瞄准器引导股骨交锁髓内钉远端锁钉的再认识

[目的]分析瞄准器引导下股骨交锁髓内钉远端锁钉困难的原因，以提高远端锁钉成功率。[方法]用配备远端瞄准器的股骨交锁髓内钉治疗股骨干骨折297例（301侧股骨），髓内钉301枚，国产钉216枚，进口钉85枚；粉碎性骨折108例，非粉碎性骨折189例；其中4例双侧股骨干骨折；均采取静力型固定，远近端各2枚锁钉。[结果]301枚股骨交锁髓内钉有288枚远端锁钉一次成功，有13枚初次锁钉未成功，一次锁钉成功率为95．7％。[结论]股骨交锁髓内钉远端锁钉困难的原因是多方面的，要提高远端锁钉一次成功率，必须重视包括术前准备在内的各个环节。     

闭合复位交锁髓内钉固定治疗股骨干骨折

目的探讨应用闭合复位交锁髓内钉固定治疗股骨干骨折的临床效果。方法回顾性分析2007年2月至2008年1月应用闭合复位交锁髓内钉内固定技术治疗股骨干骨折患者123例,男94例,女29例;年龄24～54岁,平均39岁;开放性骨折27例,闭合性骨折96例。根据AO分型：A型46例,B型38例,C型39例。结果 A型骨折手术时间45～62 min,平均53 min;B型骨折手术时间49～68 min,平均59 min;C型骨折手术时间48～82min,平均67 min。3例股骨近端内侧皮质粉碎骨折或骨折向内成角,其中1例髋内翻;4例骨折远端出现劈裂;1例膝关节外翻;5例术锁钉断裂或退出;1例主钉断裂;8例出现不同程度的神经牵拉伤。无一例出现深静脉血栓、肺栓塞和感染并发症。其中112例获得随访,随访时间为12～20个月,平均16个月。A型和B型骨折78例中39例行静力改动力化锁钉,骨折平均愈合时间为6个月;另39例行持续静力化锁钉,骨折平均愈合时间为8个月。C型骨折平均愈合时间为12个月。无一例患者出现骨折不愈合。术后患者髋膝关节功能优良率为98%。结论闭合复位交锁髓内钉内固定术是治疗股骨干骨折的有效方法之一。     

三种髓内钉治疗股骨转子间骨折的临床研究

目的 观察Gamma钉、股骨近端髓内钉(PFN)和防旋股骨近端髓内钉(PFNA)三种髓内钉治疗股骨转子间骨折的疗效. 方法回顾性分析2004年1月至2007年6月手术治疗的126例股骨转子间骨折患者的临床资料,其中Gamma钉治疗46例,PFN治疗29例,PFNA治疗51例.比较三组患者的手术时间、术中失血量、并发症发生情况、骨折愈合情况及术后髋关节Harris评分.结果 126例患者中共有91例获得到随访,时间11～39个月(平均21.6个月),三组患者在并发症发生情况、骨折愈合时间、关节功能评分上差异均无统计学意义(P>0.05),但PFNA组的手术时间、术中出血量少于其他两组(P<0.05),而PFN组与Gamma钉组之间差异无统计学意义(P>0.05). 结论Gamma钉、PFN和PFNA三种髓内钉均适合用于治疗股骨转子间骨折,其中PFNA操作相对简单,可缩短手术时间,减少术中出血.     

Use of Huckstep nail in the periimplant femoral shaft fracture

87-year-old female underwent open reduction of distal femoral fracture and internal fixation with locking compression plate and bone graft. She was operated for ipsilateral proximal femoral fractures and stabilized by intramedullary interlocked nail 5 years ago. She developed stress fracture proximal to locked plate. We inserted Huckstep nail after removal of the previous operated proximal femoral nail without removing the remaining plate and screws. At 15 month followup the fractures have united. The Huckstep nail has multiple holes available for screw fixation at any level in such difficult situations.     

TRIGEN股骨髓内钉在股骨骨折中的应用

目的探讨TRIGEN股骨髓内钉在股骨骨折中的应用效果。方法对54例股骨骨折患者采用TRIGEN股骨髓内钉治疗,记录髓内钉远端锁钉时间、透视次数、一次锁钉成功率及骨折愈合时间。结果54例均获得随访,时间8~36个月。患者骨折均愈合,愈合时间3~14个月。均无伤口感染、血管神经损伤。Sureshot远端瞄准系统远端锁钉时间为142~412 s,一次锁钉成功率为97.2%,透视次数为1~6次。结论TRIGEN股骨髓内钉治疗股骨骨折治疗效果满意,具有损伤小、固定简便、并发症少等优点;Sureshot远端瞄准系统一次锁钉准确率高、操作时间短、放射量小。     

闭合复位逆行交锁髓内钉治疗股骨远端骨折

目的探讨临床应用闭合复位逆行交锁髓内钉治疗股骨远端骨折的疗效。方法笔者自2002年6月～2005年5月,采用闭合复位逆行交锁髓内钉治疗股骨远端骨折28例。结果获得随访28例,时间4～20个月,平均11个月。骨折平均愈合时间5个月,根据HSS膝关节临床功能评定：优12例,良11例,优良率82．2％,可5例（17．8％）,无术后感染及内固定断裂。结论闭合复位逆行交锁髓内钉能提供坚强内固定,出血少,创伤小,有利于骨折的愈合和膝关节功能的恢复,是治疗股骨远端骨折的较理想方法。     

Mechanical study of the safe distance between distal femoral fracture site and distal locking screws in antegrade intramedullary nailing

OBJECTIVE: To determine the safe distance for distal femoral fractures relative to the distal locking screws in antegrade intramedullary femoral nailing using a currently available titanium alloy nail design. DESIGN: Cyclic (fatigue) mechanical testing study. SETTING: Biomechanics laboratory. INTERVENTION: Intramedullary nailing of left synthetic fiberglass composite femora with type 32/33-C fractures at 1, 2, 3, and 4 cm from the more proximal of the distal locking screws. MAIN OUTCOME MEASUREMENT: The number of loading cycles to failure of the nail. RESULTS: A load level of 700 N through the femoral mechanical axis was validated as adequate to cause fatigue failure within 200,000 cycles in slotted stainless- steel nails. In the nonslotted titanium alloy nails, this load level caused failure in only 1 of 3 nails with a fracture at 2 cm from the more proximal of the 2 distal locking screws and in 2 of 3 nails with a fracture at 1 cm from the more proximal of the 2 distal locking screws. All of the other nails did not fail >1 million cycles. CONCLUSIONS: Under laboratory conditions, it is safe to assume that an antegrade titanium alloy nail will survive 1 million compression/bending cycles when the fracture is > or = 3 cm from the more proximal of the 2 distal locking screws.     

交锁髓内钉治疗股骨干骨折(附45例报告)

目的: 探讨使用交锁髓内钉治疗股骨干骨折的应用、手术方式选择及疗效。方法: 对使用交锁髓内钉治疗 45例 (48肢) 股骨干骨折的疗效进行回顾性分析。手术采用闭合、小切口或有限切开复位, 用三维瞄准器锁定骨折远、近端。结果: 48例患者平均随访 13. 5个月, 肢体、关节功能恢复优良率 91. 1%(41 /45), 一期骨折愈合率 89. 6% (43 /48 )。平均骨临床愈合时间 6. 8个月。感染率 2. 1% ( 1 /45 )。1例髓内钉断裂。结论: 交锁髓内钉是目前治疗股骨干骨折的首选方法, 术中应常规静力固定, 不剥离或少剥离骨膜, 不强求解剖复位, 尽量闭合复位、有限扩髓。     

Distal locking in short hip nails: Cause or prevention of peri-implant fractures?

ObjectivesThe most common cause of femoral fractures after osteosynthesis of trochanteric fractures with short nails is weakening of the femoral cortex via distal locking and stress concentrations at the tip of the nail. The aim of the study was to verify whether the incidence of peri-implant fractures is dependent upon the distal locking technique.MethodsWe prospectively analysed a group of 849 pertrochanteric fractures (AO/ASIF 31-A1 + 2) managed with short nails from 2009 to 2013. Unlocked nailing was performed in 70.1% and distal dynamic locking was performed in 29.9%. The mean age was 82.0 years. Peri-implant fractures were divided into 3 groups according to the height of the fracture in relation to the tip of the nail.ResultsIn total 17 fractures (2.0%) were detected. One peri-implant fracture occurred after locked nailing, whereas 16 cases occurred after unlocked nailing (p = 0.037). Patients without distal locking had an 85.7% greater risk of peri-implant fracture. Fractures of the proximal femur (Type I) occurred significantly earlier than fractures at the tip of the nail (Type II) (p = 0.028).ConclusionUnlocked nails do not guarantee sufficient stability. Distal locking serves to prevent postoperative femoral fractures. We recommend the routine use of distal locking when utilizing short nails.     

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在治疗股骨远端骨折中的应用价值。方法 采用逆行交锁髓内钉对22例AO分型为A、C型新鲜股骨远端骨折病例行内固定。结果 所有病例均获随访，21例获牢固骨性愈合，未见畸形愈合、感染。1例发生主钉尾端处骨折，1例发生近端锁钉断裂。术后根据KSS评分体系，评价优14例，良6例，一般2例，优良率90．9％。结论 逆行交锁髓内钉适用于股骨远端骨折，具有高度的稳定性，操作简单，出血少，并发症少，功能恢复快。     

Effectiveness of distally slotted proximal femoral nails on prevention of femur fractures during and after intertrochanteric femur fracture surgery

IntroductionIntra- and post-operative femoral shaft fractures related with nailing remain of concern. Although manufacturers have sought to solve the problem by providing distally slotted nails, it is not clear that these implants reduce fractures.We compare two distally slotted proximal femoral nails [trochanteric nail (TRON) and proximal femur intramedullary nail (PROFIN)].Patients and MethodsThe medical records of 195 hips treated with TRONs (distally slotted in four places in the sagittal and coronal planes) and 583 hips treated with PROFINs (distally slotted in two places in the coronal plane) in two institutes were retrospectively evaluated. The inclusion criteria were follow-up for at least 6 months; pertrochanteric fractures and age over 55 years.ResultsIn total, 161 hips in the TRON group and 512 hips in the PROFIN group were included. The mean follow-up time was 28.5 (range: 6–84) months in whole group. The demographic characteristics of the groups were similar. Only 2 intraoperative shaft and 3 proximal lateral cortex fracture was detected in PROFIN group, there wasn’t any postoperative fracture. Four proximal lateral cortex and 2 femur shaft fractures were detected in TRON group (one during operation and one at postoperative 8th month after a fall at pedestrian way).ConclusionsDistal cephalomedullary nail slotting prevented intra- and post-operative femoral fractures. A distal slot 50 mm in length may increase nail elasticity and reduce nail tip stress to a greater extent than a 30-mm slot. Distal slotting in both the sagittal and coronal planes afforded no advantage compared to coronal slotting only.Level of evidenceLevel III retrospective study     

Evaluation of the long intra-medullary hip screw

There have been many publications about second generation femoral nails, such as the Russell–Taylor nail (Smith & Nephew Richards, Memphis, TN, USA) and Long Gamma Nail (Howmedica, Rutherford, NJ, USA), but little work has been published on the Long Intra-medullary Hip Screw (IMHS, Smith & Nephew). We set out to evaluate the effectiveness of the Long IMHS as a device for the fixation of proximal femoral fractures. We retrospectively reviewed 30 patients who had a Long IMHS inserted for a sub-trochanteric or proximal femoral fracture. Of the 30 patients, three had died and six were lost to follow up, leaving 21, whom we reviewed.

Of the 21 patients reviewed the mean age was 67 years and the mean follow up was 31 weeks. Mean time to union was 15.65 weeks, with one non-union. There were three superficial wound infections. In one patient there was loosening of the distal locking screws, requiring removal and there was one case of intra-operative femoral shaft fracture.

We conclude that, the Long IMHS is an effective device for the treatment of sub-trochanteric and proximal femoral fractures with a high rate of union achieved and a low complication rate.     

带锁髓内钉治疗股骨干骨折并发症原因分析及防治

目的提高带锁髓内钉的治疗效果,减少术中术后的并发症。方法自1998年10月～2001年10月用带锁髓内钉治疗的160例股骨干骨折,随访6～18个月。结果股骨颈骨折2例,主钉折断2例,锁钉折断2例,锁钉松动退出3例,术后感染4例,骨折延迟愈合6例。结论带锁髓内钉是治疗股骨干骨折较好的治疗方法,分析产生合并症的原因后采取各种防治措施可明显降低并发症的发生率。     

The treatment of fractures of the femoral shaft with the Brooker-Wills distal locking intramedullary nail

Ninety-two fractures of the femoral shaft in eighty-five patients were followed after treatment with the Brooker-Wills distal locking intramedullary nail. Twenty-one (22.8 per cent) of the fractures were open and seventy-one (77.2 per cent) were closed; 84.8 per cent of the fractures were comminuted. All but one fracture united, in a mean time of 4.4 months. Four fractures healed with mild angulation, and three had shortening of more than one but less than two centimeters. Significant rotatory deformities did not occur. No patient required postoperative traction or external stabilization, and all but five patients regained a normal range of motion of the ipsilateral hip and knee. There were intraoperative technical problems in eleven patients (12.0 per cent) and postoperative complications in eighteen patients (19.6 per cent), including fourteen patients (15.2 per cent) with pulmonary emboli, infection, or heterotopic bone at the site of the insertion of the nail. Five patients (5.4 per cent) had postoperative complications that were directly related to the proximal and distal fixation of the nail. There was one non-union (1.1 per cent). No problems were encountered with removal of the nail. The Brooker-Wills distal locking intramedullary nail proved to be an effective device for the stabilization of fractures of the femoral shaft. The use of this modified Küntscher nail with both proximal and distal fixation has been successful in preventing clinically significant femoral angulation, malrotation, and shortening and has allowed early mobilization of the patient.     

股骨髓内钉芯钻瞄准系统与体外瞄准架系统的远端锁定效果比较

目的比较股骨髓内钉芯钻瞄准系统与体外瞄准架系统在治疗股骨干骨折远端锁定过程中的应用效果。方法选取我院2015年8月至2017年8月连续收治的98例拟行髓内钉固定术治疗闭合股骨干骨折的病人,按随机数字表法分为研究组和对照组,每组49例。研究组病人采用芯钻瞄准系统进行股骨髓内钉远端锁钉操作,对照组病人应用体外瞄准架系统进行远端锁钉操作。比较分析两组病人的术中远端锁钉首次锁定成功率、远端锁定透视次数、远端锁定完成时间和术中出血量。结果研究组与对照组远端锁钉首次锁定成功率分别为93.9%和49.0%,研究组成功率明显高于对照组,差异有统计学意义(P<0.05)。研究组远端锁定透视次数、远端锁定完成时间、术中出血量[(3.2±0.5)次、(7.3±1.1)min、(220.7±10.5)ml]均少于对照组[(12.2±2.4)次、(15.2±3.6)min、(350.3±33.7)ml],差异均有统计学意义(P均<0.05)。结论采用芯钻瞄准系统进行远端锁钉的置入可以有效提高远端锁钉的锁定成功率、减少手术创伤及降低医患术中放射线暴露量。     

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。     

Russell-Taylor重建钉内固定治疗股骨干多节段骨折并同侧股骨颈骨折

目的 探讨使用Russell-Taylor股骨重建钉内固定治疗股骨干多节段骨折并同侧股骨颈骨折的临床疗效、手术要点和围手术期注意事项。方法 对1998年6月～2002年10月使用股骨重建钉静力固定治疗7例的疗效进行回顾性分析。手术采用闭合穿钉、小切口切开复位。结果 平均股骨颈骨折临床愈合时间5.2个月、股骨干骨折7.3个月,一期骨折愈合率达到71.4％(5/7),其中2例术后12、15个月远端骨折段骨延迟愈合改为动力固定,4～6个月后骨折愈合。无股骨头坏死征象。1例浅表感染。结论 股骨颈骨折强调不切开复位,并争取解剖复位;股骨干骨折则常规闭合穿钉、小切口复位、有限扩髓、静力固定。认为股骨重建钉是目前治疗股骨干多节段骨折并同侧股骨颈骨折的最佳方法。     

Occurrence of secondary fracture around intramedullary nails used for trochanteric hip fractures: a systematic review of 13,568 patients

IntroductionA sliding hip screw (SHS) is currently the treatment of choice for trochanteric hip fractures, largely due to the low incidence of complications. An alternative treatment is the use of intramedullary proximal femoral nails. Unfortunately these implants have been associated with a risk of later fracture around the implant. The aim of this study was to see if any improvements have been made to the current intramedullary nails, to reduce the incidence of secondary fracture around the distal tip of the nail.MethodsWe analysed data related to 13,568 patients from 89 studies, focusing on the incidence of post operative secondary femoral shaft fracture following the use of intramedullary nails in the fixation of trochanteric hip fractures.ResultsThe overall reported incidence of secondary fracture around the nail was 1.7%. The incidence of fracture has reduced in the 3rd generation Gamma nails when compared to the older Gamma nail (1.7% versus 2.6%, p value 0.03). However, the incidence of secondary fracture in the 3rd generation Gamma nails is still significantly higher than the other brands of short nail (1.7% versus 0.7%, p value 0.0005). Long nails had a slight tendency towards a lower risk of fracture although the difference was not statistically significant (1.1% versus 1.7%, p value 0.28). There was a significantly lower risk of fracture for those nails with a biaxial fixation as opposed to uniaxial fixation (0.6% versus 1.9%, p value <0.0001).ConclusionSecondary fracture around a proximal femoral nail is one of the most significant of fracture healing complications, and this study suggests that continuing design changes to this method of fixation has reduced the risk of this complication occurring.     

交锁髓内钉治疗股骨骨折并发症的处理及原因分析

[目的]探讨交锁髓内钉治疗股骨骨折术后并发症的发生原因和处理方法。[方法]本院1999年1月～2004年12月对243例股骨骨折行交锁髓内钉治疗，发生并发症14例，其中骨延迟愈合2例、骨不愈合3例、锁钉失败6例（锁钉松动退出4例，锁钉折弯1例，锁钉断钉1例）、主钉断钉伴骨不愈合1例、术后再骨折1例、膝关节僵直1例。2例骨延迟愈合及时改静力交锁为动力交锁；3例骨不愈合行植骨治疗；主钉断钉和再骨折行扩髓、换钉、植骨治疗；1例锁钉松动退出伴骨不愈合行换钉、植骨治疗；膝关节僵直行股四头肌成形术。[结果]14例患者经过对症治疗，骨延迟愈合、骨不愈合均骨愈合，膝关节功能恢复满意。[结论]交锁髓内钉治疗股骨骨折虽有一定并发症，比其他内固定具有较明显的优势。出现并发症后，及时采取正确有效的处理方法，能达到满意的效果。     

旋入髓内钉与交锁髓内钉治疗成人股骨干骨折疗效分析

[目的]评价旋入式自锁髓内钉、交锁髓内钌在治疗成人股骨干骨折的临床疗效.[方法]自2005年6月～2010年6月采用旋入式自锁髓内钉、交锁髓内钉治疗成人股骨干骨折53例,男38例,女15例,年龄21～65岁;53例患者中交锁髓内钉固定治疗28例,旋入式自锁钉固定治疗25例,对两组分别就其平均手术时间、骨折平均愈合时间、HSS knee rating score法评定功能的各项指标进行比较分析.[结果]53例均获随访,随访时间6～24个月,平均10个月.交锁髓内钉固定组断钉1例,伤口浅表感染1例,骨延迟愈合3例;旋入式自锁钉固定组骨折延迟愈合1例,骨折短缩移位1例.交锁髓内钉固定组的平均手术时间为(95±10) min,旋入式自锁钉固定组平均(55±10) min.交锁髓内钉固定组骨折平均愈合时间为(22.0±3.5)周;旋入式自锁髓内钉固定组平均骨折愈合时间为(20.0±2.5)周;HSS knee rating score法评定功能恢复优良率:交锁髓内钉固定组(88.5±3.0)%;旋入式自锁髓内钉固定组(92.5±3.60)%.旋入式自锁髓内钉固定组与交锁髓内钉固定组相比,统计学有显著性意义(P<0.05).[结论]旋入式自锁髓内钉结构简单,操作方便快捷,创伤小,疗效可靠,是治疗成人股骨干骨折的有效方法.