股骨远端粉碎骨折应用股骨远端内固定系统手术失败原因分析

[目的]探讨股骨远端粉碎性骨折行股骨远端微创内固定系统(less invasive stabilization system-distalfemur,LISS-DF)术后发生内固定失败的原因。[方法]自2004年8月～2008年12月应用LISS-DF治疗186例股骨远端粉碎性骨折,按AO/OTA分类:33A3型59例,33C2型71例、33C3型56例。[结果]全部病例平均随访24.5个月(11～37.5个月);最后1次随访时均完成骨性愈合,X线骨愈合时间平均6.1个月(3.5～12.6个月);18例在最后1次随访时发生膝关节僵硬(活动范围:-5°～65°);其余患者膝关节活动屈115°(109°～118°),伸0°。术后13例发生内固定松动、脱出及断裂并发症。患膝按Rasmussen骨折复位标准评分[1],平均17.6分(12～19分),其中优108例,良78例;按照Merchant膝关节功能评分[2]:优98例、良70例、可18例,优良率为90.3%。[结论]术中发生钢板位置漂移、锁钉偏向和螺纹破坏、钢板长度选择不恰当、严重骨缺损而未植骨及术后过早负重可能是股骨远端粉碎性骨折行LISS-DF术后发生内固定失败的主要原因,减少医源性因素和增加患者的医从性是有效避免此类并发症发生并取得满意疗效的关键。     

逆行交锁髓内钉治疗股骨远端骨折延迟愈合及不愈合

目的 观察逆行交锁髓内钉治疗股骨远端骨折延迟愈合、不愈合的临床疗效。方法 9例股骨远端骨折延迟愈合及不愈合,并伴膝关节不同程度关节功能活动障碍患者,行手术取出内固定,膝关节软组织松解,骨折复位,逆行交锁髓内钉内固定,并取自体髂骨植骨,术后配合CPM行患肢膝关节功能锻炼。结果 术后随访16～26个月全部患者均获得骨性愈合,无内固定物松动、断裂。膝关节功能活动观显改善。结论 逆行交锁髓内钉治疗股骨远端骨折延迟愈合、不愈合,临床效果满意,特别适宜在其它内固定物失败的情况下使用。治疗的关键在于术中膝关节软组织充分松解,骨折块准确复位,扩髓并正确插入合适的髓内钉,静力固定,植骨及术后积极地功能锻炼。     

逆行交锁髓内钉治疗股骨远端骨折

目的探讨逆行交锁髓内钉治疗股骨远端骨折的疗效。方法本组应用逆行交锁髓内钉,结合手法复位、有限切开复位加C型臂X线机透视和小切口经皮等微创技术,治疗股骨远端骨折。按A0／ASIF标准分类：A型骨折12例,C1和C2型骨折6例。固定18例股骨远端骨折。结果术后随访6～20个月,骨折全部愈合,无膝内翻及外翻无严重并发症,优11例,良5例,可2例。疗效满意。结论股骨远端骨折应用逆行交锁髓内钉固定,掌握其手术适应证,术中在C型臂X线机透视下使骨折确切复位,注意股骨远端的力线恢复,膝关节功能满意。     

股骨远端粉碎骨折微创固定术相关因素分析

目的探讨微创固定术治疗股骨远端粉碎骨折的疗效并分析相关因素。方法自2005年4月至2007年3月,应用微创内固定术（经皮钢板内固定/经关节入路经皮钢板内固定）治疗股骨远端粉碎骨折12例。男9例,女3例;年龄20～73岁,平均42岁。AO分型,33-A3型2例,33-C2型2例,33-C3型8例。手术累及关节的C型骨折采用TARPO技术,股骨远端A型骨折采用MIPPO技术。术后每2周复查一次,骨折临床愈合后每2～3个月复查一次,观察内固定及骨折愈合情况。结果除2例失访外,其余术后随访5～23个月,平均14个月,所有病例均获骨性愈合,无感染、钢板及螺钉脱出和断裂,骨折复位丢失。膝关节功能按照患者的主观感受及客观检查结果按照美国特种骨科医院膝关节评分（the hospital for special surgery,HSS）HSS评分法进行评估,优5例,良3例,可2例,优良率80%。结论微创手术治疗股骨远端粉碎骨折具有损伤小、并发症少、一般不需植骨、促进骨折愈合等优点,是一种疗效较好的方法。     

经关节入路微创钢板固定技术治疗股骨远端C型骨折

目的探讨经关节入路微创钢板固定(MIPPO)技术治疗股骨远端C型骨折的临床疗效。方法2002年4月～2005年2月,应用MIPPO技术治疗股骨远端C型骨折14例,按AO/ASIF分类：C1型3例,C2型6例,C3型5例。先行关节内骨折切开复位、松质骨螺钉固定,再行髁上部分骨折间接复位、经关节内切口插入髁支撑钢板或LISS钢板桥接固定骨折。结果12例患者获得10～32个月(平均18．4个月)随访,骨折均获愈合,愈合时间10周～12个月,平均4．6个月。按Kolmert和Wulff的评价标准：优4例,良5例,可2例,差1例,优良率为75%。结论应用MIPPO技术治疗股骨远端C型骨折实现了微创操作,具有创伤小、软组织干扰少、骨折愈合快等优点,疗效满意。     

外固定架结合内固定治疗桡骨远端关节内骨折

目的探讨外固定支架结合内固定钢板治疗桡骨远端关节内骨折的手术指征及临床疗效。方法23例桡骨远端关节面骨折患者,根据AO分型标准分类,C2型8例,C3型15例。采用外固定支架固定,结合钢板内固定。结果23例均获得随访,随访时间6～18个月,平均10.5个月。X线片示骨折均愈合,桡骨长度无丢失。掌倾角8°～16°,平均12.5°;尺偏角19°～28°,平均21.8°,均无丢失。根据Gartland等评分标准结合X线片所测参数,本组优20例,良3例。结论外固定支架结合钢板内固定治疗桡骨远端关节内骨折可获满意复位及功能。     

GSH髁上交锁髓内钉治疗股骨远端粉碎骨折

目的 :总结GSH交锁髓内钉治疗股骨远端粉碎骨折的效果。方法 :18例股骨远端骨折采用GSH钉固定 ,骨折按AO/ASIF分类 :A型 11例 ,C型 7例。A型骨折采用闭合复位 ,C型骨折采用开放复位 ,髁间用 2枚 6.5mm螺丝钉固定。结果 :平均手术时间为 2 46min ,平均手术出血量为 2 7.4ml;平均随访 10 .5个月 ,16例骨折正常愈合 ,1例骨折不愈合 ,1例延迟愈合 ,平均骨折愈合时间为 4.5个月 ;平均膝关节活动度为 98° ,A型骨折 10 1° ,C型骨折 93° ;2例钉尾外留过长 ,膝关节屈曲时撞击髌骨产生疼痛 ;1例骨折端内翻 8°。结论 :GSH交锁髓内钉可有效治疗股骨远端髁上或髁间骨折 ,具有手术时间短、出血少、固定牢靠、骨折愈合率高、并发症少等优点。     

有限切开复位逆行交锁髓内钉治疗股骨远端骨折

目的　探讨有限切开复位逆行交锁髓内钉 (GSH)治疗股骨远端骨折的疗效。方法　采用小切口开放复位GSH钉治疗 18例股骨远端骨折。结果　术后无感染、内固定断裂现象 ;骨折均复位满意 ,无延迟愈合或不愈合发生。平均随访 17个月 ,伤肢膝关节屈伸活动范围 90°～ 12 5°,平均 10 5°。结论　有限切开复位逆行交锁髓内钉治疗股骨远端骨折疗效满意 ,操作简便 ,值得推广使用。     

LISS治疗股骨远端骨折疗效及膝关节功能影响因素分析

目的评价股骨远端微创内固定技术（USS）治疗股骨远端骨折的治疗效果并分析影响膝关节功能的影响因素。方法自2009—01-2012—11应用USS—DF钢板内固定治疗股骨远端骨折81例。以临床功能和X线检查结果评价治疗效果。对可能影响膝关节功能的年龄、性别、骨折类型、创伤类型、是否为开放性损伤、是否为多发伤、手术距受伤的时间、是否早期功能锻炼、是否出现并发症作多因素Logistic回归分析。结果81例平均随访18．2（14-21）个月,78例骨折一期愈合。膝关节活动度：A型骨折平均109．1°,C型骨折平均101°。膝关节功能按HSS评分评定：A型骨折优良率91．4％,C型骨折优良率71．7％。多因素Logistic回归分析显示骨折类型、是否早期功能锻炼、是否出现并发症是影响膝关节功能的独立危险因素。结论LISS—DF钢板内固定治疗股骨远端骨折固定牢固,骨折愈合率高,是一种理想的内固定,术后患者应早期加强功能锻炼,减少并发症,提高膝关节功能恢复。     

逆行交锁髓内钉结合CPM治疗股骨远端骨折24例

目的：总结应用逆行交锁髓内钉内固定结合CPM治疗股骨远端骨折的疗效及经验。方法：应用逆行交锁髓内钉固定股骨远端骨折,术后配合CPM行患肢膝关节功能锻炼。结果：24例术后随访5～20个月,平均10个月。骨折愈合时间为3～5个月。膝关节功能恢复良好,优良率83.3％,无畸行愈合、不愈合、断钉、感染等并发症。结论：采用逆行交锁髓内钉结合CPM治疗股骨远端骨折,固定坚强并发症少,利于骨折愈合及关节功能恢复,是理想的治疗方法。     

陕西地区股骨上段骨折风险阈值研究

目的 找出最佳的预测老年人群股骨上段骨折风险的方法.方法 利用双能X线吸收仪(DEXA)和其他工具,测量30具尸体骨右侧股骨上段的骨密度、几何形态以及股骨上段极限强度.然后,通过物理公式分析摔倒时股骨上段的受力情况.结果 (1)女性各项参数多数低于男性.(2)股骨颈骨密度与股骨上段载荷之间的相关性最佳(r2 =0.807),推导出预测股骨上段骨折风险回归方程.(3)股骨颈宽度与股骨上段极限强度的相关性较好.(4)推导出骨折风险阈值.结论 (1)陕西地区老年人股骨上段骨折发生率较低,与体型小导致摔倒时的暴力低有关.(2)股骨颈骨密度为较好的骨折风险预测指标.与几何形态结合可提高预测能力.(3)通过骨折风险阈值公式早期预防骨质疏松骨折的发生.     

Comparison of complications and functional results of unstable intertrochanteric fractures of femur treated with proximal femur nails and cemented hemiarthroplasty

A prospective, comparative study was done over a period of 3 years to compare the complications and functional results of two treatment modalities of unstable intertrochanteric fractures of the femur in the elderly; i.e closed reduction and internal fixation (CRIF) with proximal femur nail (PFN) and primary cemented hemireplacement arthroplasty (HRA) with bipolar prosthesis. 100 elderly patients with unstable intertrochanteric fractures of femur were studied over a period of 3 years. 50 patients underwent CRIF with PFN and 50 patients were treated with primary cemented hemireplacement arthroplasty with bipolar prosthesis. Harris Hip score analysis revealed that the difference between the patients treated with cemented hemiarthroplasty and proximal femoral nailing was statistically significant in favour of the hemiarthroplasty group within the first 3 months. However, this difference diminished at the 6th month time point and reversed at the 12 month time point indicating a better functional outcome of Proximal Femur Nail in the long term. Although cemented hemireplacement arthhroplasty allows early pain free mobilization and has a good short term outcome, over time it is associated with a variety of complications which significantly affects quality of life of patients. On the other hand, although patients treated with PFN had delayed post op mobilization, they had better results when followed up at 1 year post surgery.     

The male neck of femur

Fractured neck of femur in elderly is associated with mortality which is reported in literature to vary between 20 and 40%. One of the factors which is suggested to be a risk factor is male sex. We reviewed 83 male necks of femur patients admitted over a period of a year to assess the patient’s physical status, influence of co-morbidities, postoperative course and mortality. The in-hospital mortality was 26.5% and 1-year mortality was 44.6%. The in-hospital mortality for female neck of femur patients during the same period was 18%. Increasing age, high ASA category and post-operative chest infections were associated with high peri-operative mortality, and fall sustained in an acute hospital ward was associated with high 1-year mortality in addition to ASA grade and chest infection. Patients who had a chest infection in the post-operative period had in-hospital mortality of 46.2% (P value 0.006) and a 1-year mortality of 73.1% (P value 0.001). Patients who fell in the ward as inpatients under geriatric care had 60% mortality.     

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.     

Proximal femur bone mineral levels of US adults

This paper describes bone mineral levels in the proximal femur of US adults based on a nationally representative sample of 7116 men and women aged 20 years and older. The data were collected in phase 1 of the third National Health and Nutrition Examination Survey (NHANES III, 1988–1991) using dual-energy X-ray absorptiometry, and included bone mineral density (BMD), bone mineral content (BMC) and area of bone scanned in five selected regions of interest (ROI) in the proximal femur: femur neck, trochanter, intertrochanter, Ward's triangle and total. These variables are provided separately by age and sex for non-Hispanic whites (NHW), non-Hispanic blacks (NHB) and Mexican Americans (MA). BMD and BMC in the five ROI tended to decline with age, whereas area did not. BMD and BMC were highest in NHB, intermediate in MA and lowest in NHW, but areas were highest in NHW, intermediate in NHB and lowest in MA. Men had greater BMD, BMC and area than women in all three race/ethnic groups. Differences by age, sex or race/ethnicity tended to be the largest in Ward's triangle, followed by the femur neck; patterns in the trochanter, intertrochanter and total ROI were reasonably similar to each other. This report provides extensive data on femur bone mineral levels of adults from one of the largest samples available to date and should be valuable as reference data for other studies which examine this skeletal site in adults.     

Custom total femur spacer and second-stage total femur arthroplasty as a novel approach to infection and periprosthetic fracture

Total femur arthroplasty procedures have previously been used after tumor excision and as a last resort for failed revision arthroplasty. The patient in this case presented with massive loss of femoral bone stock, a periprosthetic fracture, and recurrent Staphylococcus epidermidis infection. A specially designed total femoral spacer impregnated with antibiotics was created for a 2-stage revision procedure that successfully restored functional ability and eradicated the infection. Although 2-stage protocols with spacers have been used to treat persistent infections after hip and knee arthroplasty, this is the first reported instance of the creation of a total femur antibiotic-impregnated cement spacer and subsequent total femoral arthroplasty as a 2-stage protocol at our institution.     

儿童股骨颈骨折的外科治疗

目的 探讨儿童股骨颈骨折的外科治疗方法的选择问题。方法 收集并随访20例儿童股骨颈骨折,平均随访3年5个月,按Colonna分类,包括:Ⅰ型:骨骺分离3例;Ⅱ型:经颈骨折8例:Ⅲ型;基底部骨折5例;Ⅳ型:经转子骨折4例。所有患儿均采用闭合复位,其中Ⅰ型,Ⅱ型及Ⅲ型中移位明显不稳定者复位后采用克氏针内固定并行髋人字石膏固定4～6周;Ⅱ型及Ⅲ型中无移位者及Ⅳ型行髋人字石膏固定4～6周;Ⅱ型及Ⅲ型中无移位者及Ⅳ型行髋人字石膏固定4～6周。结果 临床及X线征象均较优者占65％,良好者20％,较差者15％,效果满意。结论 对于儿童股骨颈骨折,应该于基于解剖分型,X-线征象,以及其它临床表现进行“个体化”的治疗。     

Subtrochanteric femur fracture treated by intramedullary fixation

Purpose: To discuss surgical technique, operative efficacy and clinical outcome of intramedullary fixation in the treatment of subtrochanteric femur fractures. Methods: From February 2011 to February 2013, 76 cases of subtrochanteric femur fractures were treated by intramedullary fixation in our hospital, including 53 males and 23 females, with the age range of 37-72 years (mean 53.5 years). According to Seinsheimer classification, there were 2 cases of type I, 7 type II, 15 type III, 23 type IV and 29 type V. Firstly, all patients underwent closed reduction with the guidance of C-arm fluoroscopy in a traction table. Two cases of type I and 3 cases of type III fractures had ideal closed reduction followed by internal fixation. The others needed additional limited open reduction. Radiographic examination was used to evaluate callus formation and fracture healing in postoperative 1, 3, 6 and 12 months follow-up. Functional recovery was evaluated by Harris Hip Scoring (HHS) system. Results: Patients were followed up for 6e12 months. All fractures were healed except one patient with delayed union. The average bone union time was 4.5 months. According to HHS system, 65 cases were considered as excellent in functional recovery, 8 good, 2 fair and 1 poor. The proportion of the patients with excellent and good recovery was 96.05%. Conclusion: Intramedullary fixation is feasible for the treatment of subtrochanteric femur fracture. The accuracy of intraoperative reduction and surgical skill are important for the clinical outcome and the patients'' prognosis.     

微创固定系统倒置治疗股骨转子下骨折

[目的]探讨微创固定系统(less invasive stabilization system,LISS)倒置治疗股骨转子下骨折的治疗方法和临床疗效。[方法]2007年10月～2009年5月,采用倒置LISS治疗31例股骨转子下骨折。本组男23例,女8例;年龄27～83岁,平均48.6岁。致伤原因:交通伤12例,坠落伤6例,压砸伤4例,摔伤9例。骨折按Seinshei-mer分型,ⅡC型4例,ⅢA型12例,ⅢB型6例,Ⅳ型6例,Ⅴ型3例。手术方法:麻醉满意后利用牵引床对股骨转子下骨折进行闭合复位,此后通过大转子外侧切口将对侧的LISS钢板倒置插入,骨折复位满意、钢板位置适宜后,在瞄准臂引导下分别在远、近骨折段钻入4～5枚锁定螺钉。[结果]本组手术时间35～80min,平均50min;术中出血60～150ml,平均失血量90ml。31例患者随访平均15.6个月,术后平均18.2周X线片显示明显骨痂形成或骨折线消失。无内固定松动及深部感染。患肢髋关节平均活动度为:屈曲115°,外旋35°,内旋15°,内收15°,外展36°。采用改良Harris髋关节评分法进行评估,平均92.6分(82～100分),优24例,良7例,无疗效不良病例。[结论]倒置LISS微创固定股骨转子下骨折效果良好,具有固定可靠、手术创伤小等优点,是一种治疗股骨转子下骨折的有效方法。