针方向精确,拉力螺钉位置好,切口小,而且还可以减少术者的X线暴露时间。由于Gamma-3依据导航特性设计,其效果优于Gamma-AP系统。     

Bone mineral density in patients with cervical and trochanteric fractures of the proximal femur

The bone mineral density (BMD) of the proximal femur, spine and radius shaft was determined in 75 women with atraumatic fractures of the proximal femur (FXf) (average age: 70.1±9.6 years) and 51 controls of similar age. Fractures were classified as either cervical (n=36) or trochanteric (n=39) on the basis of radiographic and surgical finding. The BMD of spine and proximal femur was determined by dual-photon absorptiometry (Lunar DP3) and the BMD of the radius shaft by single photon absorptiometry. The BMD of patients with FXf was significantly decreased over all skeletal sites compared to controls of similar age. No significant correlation was found between age and the BMD of the femoral neck in patients with FXf. Patients with trochanteric FXf were older and thinner (average: age, 72.9±9.4 years; weight, 53.1±7.8 kg) compared with patients with cervical fractures (age, 67.2±8.9 years; weight, 59.3±8.3 kg). Likewise the BMD of trochanteric FXf was lower at all measured sites: femoral neck, 0.548±0.066 g/cm² vs 0.624±0.055 g/cm² (P<0.001); L2-L4, 0.799±0.115 g/cm² vs 0.925±0.106 g/cm² (P<0.001); radius shaft, 0.454±0.057 g/cm² vs 0.502±0.083 g/cm² (P<0.05). Of the patients with trochanteric fractures 66% had concomitant vertebral fractures, while this occurred in only 28% of the patients with cervical fractures (P (Fisher)=0.0007). In summary, females with trochanteric FXf are older, thinner, have less bone mass in all measured sites and suffer with a significantly greater frequency of vertebral fractures. These patients have a generalized osteoporosis of the skeleton. Patients with cervical FXf seem to have more specific loss of the proximal femur (regional osteoporosis). The physiopathological process leading to trochanteric and cervical fractures is probably different.