股骨近端骨折AO内固定术后功能锻练

根据AO(国际内固定协会)骨折处理的原则，综述目前临床上最常用的股骨近端骨折(股骨颈骨折、转子骨折及转子下骨折)的内固定选择方法及其术后功能锻炼的时机及方法。     

股骨近端髓内钉治疗股骨近端骨折疗效分析

目的　探讨股骨近端髓内钉 (PFN)是否为治疗股骨近端骨折的最佳方法之一。方法　 6 0例股骨近端骨折采用了PFN内固定手术方法。结果　随访 12个月术后 39例达到了接近主要骨块的解剖复位。 5 4例达到了完全的负重 ,2例由于选择了太短的近端滑动螺钉导致了内固定物的退出。 5例由于无法进行闭合复位而采取了开放复位钢丝内固定的方法。结论　仔细的外科技术和选择合适的PFN可以减少并发症发生的比率。当可以进行闭合复位时 ,PFN是一种良好且侵害小的治疗不稳定股骨近端骨折的内固定物。     

股骨近端骨折的手术治疗分析

目的探讨和分析空心螺钉内固定和解剖钢板固定治疗老年股骨近端骨折的临床疗效,总结其临床价值。方法将100例具有完整临床资料的老年股骨近端骨折患者随机分2组,每组各50例,分别采用空心螺钉内固定和解剖钢板固定,比较2组患者的治疗效果。结果 2组疗效差异无统计学意义(P>0.05),但空心螺钉内固定术出现2例患者退钉,经解剖板固定治疗后情况好转。结论空心螺钉内固定和解剖板均可有效治疗老年股骨近端骨折,可根据患者的骨折类型和严重程度加以选择。     

股骨近端骨折AO内固定术后功能锻练

根据AO(国际内固定协会 )骨折处理的原则 ,综述目前临床上最常用的股骨近端骨折 (股骨颈骨折、转子骨折及转子下骨折 )的内固定选择方法及其术后功能锻炼的时机及方法。     

股骨近端骨折的治疗

股骨近端包括股骨头、股骨颈及股骨的转子．受到间接旋转外力时容易造成股骨颈和转子部位的骨折。保守治疗并发症发生率和死亡率较高,近年来更多医生主张行早期内固定治疗。目前国际上治疗股骨颈骨折的首选方法是空心加压螺钉内固定,适用于骨质较好、基底和经颈型骨折、头下型骨折中Garden分型Ⅰ、Ⅱ及部分Ⅲ型患者。转子间骨折相对稳定,但为了更好的促进骨折愈合,避免并发症,现多采用内固定治疗。动力性髋螺钉(dvnamic hip screw,DHS)适用于AO转子部骨折分型中A1型、部分A2型和A3型骨折,其中A1型是最佳适应证。股骨近端髓内钉(proximal femoral nail,PFN)适用于股骨转子间骨折、股骨转子间反向骨折和高位股骨转子下骨折。对于70岁以上、较严重的骨质疏松、AO分型为A2-3、A3-3的粉碎骨折,我们自行设计的人工特制股骨上端假体置换手术,取得了满意的疗效。     

股骨近端钉治疗老年股骨粗隆间骨折

目的探讨股骨近端钉(proximalfemoralnail,PFN)治疗老年股骨粗隆间骨折的疗效。方法2001年10月~2003年9月,采用PFN治疗老年股骨粗隆间骨折患者62例,其中男42例,女20例。年龄60~92岁,平均67.3岁。均在伤后1周内施行手术。记录每例患者的手术时间、术中出血量、术中并发症、术后切口引流量、术后并发症、骨折愈合时间及髋关节功能评分等相关数据,并与文献进行比较,对该治疗方法进行评价。结果术后均随访8~22个月,平均13.6个月。2例发生术中股骨粗隆骨折部再骨折,2例术后分别死于脑栓塞和肺部感染,2例发生异位骨化,1例发生髋内翻,1例发生股骨头过度前倾,其余患者皆获满意疗效。手术时间76.5±29.1min,术中平均出血量385.7±98.4ml,术后切口引流量45.5±21.7ml,骨折愈合时间13.2±3.8周;参照Sanders髋关节创伤后的功能评分标准,术后髋关节功能恢复优良率达89.6%。结论PFN具有手术时间短、出血少且固定牢靠的优点,适用于老年股骨粗隆间骨折的治疗。     

防旋股骨近端髓内钉与股骨近端锁定钢板治疗股骨转子间骨折疗效比较

目的比较使用防旋股骨近端髓内钉(PFNA)和股骨近端锁定钢板(PFLP)治疗股骨转子间骨折的疗效。方法对50例股骨转子间骨折患者采用PFNA治疗25例、PFLP治疗25例。观察两组切口长度、手术时间、术中出血量、术中输血量、住院天数、术后引流量、术后Hb下降情况、术后输血量、术后扶拐下地负重时间及骨折愈合时间,按髋关节Harris评分评价两组术后疗效,并进行统计学分析。结果 50例患者均获得随访,时间12~20(18.8±5.6)个月。两组在切口长度、住院天数、术后引流量及骨折愈合时间、髋关节Harris评分各项比较差异均无统计学意义(P0.05);两组在手术时间、术中出血量、术中输血量、术后Hb下降情况、术后输血量及术后下地扶拐负重时间各项比较差异均有统计学意义(P0.05)。结论 PFNA及PFLP内固定均是治疗股骨转子间骨折的有效方法。PFLP可明显减少术中、术后输血量;PFNA相对手术时间短、扶拐行走时间早。     

股骨近端锁定接骨板治疗特殊类型股骨近端骨折

背景：应用髓内固定系统规范化治疗股骨近端骨折已得到临床上的广泛共识,但是对于某些特殊类型的股骨近端骨折如股骨转子下骨折、股骨近端外侧壁不完整等的治疗仍较困难。目的：探讨股骨近端锁定接骨板（LPFP）治疗特殊类型股骨近端骨折的疗效。方法：2012年5月至2014年5月应用LPFP治疗特殊类型股骨近端骨折22例,其中股骨转子间骨折伴股骨近端外侧壁不完整9例（Evans-Jensen分型：Ⅲ型5例,Ⅴ型4例）;股骨转子下骨折10例（Seinsheimer分型：ⅡA型2例,ⅡB型2例,ⅢB型4例,Ⅴ型2例）;股骨颈骨折伴股骨转子下骨折2例,股骨转子间骨折伴股骨上段骨折1例。所有患者均采用LPFP内固定术,记录手术时间、术中出血量、术后并发症、骨折愈合时间和术后髋关节功能评分。采用Harris评分评估髋关节功能情况。结果：手术时间为65~150 min,平均96 min;出血量为80~750 ml,平均360 ml。22例全部获得随访,随访时间为3~27个月,平均12.8个月。1例患者在术后4个月发生锁钉断裂,2例发生延迟愈合,无一例出现切口感染和深静脉血栓。骨折愈合时间为2~20个月,平均3.2个月。髋关节Harris评分为78~99分,平均86分。结论：LPFP治疗股骨转子下骨折、股骨近端外侧壁不完整等特殊类型股骨近端骨折,具有创伤小、安全性高等特点,是髓内固定治疗股骨近端骨折的有益补充。     

胫骨平台骨折的分类与功能评价

胫骨平台骨折属胫骨近端的关节内骨折。胫骨平台骨折的分类方法，主要包括Hohl修正后分类(1991)、Schatzker分类(1979)及AO分类(1990)。AO分类内容详尽，共分为两型(41-B和41-C)6组18个亚组，对资料积累极为有利，2000年已被美国．JBJS杂志推荐使用，并作为美国创伤骨科学会(OTA)会议与J，Orthop Trauma杂志论文的标准骨折分类。Schatzker分类分为6型，临床实用性很强，目前应用最为广泛。胫骨平台骨折治疗后的功能评价，多选用Rasmussen膝关节功能评分、HSS膝关节临床功能评分；放射学评价早期多用Rasmussen评分标准，远期可参考Resnick-Niwoyama退行性关节疾病评分标准。     

股骨近端髓内钉治疗股骨近端骨折疗效分析

目的 探讨股骨近端髓内钉(PFN)是否为治疗股骨近端骨折的最佳方法之一。方法 60例股骨近端骨折采用了PFN内固定手术方法。结果 随访12个月术后39例达到了接近主要骨块的解剖复位。54例达到了完全的负重，2例由于选择了太短的近端滑动螺钉导致了内固定物的退出。5例由于无法进行闭合复位而采取了开放复位钢丝内固定的方法。结论 仔细的外科技术和选择合适的PFN可以减少并发症发生的比率。当可以进行闭合复位时，PFN是一种良好且侵害小的治疗不稳定股骨近端骨折的内固定物。     

Pilon骨折的分类与功能评价

Pilon骨折的概念由Destot于1911年提出，其特征是涉及胫骨远端关节面上干骺端骨折，呈现不同程度的嵌插与粉碎，伴有关节软骨损伤和关节面分离，可涉及内踝、外踝、后踝的骨折。Pilon骨折的分类，目前临床应用较多的是Rtiedi-Allgoewer分类(1969)与AO／OTA分类方法(1996)。Rueedi-Allgoewer分类依据关节面的粉碎程度和移位程度，将Pilon骨折分为三型。AO／OTA分类中，Pilon骨折主要涉及43-B3、43-C1、43-C2、43-C3，共分为两型4组12个亚组。Pilon骨折治疗结局评价主要用Burwell-Charnley(1965)骨折复位放射学评价标准和Tornetta(1993)临床治疗结果评价标准，也可用Mazur(1979)踝关节评价分级系统、Baird-Jackson(1987)踝关节评分系统。     

加强股骨近端骨折的临床研究

股骨近端骨折目前创伤骨科领域最具有挑战性的骨折之一。其中对股骨转子间骨折的临床研究有待加强。术前影像学诊断应重视内侧弓的完整性和后侧皮质的粉碎程度，对骨折的稳定性做出准确性判断。目前对股骨转子间骨折以早期手术治疗为主，包括动力髋螺钉（dvnamic hip screw，DHS)、Gamma钉、股骨近端髓内钉(Proximal femoral nail，PFN)．对于不稳定性转子间骨折尤其是反转子间骨折，应首选髓内钉中心位固定。导航系统的骨科辅助手术技术的应用，循证医学的临床研究将促进股骨近端骨折的诊疗水平的提高。     

Classification of subtrochanteric femoral fractures

A review of the literature identified 15 different classification methods for subtrochanteric femoral fractures. Only eight of those classifications defined the area of bone, which constituted a subtrochanteric fracture. The actual length of femur defined as the subtrochanteric zone varied from 3 cm up to the level of the femoral isthmus. There was no agreement between the different classifications regarding the proximal and distal border or for those fractures, which traverse anatomical boundaries. In the various classifications, fractures were subdivided into 2-15 subgroups. The majority of the identified studies were unable to find the classifications useful in either determining treatment or predicting the outcome after treatment. We subdivided subtrochanteric fractures into three types based on the degree of fracture comminution. We examined the inter- and intra-observer agreement of our recommended classification. One orthopaedic consultant, one specialist hip fracture surgeon, two trainee registrar orthopaedic surgeons and one specialty trainee in orthopaedics, on two different occasions, 8 weeks apart, independently classified the radiographs of 20 patients with a subtrochanteric fracture. The mean kappa value for inter- and intra-observer variation was 0.71 and 0.79, respectively, with both showing substantial agreement and, therefore, this simpler classification is recommended. Based on the review of previous classification methods, we also recommend that the subtrochanteric zone be defined as the one in which the fracture line crossing the femur is predominantly within the area of bone extending 5 cm below the lower border of the lesser trochanter.     

Classification of proximal tibial fractures in children

Purpose  To develop a classification system for all proximal tibial fractures in children that accounts for force of injury and fracture patterns. Methods  At our institution, 135 pediatric proximal tibia fractures were treated from 1997 to 2005. Fractures were classified into four groups according to the direction of force of injury: valgus, varus, extension, and flexion–avulsion. Each group was subdivided into metaphyseal and physeal type by fracture location and Salter–Harris classification. Also included were tibial tuberosity and tibial spine fractures. Results  Of the 135 fractures, 30 (22.2%) were classified as flexion group, 60 (44.4%) extension group, 28 (20.8%) valgus group, and 17 (12.6%) varus group. The most common type was extension-epiphyseal-intra-articular-tibial spine in 52 fractures (38.5%). This study shows that proximal tibial fractures are age-dependent in relation to: mechanism, location, and Salter–Harris type. In prepubescent children (ages 4–9 years), varus and valgus forces were the predominate mechanism of fracture creation. During the years nearing adolescence (around ages 10–12 years), a fracture mechanism involving extension forces predominated. With pubescence (after age 13 years), the flexion–avulsion pattern is most commonly seen. Furthermore, metaphyseal fractures predominated in the youngest population (ages 3–6 years), with tibial spine fractures occurring at age 10, Salter–Harris type I and II fractures at age 12, and Salter–Harris type III and IV physeal injuries occurring around age 14 years. Conclusion  We propose a new classification scheme that reflects both the direction of force and fracture pattern that appears to be age-dependent. A better understanding of injury patterns based on the age of the child, in conjunction with appropriate pre-operative imaging studies, such as computer-aided tomography, will facilitate the operative treatment of these often complex fractures.     

桥接组合式内固定系统治疗股骨干骨折合并同侧股骨近端、股骨远端骨折

目的 探讨桥接组合式内固定系统治疗股骨干骨折合并同侧股骨近端、股骨远端骨折的临床疗效.方法 回顾性分析2013年1月至2016年12月于我院骨科接受手术治疗的4例股骨干骨折合并同侧股骨近端及远端骨折病人的临床资料,其中男3例,女1例,年龄为(33.5±9.3)岁(23～44岁),闭合性骨折3例,开放性骨折1例.3例病人...     

A computed tomography-based analysis of proximal femoral geometry for lateral impingement with two types of proximal femoral nail anterotation in subtrochanteric fractures

Objective

To evaluate and analyse the geometrical discrepancies between the proximal femur and two types of AO/Association for the Study of Internal Fixation (AO/ASIF) Proximal Femoral Nail Anterotation (PFNA/PFNA-II) using computed tomography (CT)-based analysis in Asian patients, and its implication in lateral cortical impingement during reduction intra-operatively in subtrochanteric fractures.

Materials and methods

Coronal CT images of hips in 50 randomly selected healthy cases were analysed using a unique measurement method with respect to the height, diameter, bending angle and inclination angle of lateral cortex of proximal femur. The data were then compared with dimensions of PFNA and PFNA-II.

Results

The average height of proximal femur was 61.1 ± 5.2 mm, diameter 18.1 ± 1.5 mm, bending angle 8.4 ± 2.2° and inclination angle of lateral cortex 11.9 ± 1.1°. The average impingement length of the lateral cortex was 54.2 ± 4.7 mm (range 41.4-64.2 mm), which was shorter than the height of the proximal femur. On comparison with dimensions of PFNA and PFNA-II, the lateral inclination angle and impingement length were found to be discrepant in PFNA; however, in the latter the flat lateral surface helps avoiding impingement with the lateral femoral cortex.

Conclusion

Our study provides clear evidence that the flat lateral shape of PFNA-II is better suited for the femur of Asian patients by reducing the chances of impingement with the lateral proximal femoral cortex during intra-operative reduction in subtrochanteric fractures.     

采用国产股骨近端髓内钉治疗老年股骨转子间骨折

目的：评价国产股骨近端髓内钉治疗老年股骨转子间骨折的临床效果。方法：2002年4月～2003年12月共32例老年股骨转子间骨折患者接受国产股骨近端髓内钉内固定术，其中男14例，女18例，年龄57—98岁，平均75岁。按AO骨折分类，7例为A2．2，14例为A2．3，4例为A3．1，2例为A3.2，5例为A3．3。93．8％合并内科疾病。结果：所有患者均获得随访，随访时间8—15个月，平均11个月，骨折愈合时间为12—21周，平均15．6周。按Harris髋关节功能评分，优19例，良9例，中3例，差1例，优良率87．5％。结论：采取国产股骨近端髓内钉治疗老年股骨转子间骨折具有创伤小、出血少、固定牢靠、术后康复快、费用低廉等优点，值得在临床上推广应用。     

股骨转子间骨折两种髓内固定方法的比较

目的比较用两种不同的髓内固定方法(Gamma钉和PFN)治疗股骨转子间骨折的临床结果。方法对2000～2003年在我院采用Gamma钉和PFN治疗的205例股骨转子间骨折进行回顾性总结分析,其中116例用Gamma钉治疗,89例用PFN治疗。结果197例患者得到随访,随访12～48个月,平均23.5个月。Gamma钉组:手术时间为68.3min(48～106min),术中失血量为261mL(180～400mL),下地行走时间为5.0周(2.3～8.9周),骨折愈合时间为8.6周(7.1～12.6周);PFN组:手术时间为48.0min(36～85min),术中失血量为192mL(120～360mL),下地行走时间为5.3周(2.5～8.1周),骨折愈合时间为8.8周(6.9～12.1周)。两组在手术时间和术中失血量方面差异有显著性意义(P<0.05)。结论两种髓内固定系统能有效地治疗股骨转子间骨折,但Gamma钉的手术时间和术中失血量较高。