重建交锁髓内钉和动力髋螺钉治疗股骨转子下长节段粉碎骨折的对比研究

[目的]对比分析股骨转子下长节段粉碎性骨折重建交锁髓内钉(重建钉)内固定和动力髋螺钉(DHS)内固定的手术时间、出血量、并发症、下地负重时间、骨折愈合时间及临床疗效,寻求其中比较理想的一种内固定方法.[方法]回顾性分析2001年1月～2006年1月本院手术治疗的股骨转子下长节段粉碎性骨折患者27例,将27例按不同的内固定方法分为2组,其中DHS内固定组(A组)11例,男9例,女2例,平均38.75±6.25岁;重建钉内固定组(B组)16例,男14例,女2例,平均36.80±4.54岁;对2组手术时间、出血量、并发症、下地负重时间、骨折愈合时间及疗效评定方面进行对比分析.[结果]随访12～28个月,平均14.71个月,结果发现股骨转子下长节段粉碎性骨折2种内固定方法在手术时间(t=1.78,P＞0.05)、出血量(t=1.96,P＞0.05)、并发症(Fisher精确概率检验P=0.38)和疗效评定方面(Fisher精确概率检验P=0.50)无显著性差异;在下地负重时间(t=3.01,P＜0.05)和骨折愈合时间(t=2.71,P＜0.05)方面有显著性差异,重建钉较DHS短.[结论]对于股骨转子下长节段粉碎性骨折的治疗,重建交锁髓内钉内固定较动力髋螺钉更为理想.     

股骨近端防旋髓内钉内固定治疗高龄股骨转子间骨折的疗效

目的探讨股骨近端防旋髓内钉(PFNA)内固定治疗高龄股骨转子间骨折的疗效。方法将90例高龄股骨转子间骨折患者按照治疗方式分为PFNA组(采用PFNA内固定,n=50)与动力髋螺钉(DHS)组(采用DHS内固定,n=40)。比较两组手术情况、术后下床活动时间、负重行走时间、骨折愈合时间及并发症发生率。末次随访采用Harris评分评定髋关节功能情况。结果切口长度、手术时间、术中出血量、住院时间、术后下床活动时间、术后负重时间、骨折愈合时间PFNA组均短(少)于DHS组,差异均有统计学意义(P 0. 05)。患者均获得随访,时间8～12个月。髋关节功能恢复优良率PFNA组高于DHS组,并发症发生率PFNA组低于DHS组,但差异均无统计学意义(P 0. 05)。结论 PFNA内固定治高龄股骨转子间骨折内固定效果稳定,可促进患者髋关节功能恢复,减少术后并发症。     

交锁髓内钉治疗股骨、胫骨干粉碎性骨折

目的：交锁髓内钉治疗股骨、胫骨干粉碎性骨折临床观察。方法：应用小切口切开复位，选择性扩髓，交锁髓内钉内固定治疗股骨，胫骨干粉碎性骨折26例，结果：本组26例随访时间6－24个月，平均14个月，骨折平均愈合时间14周，无术后感染，脂肪栓塞，断钉，骨折不愈合，畸形愈合，关节僵硬，再骨折等严重并发症发生，结论：本组股骨、胫骨干粉碎性骨均属不稳定型骨折，交锁髓内钉固定疗效是确切的，可采用小切口切开复位并选择性扩髓，不主张早期负重或做动力化处理。     

闭合复位交锁髓内钉内固定治疗胫腓骨骨折效果分析

目的比较闭合复位交锁髓内钉内固定和切开复位交锁髓内钉内固定治疗胫腓骨骨折的效果。方法将88例胫腓骨骨折患者随机分为2组,每组44例。对照组采用切开复位交锁髓内钉内固定术,观察组采用闭合复位交锁髓内钉内固定术。比较2组的治疗效果。结果观察组手术时间、骨痂出现时间、骨折愈合时间、住院时间均短于对照组,术中出血量和术后并发症发生率低于对照组,治疗总有效率高于对照组,差异均有统计学意义(P0.05)。结论闭合复位交锁髓内钉内固定治疗胫腓骨骨折的效果优于切开复位交锁髓内钉内固定。     

加长Gamma 3型髓内钉与股骨近端锁定钢板治疗股骨转子下骨折的疗效对比

目的:比较加长Gamma 3型髓内钉与股骨近端锁定钢板(proximal femur locking plate,PFLP)治疗股骨转子下骨折的临床疗效。方法:回顾性分析2010年1月至2017年1月治疗股骨转子下骨折且随访超过12个月的58例患者,采用加长Gamma 3型髓内钉治疗35例,其中男18例,女17例;年龄25～78(66.5±23.5)岁;摔伤18例,交通伤7例,高处坠落伤10例;受伤至手术时间2～9 d,平均4.8 d。采用PFLP固定治疗23例,其中男8例,女15例;年龄31～81(63.4±22.4)岁;摔伤12例,交通伤6例,高处坠落伤5例;受伤至手术时间2～12 d,平均5.2 d。观察并比较两组患者的手术时间、总失血量(术中+隐性失血)、住院天数、骨折愈合情况、并发症及髋关节功能。结果:51例获得随访,时间14～36个月,平均24.8个月。其中加长Gamma 3型髓内钉组31例,PFLP组20例。加长Gamma 3型髓内钉组总失血量(术中+隐性失血)高于PFLP组(P0.05);两组患者手术时间、住院天数、并发症比较差异无统计学意义(P0.05);术后骨折愈合时间加长Gamma 3型髓内钉组为(17.2±2.4)周与PFLP组(18.1±2.6)周比较差异无统计学意义(P0.05);加长Gamma 3型髓内钉组术后首次完全负重时间早于PFLP组(P0.05)。术后1年随访加长Gamma 3型髓内钉组Harris评分80.29±10.28与PFLP组76.49±12.28比较差异无统计学意义(P0.05);两组患者均未发生深部感染、肺栓塞、骨不连等并发症;2例住院期间出现下肢深静脉血栓,予血管外科放置滤网治疗;术后4例出现肺部感染,经抗感染等治疗后治愈。结论:加长Gamma 3型髓内钉及PFLP均能有效治疗股骨转子下骨折,加长Gamma 3型髓内钉不适于髓腔过细、前弓过大患者,PFLP因偏心固定,术后不应强调过早负重。     

髓内钉与钢板治疗肱骨干骨折79例疗效比较

目的　比较交锁髓内钉与加压钢板治疗肱骨干骨折的疗效以提高肱骨干骨折的治疗水平。方法　手术治疗 79例 ,肱骨干骨折 ,其中肱骨加压钢板内固定 5 6例 ,交锁髓内钉固定 2 3例 ,骨折均为闭合性 ,比较两种技术的手术时间、住院时间、骨折愈合时间等疗效指标和桡神经损伤、骨不连、肩关节功能障碍等并发症发生情况。结果　与钢板内固定相比 ,髓内钉内固定操作的手术时间短 (P <0 0 1) ,骨折愈合时间提前 (P <0 0 1) ,而住院时间两者之间没有统计学差异 (P >0 0 5 )。髓内钉内固定未发生骨不连 ,钢板有 9例出现骨不连接。暂时性的桡神经麻痹钢板与髓内钉分别为 6例、 1例 ,肩功能功能障碍分别为3例、 5例 ,所有病例未发生骨感染。结论　与钢板相比交锁髓内钉治疗肱骨干骨折的治愈率高 ,并发症少。     

逆行交锁髓内钉治疗肱骨干骨折

目的报告应用逆行交锁髓内钉治疗肱骨干骨折的疗效。方法采用肱骨交锁髓内钉逆行进钉内同定治疗肱骨干骨折16例，钢板内固定治疗肱骨干骨折17例分别从手术情况、并发症、生物力学、骨折愈合情况、功能恢复等方面进行比较与分析结果所有患随访5～18个月．平均7．6个月，髓内钉逆行内固定组：平均骨折愈合时间6．3个月．术后尺神经麻痹1例，无一例髓内钉和锁钉折弯或断裂，功能煅练时间早．骨折愈合牢固，功能恢复良好：钢板内固定：平均骨折愈合时间5．6个月，术后桡神经麻痹2例，螺钉松动、折断和钢板弯曲各1例，骨不连1例，骨延迟愈合3例．结论肱骨干骨折逆行交锁髓内钉内固定术，方法简单安全．内固定牢靠，术后并发症少．疗效优于钢板内固定术。     

钢板与交锁髓内钉内固定治疗股骨干骨折的疗效比较

目的探讨钢板与交锁髓内钉内固定治疗股骨干骨折的临床疗效。方法对110例股骨干骨折患者分别采用闭合复位交锁髓内钉内固定(交锁髓内钉组,45例)和切开复位钢板内固定(钢板组,65例)治疗。比较两组患者术中出血量、手术时间、骨折愈合时间、并发症及术后12个月HSS评分。结果患者均获得随访,时间12～36个月。术中出血量、骨折愈合时间、并发症发生率及术后12个月HSS评分交锁髓内钉组均少(优)于钢板组(P 0. 05),手术时间两组比较差异无统计学意义(P 0. 05)。结论采用交锁髓内钉内固定治疗股骨干骨折,失血少、愈合时间快、功能恢复满意。     

交锁髓内钉和经皮钢板固定治疗胫骨远端干骺端骨折的疗效比较

目的 比较交锁髓内钉和经皮钢板固定治疗胫骨远端干骺端骨折的疗效。方法 回顾性分析2004年5月～2005年8月采用交锁髓内钉或经皮钢板固定的51例胫骨远端干骺端骨折的治疗效果，根据内固定方式分成髓内钉组（n=27）和钢板组（n=24），比较两组的手术时间，出血量，透视次数，骨折愈合时间，踝关节前后向、内外翻成角，踝关节最大背伸度及并发症，并采用Olerud-Molander踝关节评分评价结果。结果 所有患者获得12—27个月（21．2个月）随访，两组患者在手术时间、透视次数、踝关节最大背伸度方面差异无统计学意义（P〉0．05）。所有骨折均获得愈合，平均愈合时间髓内钉组为20．0周，钢板组为18．6周。Olerud-Molander踝关节评分结果均为优良。髓内钉组具有较少的手术出血量，钢板组具有更好的骨折对线；髓内钉组有5例发生畸形愈合，钢板组有4例发生局部软组织并发症。结论 对于胫骨远端骨折，交锁髓内钉和经皮钢板固定都是有效的固定方式，经皮钢板能够提供更好的骨折端稳定性，而交锁髓内钉有利于处理伴有局部软组织损伤的骨折。     

小切口复位重建交锁髓内钉治疗股骨复杂骨折

目的：探讨重建交锁髓内钉固定股骨复杂骨折方法和疗效。方法：采用重建型交锁髓内钉治股骨复杂骨折18例.结果：15例获6～24个月随访，骨折愈合时间7～15个月，平均8．9个月，患肢关节功能恢复接近正常，无相关严重并发症发生。结论；重建型交锁髓内钉治疗股骨复杂骨折固定牢靠。可早期进行功能锻炼,骨折愈合率高。     

The treatment of unstable,extracapsular hip fractures with the AO/ASIF proximal femoral nail (PFN)--our first 60 cases

The most widely used implant in unstable proximal femoral fractures is the dynamic hip screw (DHS). Intramedullary implants include the intramedullary hip screw (IHMS), gamma nail and proximal femoral nail (PFN). There have not yet been any randomised trials comparing the PFN and DHS. We report our experience of stabilising 60 consecutive proximal femoral fractures with the PFN. Fifty fractures were unstable trochanteric fractures, seven were subtrochanteric (32A), one segmental, and two were at the level of a DHS plate. The mean age was 79 years and there were 12 male and 48 female patients. Twenty-eight patients were graded as ASA 3 or 4. Two patients had multiple injuries, all fractures were closed and there were five pathological fractures. The patients were followed up for a minimum of 4 months. Within this period, there were 12 deaths due to cardiopulmonary complications. Of the remaining 48 patients, two were lost to follow-up and 39 had united by 4 months. The local complications were: four implant cut-outs, two high energy fractures below the implants and one implant failure at 7 months due to delayed union. We believe that the PFN is a good choice for stabilising subtrochanteric fractures. We also believe that the use of the PFN for unstable trochanteric fractures is very encouraging. A large, randomised controlled trial against the DHS would be helpful to clarify the relative risks and benefits.     

INTERTAN髓内钉与滑动髋螺钉治疗老年性粗隆间和粗隆下骨折的临床比较

目的比较INTERTAN髓内钉与滑动髋螺钉(DHS)治疗老年性粗隆间和粗隆下骨折的手术疗效。方法自2010年1月至2012年1月,对120例股骨粗隆间或粗隆下骨折患者分别行INTERTAN髓内钉或DHS固定治疗,其中INTERTAN组67例,DHS组53例。记录手术时间、术中出血量、术后引流量;进行术后疼痛评估、Harris髋骨评分、SF-36生活质量评估;记录并发症情况。结果本组中共有111例(INTERTAN组64例、DHS组47例)患者完成随访。两组间的手术时间无显著差异。DHS组的平均失血量及术后引流量较大,与INTERTAN组相比存在明显差异。VAS疼痛评分中,INTERTAN组术后3 d的VAS评分要优于DHS组,存在统计学差异;但术后3个月及12个月的随访中无明显差异。在术后3个月及12个月后,两组的Harris髋关节评分和SF-36生活质量评分没有统计学差异。结论 INTERTAN和DHS治疗股骨粗隆间或粗隆下骨折,术后疼痛、功能、并发症的结果无明显差异。     

不稳定型转子周围骨折的临床治疗分析

目的比较不稳定型转子周围骨折采用亚太型Gamma钉(Gamma-AP钉)和动力髋螺钉(DHS)固定的手术疗效。方法68例不稳定型骨折患中，31例使用Gamma-AP钉固定，37例使用DHS固定，并对手术资料、术后并发症及髋关节功能进行临床随访分析。结果Gamma钉手术切口长度、术中出血量较DHS手术小，而且患可早期下床负重而不增加术后并发症发生率。结论Gamma钉手术创伤小，适用性强，是治疗不稳定型转子周围骨折的理想方法之一。     

单纯髓内钉与髓内钉附加钢板固定股骨粗隆下粉碎性骨折的对比

[目的]探讨和对比单纯髓内钉固定与髓内钉附加锁定钢板固定治疗股骨粗隆下粉碎性骨折的疗效。[方法]回顾性分析2013年1月~2017年12月本院手术治疗的股骨粗隆下IV、V型粉碎性骨折患者46例。术中先行闭合牵引复位,若透视显示骨折复位不满意,则行髓内钉附加锁定钢板手术,共27例;若透视复位满意,则行常规的单髓内钉置入手术,共19例。比较两组围手术期、随访与影像资料。[结果]两组手术均顺利完成。所有患者无血管、神经损伤等并发症。复合固定组手术时间、切口长度、术中失血量、术后引流量和输血量均显著大于单髓内钉组,差异有统计学意义(P<0.05)。但复合固定组术后卧床伤肢主动活动时间显著早于单髓内钉组(P<0.05)。平均随访时间(15.59±5.15)个月,随术后时间推移,两组下肢功能均逐步恢复。复合固定组术后完全负重行走显著早于单髓内钉组,差异有统计学意义(P<0.05)。随术后时间推移,两组患者的髋关节伸-屈ROM和Harris评分显著增加,而VAS评分显著减少,不同时间点间差异均有统计学意义(P<0.05)。术后3个月时,复合固定组的ROM和Harris评分显著大于单髓内钉组(P<0.05),而VAS评分显著小于单髓内钉组(P<0.05),但是两组间差异在6个月和末次随访时无统计学意义(P>0.05)。影像评估方面,复合固定组骨折愈合时间为(3.89±0.80)个月,而单髓内钉组为(4.53±0.80)个月,两组间差异有统计学意义(P<0.05)。至末次随访时,两组患者均未发生内固定松动、断裂,未发生骨不连、再骨折。[结论]髓内钉附加锁定钢板固定治疗股骨粗隆下粉碎性骨折具有髋关节功能恢复快、骨折愈合时间短等优点。但不可避免会延长手术时间,并增加输血率。     

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。     

Elastic intramedullary nail for treatment of extremity fractures in children

Objective： To assess the clinical therapeutic effects of elastic intramedullary nail on extremity fractures in children.
Methods： From June 2005 to March 2008, 40 children with extremity fractures were treated by elastic intramedullary nail, in whom femoral shaft fractures occurred in 26 cases, tibiofibular fractures in 8 cases, radial capitular fractures in 4 cases, ulnoradial fractures in 2 cases. All patients were treated by closed reduction and elastic intramedullary nail fixation. Results： All the fractures gained satisfactory reduction and healing. The average duration needed for fracturehealing was 1-2 months. Postoperative follow-up confirmed a sound functional recovery.
Conclusions： The elastic intramedullary nail is a minimally invasive and effective surgical approach for treatment of extremity fractures in children. It allows early functional exercises after operation and secures a satisfactory bone union and functional recovery.     

Percutaneous cerclage wiring followed by intramedullary nailing for subtrochanteric femoral fractures: a technical note with clinical results

Background

Although intramedullary nailing is an ideal treatment for subtrochanteric femoral fractures, it is technically challenging in fractures extending into the nail entry area and/or involving the lesser trochanter. Although the application of circumferential wire may facilitate reduction in these situations, its use remains controversial due to possible blood supply disturbances to underlying bone. In the present study, we evaluated complex subtrochanteric fractures treated by percutaneous cerclage wiring followed by intramedullary (IM) nailing for anatomical fracture reduction and union.

Methods

Twelve patients (mean age 48.3 years) with an unstable subtrochanteric fracture were prospectively treated. Indications of percutaneous cerclage wiring followed by IM nailing were a fracture extending proximally into the nail entry area deemed difficult to treat by anatomical reconstruction by IM nailing or a fracture with long oblique or spiral component. One or two cerclage wires were percutaneously applied for the temporary reduction of main fragments, and then, a cephalo-medullary or a reconstruction nail was fixed. We assessed radiologic results (union time, alignment), functional results, and complications.

Results

All 12 cases healed, without a bone graft, at an average of 19.1 weeks after surgery (range 16–24). In 11 cases, acceptable alignment was achieved (mean, valgus 0.3° extension 0.6°) with minimal leg-length discrepancy; the other exhibited 1 cm of shortening. All patients were able to return to pre-injury activity levels, and median Merle d’Aubigne score was 16.9 (15–18). No infection or implant-related complication was encountered to latest follow-up (minimum 12 months postoperatively).

Conclusion

Temporary reduction by percutaneous wiring offers a means of satisfactory nailing in difficult subtrochanteric femoral fractures, and affords anatomical reconstruction and favorable bony union.     

Open reduction and intramedullary stabilisation of subtrochanteric femur fractures: A retrospective study of 56 cases

Subtrochanteric femur fractures commonly present with predictable displacement because of the deforming muscle forces acting upon the proximal femur. For this reason, successful closed reduction and femoral nailing can be a technically demanding procedure. Open reduction prior to nail placement has been advocated to improve and maintain anatomic fracture alignment. The purpose of this study was to evaluate the results of patients with closed subtrochanteric femur fractures treated with open reduction and a reamed antegrade statically locked intramedullary nail. An initial query of our database identified 154 patients who had sustained a subtrochanteric femur fracture over the defined study period. Ninety-six patients had adequate radiographic and clinical follow-up. Fifty-six (58%) patients were treated with open reduction and nail placement. There were no wound complications or infections and all patients went on to successful osseous union. There was no loss of reduction and a final coronal and sagittal plane deformity of <5 degrees in 55 of 56 (98%) patients. Open reduction of closed subtrochanteric femur fractures followed by intramedullary nailing leads to high union rates with rare complications.     

长Gamma 3型髓内钉内固定治疗股骨粗隆下骨折临床疗效分析

目的探讨长Gamma 3型髓内钉内固定治疗股骨粗隆下骨折的疗效。方法对60例股骨粗隆下骨折采用闭合复位或有限切开复位长Gamma 3型髓内钉内固定治疗。结果 60例均获随访10-24个月,平均18个月。骨折愈合时间9-15个月,平均10个月。末次随访时髋关节功能Harris评分：优16例,良35例,可9例,优良率85%。未发生拉力螺钉切割出股骨头、股骨干骨折、髋内翻畸形等严重并发症。结论采用长Gamma 3型髓内钉内固定治疗股骨粗隆下骨折创伤小,疗效好,便于术后早期功能锻炼,并发症发生率低。