3种动力髋螺钉固定方式治疗骨质疏松性股骨粗隆间骨折的比较研究

目的比较单纯动力髋螺钉(DHS)内固定、骨水泥强化联合DHS内固定以及异体人工骨主钉道植骨配合DHS内固定3种术式治疗老年性骨质疏松股骨粗隆间骨折的疗效差别。方法采用随机数字表法将2010年1月至2012年9月广州医科大学附属第二医院收治、符合病例选择标准的90例老年骨质疏松性股骨粗隆间患者随机分入单纯DHS内固定组(对照组)、骨水泥强化联合DHS内固定组(骨水泥组)和异体人工骨主钉道植骨配合DHS内固定组(植骨组),每组30例。比较3组术后Harris髋关节功能评分优良率、骨折愈合时间及术后并发症发生率的差异。结果 90例患者均获完整随访,随访时间12~18个月(平均14.8个月)。植骨组、骨水泥组和对照组术后Harris功能评分优良率分别为93%、80%、70%,植骨组明显优于对照组(P0.05);与对照组、骨水泥组比较,植骨组骨折愈合时间明显缩短(P0.05);3组中植骨组并发症发生率最低(3%),远低于对照组和骨水泥组(27%和10%)。结论异体人工骨主钉道植骨配合DHS内固定治疗老年性骨质疏松股骨粗隆间骨折具有髋关节功能恢复好、骨折临床愈合时间短、并发症少等优点,临床效果满意。     

DHS和防旋钉结合Genex植骨治疗老年股骨粗隆间骨折23例

目的:探讨微创DHS和防旋钉内固定结合Genex植骨治疗老年股骨粗隆间骨折的临床疗效.方法:对23例70岁以上老年股骨粗隆间骨折病例采用微创DHS和防旋钉内固定结合Genex植骨治疗,对其骨折类型、合并症及临床疗效进行回顾性分析.结果:23例术后1年以上随访,无螺钉松动、髋内翻、骨折延期愈合等并发症,髋关节功能评价优良率91%.结论:微创DHS和防旋钉内固定结合Genex植骨治疗老年股骨粗隆间骨折,具有创伤小、固定牢靠、促进骨折愈合及早期功能锻炼等优点.     

植骨在DHS固定治疗股骨粗隆间骨折中的作用

目的探讨植骨在动力髋螺钉（dynamic hip screw，DHS）内固定治疗股骨粗隆间骨折中的临床作用。方法2004-2007年我院收治60例Evans分型Ⅰ～Ⅳ型股骨粗隆间骨折病例，采用动力髋螺钉治疗股骨粗隆间骨折。手术分两组，术中不植骨组30例，采用常规实心三联扩孔器扩孔DHS内固定；术中植骨组30例，采用我院自行研制的DHS空心扩孔器扩孔，取骨、植骨，DHS内固定，术后进行随访比较。结果采用黄公怡 髋关节功能评定标准进行评价，不植骨组30例，优14例，良9例，可4例，差3例，髋内翻7例，术后螺钉切割拔出2例，钢板断裂1例，骨不连2例，优良率76．7％。植骨组30例，优18例，良9例，可2例，差1例，髋内翻3例，术后髋螺钉切割拔出1例，无钢板、螺钉断裂，无骨不连，优良率90.0％。结论DHS内固定治疗股骨粗隆间骨折时，预防性植骨可加速骨折愈合，迅速重建内侧支持结构，减少髋内翻及相关并发症。     

Gamma3钉与DHS内固定治疗股骨粗隆间骨折的疗效比较

目的比较Gamma3钉与动力髋螺钉(dynamic hip screw,DHS)内固定治疗股骨粗隆间骨折的疗效。方法回顾性分析2006年1月至2011年3月分别采用闭合复位Gamma3钉或DHS内固定治疗股骨粗隆间骨折89例,其中DHS内固定51例(DHS组),Gamma3钉内固定38例(Gamma3钉组)。病例选择时排除病理性骨折及严重多发伤。比较两组患者手术时间和术中失血量、术后骨折复位丢失、骨折愈合时间及术后关节功能恢复的情况。结果术后随访6~12个月,平均10.4个月,无骨折不愈合。两组相比在手术时间、术中失血量及髋关节功能恢复方面差异无统计学意义,Gamma3钉组骨折愈合时间较DHS组延长但术后骨折复位丢失少。结论 DHS和Gamma3钉内固定治疗稳定型股骨粗隆间骨折可获得同样的疗效,但对于不稳定型股骨粗隆间骨折,Gamma3钉内固定能有效减少骨折复位丢失,降低术后髋内翻的发生率。     

动力髋螺钉治疗股骨粗隆间骨折致股骨头坏死的原因探讨

目的 探讨动力髋螺钉内固定术治疗股骨粗隆间骨折并发股骨头缺血性坏死的原因.方法 我们报告2例股骨粗隆间骨折行动力髋螺钉内固定术而并发股骨头缺血性坏死患者的诊疗过程,分析发生股骨头缺血性坏死的原因.结果 两者均行动力髋螺钉取出+钉道自体髂骨植骨,术后获得了较好疼痛缓解和髋关节功能改善.结论 影响动力髋螺钉内固定术治疗股骨...     

动力髋螺钉治疗股骨粗隆间骨折临床分析

目的探讨动力髋螺钉(DHS)在股骨粗隆间骨折的临床疗效分析。方法总结2003年至2007年用DHS在股骨粗隆间骨折的治疗经验。结果55例患者术后平均随访15个月,无髋内翻、钢板螺钉滑脱、折弯、折断,无加压钉穿出股骨头,无加压钉位置不良,全部骨性愈合。结论DHS治疗股骨粗隆间骨折是一种有效可靠内固定方法。     

DHS加防旋钉治疗股骨粗隆间骨折

目的评价动力髋螺钉(DHS)加防旋钉内固定治疗老年股骨粗隆间骨折的疗效。方法应用DHS加空心加压螺钉治疗股骨粗隆间骨折43例,以空心加压螺钉发挥防旋钉的作用。对临床疗效、并发症等进行分析。结果 41例得到7~25个月的随访,骨折愈合良好,无髋内翻等并发症。结论 DHS加防旋钉能有效地固定股骨粗隆间骨折,防止骨折旋转移位,有利于骨折愈合,适合老年股骨粗隆间骨折的治疗。     

股骨近端髓内钉内固定治疗老年股骨粗隆部位骨折优势分析

老年股骨粗隆部位（包括粗隆间及粗隆下）发生骨折后，保守治疗常导致骨不连、骨延迟愈合及骨畸形愈合，且长期卧床会带来褥疮、肺部感染等并发症，目前多主张手术治疗。目前，最常见的髓外固定系统是动力髋螺钉（DHS），髓内固定系统是Gamma钉和股骨近端髓内钉（PFN）。我院采用PFN治疗股骨粗隆部位的骨折97例，并与传统的DHS和Gamma钉固定相比较，研究PFN内固定的特点与优势。     

DHS治疗股骨粗隆间骨折

目的 探讨DHS内固定治疗股骨粗隆间骨折临床疗效。方法 选择髋关节外侧切口，直视下复位，C形臂X线机监视下选择最佳髋螺钉进钉点后钻入导针，扩髓、攻丝，置放髋螺钉及钢板螺钉。本组50例，男37例，女13例；年龄21～89岁，平均60岁。结果 50例随访时间3～22个月，平均8个月。复位及内固定满意率88．0％(44／50)，愈合率为96．0％(48／50)，功能恢复接近伤前水平为68％(34／50)。并发髋内翻为6．0％(3／50)，其中2例为髋螺钉钉位不正、1例复位不良。骨不连为4．0％(2／50)，均为反斜形粗隆间骨折，DHS固定失败螺钉折断后骨分离所致。1例髋螺钉钉位不正，经早期再手术换钉固定后骨折愈合。结论 正确掌握DHS固定治疗股骨粗隆间骨折手术指征、规范手术操作及完善围手术期处理，是提高治疗效果的关键。     

植骨内固定治疗成人股骨近端纤维结构不良的临床研究

目的探讨成人股骨颈纤维结构不良的手术治疗效果。方法采用病灶彻底刮除、自体和同种异体骨植骨、动力髋螺钉（DHS）／股骨近端髓内钉（PFN）内固定治疗13例成人股骨近端纤维结构不良，对治疗方式及术后疗效进行回顾性分析。结果所有患者术后早期不负重活动，平均3个月骨折愈合，随访18～48个月，症状缓解，X线片显示骨皮质增厚，病损植骨区内有结实的骨化；仅4例有部分骨吸收，无临床复发。结论彻底刮除病灶、带皮质的自体和同种异体骨植骨加DHS／PFN内固定是治疗成人股骨近端纤维结构不良可靠的方法，疗效满意。     

Vertically oriented femoral neck fractures: mechanical analysis of four fixation techniques

OBJECTIVE: Femoral neck fractures in young individuals are typically high angled shear fractures. These injuries are difficult to stabilize due to a strong varus displacement force across the hip with weight bearing. The purpose of this study was to compare the biomechanical stability of four differing fixation techniques for stabilizing vertical shear femoral neck fractures. METHODS: Vertical femoral neck fracture stability was assessed using 4 surgical constructs in 32 cadaveric femurs: 7.3 mm cannulated screws placed in a triangular configuration (group 1), a 135-degree dynamic hip screw (group 2), a 95-degree dynamic condylar screw (group 3), and a locking proximal femoral plate (group 4). The 4 groups were matched for mean bone density and each specimen was tested under incremental loading, cyclical loading, and loading to failure. The modes of fixation failure were recorded for each specimen and the mean group stiffness, failure loads, and failure energies were calculated. RESULTS: All 8 specimens failed during incremental loading in group 1. Five of 8 constructs failed with incremental loading, and 3 failed with cyclical testing in group 2. The combined 16 specimens in groups 3 and 4 survived both incremental and cyclical loading. The differences in stiffness, failure loads, and failure energies between the 4 groups were statistically significant (P < 0.001). The strongest construct was the locking plate and the weakest construct was the 7.3-mm cannulated screw configuration. The cannulated screw configuration group failed as the screws backed out of the femoral head and by varus collapse of the osteotomy; the fixed angled devices all failed at the bone-implant interface. CONCLUSIONS: The strongest construct for stabilizing a vertical shear femoral neck fracture is the proximal femoral locking plate, followed in descending order by the dynamic condylar screw, the dynamic hip screw, and the 3 cannulated screw configuration.     

Vertical shear fractures of the femoral neck. A biomechanical study.

A biomechanical cadaver study was performed to compare the strength and stability of three cannulated cancellous lag screws with a sliding hip screw for fixation of a vertically oriented fracture of the femoral neck (Pauwels Type III). Using eight matched pairs of human cadaveric femurs, vertically oriented femoral neck osteotomies were created, reduced, and randomized to one of the two fixation methods. The constructs were tested with incremental axial loading from 100 N to 1200 N and cyclical loading at 1000 N for 10,000 cycles; fracture displacements and ultimate load to failure were determined. The specimens stabilized using a sliding hip screw showed less inferior femoral head displacement, less shearing displacement at the osteotomy site, and a much greater load to failure than did those stabilized with multiple cancellous lag screws. These results support the use of a sliding hip screw for treatment of vertically oriented fractures of the femoral neck.     

Erste erfahrungen mit der dynamischen hüftschraiibe im vergleich zu anderen osteosyntheseverfahren

30 fractures of the proximal end of the femur were stabilised with so-called ”dynamic hip screws“ (AO/ASIF). This method seems to be more suitable for some inter-trochanteric fractures which pose problems questioning our usual treatment with Ender’s elastic round nails. The dynamic hip screw system is also more stable for femoral neck fractures of type Pauwels III than 4 cancellous bone screws. One phenomenon which can not yet be fully explained is the slipping out of the screw to an extent unobserved in other procedures.     

Differentiated procedure in fractures of the coxal femur end in adults

After own clinical observations a choice of surgical treatment in coxofemoral fractures is pointed out: Femoral neck fractures of stage Garden I will be stabilized by lag screws. For the rest of subcapital fractures we use lag screws or Smith-Peterson nailing for stabilization; only old patients without the possibility of mobilisation without weight-bearing after operation are treated by endoprosthesis of the hip. In Garden-IV-fractures and fracture-type Pauwels III indication for endoprosthesis is conditioned in most elderly patients. In basocervical and pertrochanteric fractures of younger patients a dynamic hip screw will be performed; in older patients we use elastic nails described by Simon-Weidner and Ender with good success. For stabilization of subtrochanteric fractures different operations dependent on type of fracture, bone-structure and general condition are used: elastic nails with or without wire-loops, interlocking nailing, Y-nail, dynamic hip screw, angled plate and compound internal fixation.     

Operative management of ipsilateral fractures of the hip and femur

Thirteen patients with ipsilateral hip and femoral shaft fractures are discussed. In nine patients, the femoral shaft fracture was managed by a combination of dynamic compression plating with a medial cancellous bone graft and either multiple cancellous screws or a dynamic hip screw for the proximal fracture (Group I). Four patients had Ender pin fixation (Group II). In Group I, both fractures were united within 16 weeks in all patients, and at least 90% of normal hip and knee motion was regained. Nonunions developed in two of the four Group II patients. Immediate separate fixation of ipsilateral hip and femoral shaft fractures allows definitive management of the proximal fracture and immediate mobilization without external support and provides satisfactory results with a low complication rate.     

支撑-牵张效应对股骨转子间骨折内固定稳定的影响

股骨转子间骨折是常见的老年骨质疏松性骨折,手术内固定是首选的治疗方法,目的是利用内固定物分担髋关节传导的负荷。当前开展的研究大多围绕股骨近端的外侧壁、内侧壁、尖顶距及棘轮机制等学说,基于这些学说设计的单一头颈螺钉或双头颈螺钉的髓外、髓内设计均无法完全避免股骨头穿透的发生。根据股骨近端骨小梁的分布及骨折前后的生物力学变化...     

Cadaveric-biomechanical evaluation of bone-implant construct of proximal humerus fractures (Neer type 3)

BACKGROUND: A biomechanical cadaver study was performed to test the stability and strength of screw osteosynthesis of surgical neck fractures of the humerus. METHODS: After bone density measurement, 64 cadaver proximal humerus bones were bent to create a subcapital fracture. The fracture was then stabilized by means of screw osteosynthesis randomly assigned to subgroups of screw positioning, size of screw, and stress test (torsion/bending). RESULTS: Two screws applied laterally and parallel were 34.2% more stable than the normal arrangement. Bone density had a dominant role with regard to maximal bending and torsion force, but no significance was found with respect to additional screws through the major tuberculum or diameter of screws. CONCLUSION: Two of the smaller 4.5-mm cannulated screws should be applied parallel from the lateral direction. Only range-of-motion exercises that produce a bending stress should be considered early after surgery, avoiding axial stress.     

A biomechanical analysis of the sliding hip screw: the question of plate angle

There is general agreement that the implant of choice for intertrochanteric fractures is the sliding hip screw (SHS). However, considerable differences of opinion exist as to which plate angle--varying from 130 to 150 degrees--is preferred. Thus far there has been no cadaver-based biomechanical analysis of this problem. To examine these questions, we determined the effect of plate angle on plate strain and proximal medial femoral strain distribution in cadaver femurs fixed with 130, 135, 140, 145, and 150 degrees SHS after experimentally produced stable and unstable intertrochanteric fractures. Twenty-four fresh adult cadaver femurs were assigned randomly to either the 130, 135, 140, 145, or 150 degrees SHS group. Each femur was radiographed and bone mineral density was determined by dual-photon absorptiometry. Multiple-strain gauges were affixed to the femur, with specific focus on the proximal femur and plate. Femurs were loaded at 25 degrees adduction in increments of 70 N from 0 to 1,800 N in a servohydraulic testing machine. Femurs were tested in a progressive manner: (a) intact femur; (b) intact femur with SHS inserted; (c) a stable two-part intertrochanteric fracture reduced with SHS; (d) a four-part fracture with the posteromedial fragment (PMF) reduced anatomically by a lag screw; (e) the same fracture with the PMF rotated 180 degrees and held in place by a lag screw to approximate a "near-anatomic" reduction; and (f) the same fracture with the PMF discarded. Screw sliding measurements were determined at regular intervals throughout each test.(ABSTRACT TRUNCATED AT 250 WORDS)     

A biomechanical evaluation of the Gamma nail.

We examined the effect of the Gamma nail on strain distribution in the proximal femur, using ten cadaver femora instrumented with six unidirectional strain gauges along the medial and lateral cortices. The femora were loaded to 1800 N and strains were determined with or without distal interlocking screws before and after experimentally created two-part and four-part fractures. Motion of the sliding screw and the nail was also determined. Strain patterns and screw motion were compared with previously obtained values for a sliding hip screw device (SHS). The Gamma nail was shown to transmit decreasing load to the calcar with decreasing fracture stability, such that virtually no strain on the bone was seen in four-part fractures with the posteromedial fragment removed; increasing compression was noted, however, at the proximal lateral cortex. Conversely, the SHS showed increased calcar compression with decreasing fracture stability. The insertion of distal interlocking screws did not change the pattern of proximal femoral strain. The Gamma nail imparts non-physiological strains to the proximal femur, probably because of its inherent stiffness. These strains may alter bone remodelling and interfere with healing. Distal interlocking screws may not be necessary for stable intertrochanteric fractures.