16:32,2,Aug,2007 | (844/0/0) | Original

subtrochanter femur fracture


Of nonunion has been confirmed to be removed when the surgical treatment of hardening side, open up the canal to improve the blood supply to the fracture, parallel rigid fixation. Intertrochanteric fracture of the clinical treatment of alternative healing methods are not large, such as the Zickel nail, plate fixation, DHS and PFN, etc., and Gamma nail fixation and autogenous bone graft has its obvious advantages. Gamma nail fixation is a minimally invasive surgical methods, small incision, less trauma, intraoperative blood transfusion or less can not lose, which has a short arm, bending moment is small, the direct role of the local characteristics of pressure through the intramedullary nail and The combination of lag screw, the proximal femur and femoral neck combined into one firm, fixed on the greater trochanter, proximal, distal locking screw can choose dynamic or static locking, anti-shortening and rotation capacity, shear force is also large, fixed stable and reliable. While in the rigid internal fixation with autogenous cancellous bone graft, autogenous bone with BMP, can induce tissue repair, so that the surrounding undifferentiated mesenchymal cells to form cartilage and bone mother cell mother cell, it is because bone has a creeping substitution The bone conduction and induction into the role, so the clinical surgical treatment of nonunion at the same time is necessary for autologous bone grafts [2], but larger defects in the fracture, more than 6 cm, the method prone to failure [5] , need to select with vascular pedicle bone graft. Bed after 6 to 8 weeks after X-ray examination shows that only after clinical healing gradually functional exercise. In addition, you can try to apply a variety of physical methods such as extracorporeal shock wave, local micro-, low-energy pulsed ultrasound and other interventions. Experimental study found that extracorporeal shock wave at a certain intensity, the first cause of bone cell necrosis, approximately 72 h, osteoblasts are activated osteoblast aggregation, thereby stimulating bone formation, especially in callus formation; fracture minor activities can promote callus formation and calcification, accelerate fracture healing, but to control the manner and extent of micro, should be primarily passive, micro-axial load should be [6]; U.S. orthopedic expert application of low energy as early as 1983 success of pulsed ultrasound treatment of nonunion.
subtrochanter femur fracture

Intertrochanteric fractures can be complicated by the diseases?
1. Coxa vara coxa vara is the most common complications of intertrochanteric fractures, the root cause abductor muscle pull on the distal femur and another into the marrow needle causes the needle point is not correct, prevent accurate insert the key in the first 1 marrow needle into the needle, as the fracture of the proximal flexion, abduction, external rotati
on, it is difficult to choose exactly the point of pyriform fossa, and femoral anatomic axis open pulp, must be observed in the C-arm lateral two planes is confirmed There are 2 ways to reduce this difficulty, one incoming trunk, the second is inserted in the femoral neck Steinmann pin fractures of the proximal adductor, the first two reasons for the medial femoral cortex structure is not complete, if those who open reduction , bone graft reconstruction of the medial femoral must complete and indirect reduction who pay attention to intraoperative measurement of anterior superior iliac spine to the midpoint of 1,2-toes between the lines of force through the patella is generally believed that <10
Current location: China paper Download Center> Medicine> Medical> text intertrochanteric fractures of the surgical treatment
Source: China paper Download Center [08-06-28 16:10:00] Editor: studa20
Of: Machinating and Promulgating Harmony, Cao Xuecheng, Cai Jin Fang
Key words intertrochanteric fractures
Intertrochanteric hip fractures that occurred in the line outside the joint capsule to the bottom of the rotor within the region of small fractures occur in elderly patients. As our population ages, the incidence of such fractures continue to increase. Because of complications caused by bedridden patients with severe life-threatening, making the conservative treatment more than doubled the mortality rate to surgical treatment group. Thus for patients who can tolerate surgery, most scholars advocate aggressive surgical treatment.

Intertrochanteric fractures in elderly patients with the following characteristics: (1), osteoporosis, bone loss and bone micro-structural damage, the physical strength of bone was significantly reduced, the reliability of fracture fixation was significantly reduced [1]; (2) the elderly often associated with hypertension, diabetes and other chronic medical illness, poor physical tolerance, difficult to tolerate the larger surgical trauma; (3) bed-ridden prone respiratory tract, urinary tract infections, pressure ulcers, deep vein thrombosis (DVT ) and other complications, endangering the lives of patients.

Therefore, the elderly intertrochanteric fractures of the treatment goal should be to minimize surgical trauma, access to good fracture reduction, early fixation, allows patients to activities away from the bed as soon as possible, reduce complications, and early resumption of the hip joint function, quality of life [2].

Currently, the main surgical incision or closed reduction and application of nail - board system or intramedullary screw fixation, in addition to external fixation system and the artificial joint replacement and so on. Common nails - board system, including DHS and DCS, etc., including the Gamma nail intramedullary nail system, and the PNF, and recent clinical application Fixion expandable proximal femoral nail.

1 DHS

DHS by the composition of a steel plate and sliding screw, neck shaft angle was 135 °. The living femoral side plate, slide the screw holes through the plate into the femoral neck, which play a fixed role. DHS with a biomechanical study found that static and dynamic compression effect, and has a tension band effect can be tight compression fracture, is conducive to fracture healing, it is mainly applicable to a stable fracture, the unstable intertrochanteric fractures and fracture should not reverse the child to use. DHS has found clinical application of the following disadvantages: (1) the need to cut exposure to reset the fracture, trauma, excessive stripping of fracture healing of the fracture extended; (2) No effective anti-rotation effect, easy to produce rotation fracture shift; (3) DHS mechanical characteristics of the femoral neck fracture with screws along the sliding movement of produce entrapment, but the femur around the high stress area, and femoral neck stress contrast, the medial cortex of stress relief for poor , the stress will be concentrated in the nail plate and screws, the screw plate and a higher proportion of the fracture; (4) force the femoral head, the load transmission through the lateral femoral neck nailing and cortical bone on the outside close to the greater trochanter side of the bone cortex of the plate has pulled out of the force, reducing the fixed effects, in the small role of stress shielding produced around the rotor, an increase occurred after the removal of internal fixation of fracture risk of early relapse [3]; (5) DHS's plate located in the lateral femoral, medial support the need for good, but the elderly patients osteoporosis, the bone around the femoral head and femoral strength from the lack of support for reducing or crushed, resulting in nail plate and bone interface with the poor, hard to play the DHS slide and the advantages of pressure, making it easier from the collapse of the femur, femoral neck shortening, resulting in varus deformity of hip screw cut out of the femoral head or neck. Kim et al [4] reported unstable fracture patients with osteoporosis more than 50% failure rate, that in this case should not choose the DHS treatment.

2 DCS

DCS are derived from the DHS, neck shaft angle is 95 °, half the 10.5 mm screw thread design and the motherboard can be pressurized to end the automatic sliding design, it is designed for AO femoral supracondylar and intercondylar fractures of the design. Later, in the treatment of femoral fractures when the fracture line was found just in the DHS entrance point of DHS or rotor smashed into the needle, the use of DCS and DHS can get a similar mechanical effect, and the deep thread design DCS screw loose bone can be overcome Quality internal fixtures of the lack of holding force, making the DCS treatment of elderly subtrochanteric fractures by academic recognition [5], and it also can reverse the child for the treatment of fractures. The disadvantage is the relatively large wounds, preoperative need for subtrochanteric fractures in elderly patients who do the right assessment.

3 Gamma nail

Gamma nail intramedullary nail by a 1, a sliding screw and a anti-rotation screws composition. The nail in the medullary cavity after reaming, the load transfer to the expansion of extrusion, the medial and lateral femur are under great stress, improves the overall stability of fracture fixation.

Gamma nail and DHS combines the advantages of intramedullary nails: nails and connected to the head and neck, arm shortened, the torque decreases, the shear is small, the role of the bending force in the fracture is relatively small, a more direct role of the local pressure, two femoral neck can effectively prevent the lag screw rotation, combined with shortening of distal locking screw and rotating with the ability of resistance on the rotor area has a good fixation of fractures. Reliable fixed to allow patients earlier than the DHS functional exercise is conducive to the recovery of joint function. In addition to closed fracture reduction operations, less blood loss, reduced wound infections caused by open reduction and other related complications, will undoubtedly help the elderly postoperative rehabilitation. Sadowski et al [6] The study confirmed the intramedullary fixation system is more stable than the screw-plate system, and surgery and 32% shorter hospital stay, blood loss decreased by 24%, especially for unstable intertrochanteric fractures, intramedullary fixation system more advantage.

Because of these advantages, Gamma nail, once widely used there Jibei intertrochanteric fracture. Gamma nail clinical findings but there are more complications: (1) nail into difficulties, and likely into the proximal femoral fractures. The intraoperative iatrogenic fracture is a major complication; (2) after distal femoral shaft fracture-prone, and often appear close to regional pain. Has been reported, Gamma nail at the end of femoral shaft fracture incidence as high as 18% [7]; (3) a single anti-rotation screw poor femoral neck, and the lag screw within the femoral head position if the poor are cut a certain percentage of the femoral head screw extrusion . Especially for elderly patients with osteoporosis severe osteoporosis, but also easily lead to lag screws in the femoral head, neck and hip varus cut out.

Friedl et al [8] that the fracture collapse, compression screw cutting the occurrence of complications such as femoral head fracture and the potential rotation of the shear related. In addition, biomechanical testing showed, Gamma trochanteric nail proximal bold in close contact with the uniform distribution of stress, but increased the distal tip of the femoral intramedullary nail pry cutting of cortical bone, and the Gamma nail intramedullary nail valgus angle is too large to form a three-point fixation, intramedullary nail is too short to load the body can not reasonably be passed by the fixation to the bone, resulting in nail and nail distal stress concentration, and postoperative femoral shaft fractures the main reason for the lock screw fracture [9]. These are reflected in the design of the Gamma nail defects.

4 PFN

1996, AO / ASIF nail for a number of design flaws Gamma improved design PFN. Compared with the Gamma nail, PFN has the following advantages: (1) nail diameter and valgus angle decreased, not reamed, more simple operation; (2) nail growth, and increased the keyhole with the main remote delivery nail remote distance, keyhole to slip hole, reducing the stress concentration caused by the incidence of femoral shaft fractures; (3) the proximal femoral neck increased by a 6.5 mm diameter anti-rotation hip screw, nail plate - bone contact interface greater reduction of the average arm, stronger anti-shortening and rotation capability, and reduce the varus and the incidence of femoral head screw cutting; (4) were designed in the nail rod cross keyhole dynamic and static , an increase of intramedullary stability.

PFN maintained over design makes Gamma nail trauma, allowing patients the advantages of early functional exercise, and better than the Gamma nail dynamic action [10], lower incidence of complications [11], more applicable to non- stable intertrochanteric fracture, fracture, and high reverse the sub-subtrochanteric fractures.

PFN there are some problems: (1) the right side of the femoral neck into 2 parallel screws has some difficulties, especially for short neck, a smaller average diameter of the femoral neck, short stature, elderly women, and 2 root of power between the bone screw susceptible to degradation with the risk of femoral head necrosis [5]; (2) PFN length and curvature of large, it is not appropriate for the femoral shaft in patients with excessive anterior arch, otherwise the tip would be oppression intramedullary nail , piercing the femoral shaft in front of the cortex, resulting in distal fractures; (3) Simmermacher RK et al [12] reported screw cutting PFN is the probability of femoral neck 0.6%, the probability of postoperative compression screws was 21.4% slide. This is related to osteoporosis or premature weight bearing. Therefore, patients with severe osteoporosis, PFN must be cautious, when you have that information with patients to avoid premature weight bearing.

5 EPFN

EPFN by Israel Disc  O  Tech development company in 1999 and gradually used in clinical orthopedics, it is implanted in the femoral shaft by the nail and the femoral head of hip implant components studs, if necessary, can be implanted in the femoral head a nail through the nail and the hip peg expansion to obtain rigid fixation.

EPFN compared with other intramedullary fixation has the following advantages: (1) hip biomechanics experiments showed that the pull stud with ordinary screws similar, but reversed the anti-hip stability stud bolt is 5 times normal [13], and hip After expanding around the stud BMD (bone mineral density, bone mineral density) increased, while the surrounding normal BMD interlocking nail reduced the increase in hip bone density increased the potential of fixed pegs, thus greatly reducing the screw cutting stock The incidence of bone prolapse [14]; (2) nail canal wall radial spokes tightly with clothes, nails body along the length of the load evenly distributed in the screw - bone interface, the stress evenly distributed throughout the backbone, Thus the medullary cavity of the load is the same, different from the ordinary to rely on three interlocking intramedullary nail fixation principle, lead to stress too much focus on the nail and nail down the canal EPFN allow a small range of vertical movement, thus avoiding the distal femoral shaft fracture risk; (3) whether the size of the patient's marrow, osteoporosis, and to what extent differences can be through the main nail and hip peg expansion and distal femoral bone marrow cavity and close fitting clothing, to ensure the reliability of the fixed [15]; (4) any reamed without distal locking screw, the operation simplified, while avoiding the reamed and the nail caused by the lack of complications or failure. Hopp et al [16] reported the treatment of senile intertrochanteric fractures EPFN 30 cases, average age 78 years; and Gamma nail in treatment group, mean operation time from 89 min decreased to 53.6 min, mean fluoroscopy time was reduced by a 4.08 min 1.44 min The average healing time was 10 weeks; that EPFN treatment of intertrochanteric fractures with a simple operation, short time, perspective and less obvious advantages.

Since the application time is short, EPFN reported fewer complications, there are patients in the bone caused by excessive expansion nail splitting, such as deep infection after surgery, but the incidence is very low.

6 External Fixation

External fixation is mainly used in the treatment of severe multiple trauma and the elderly infirm and can not be tolerated in patients with internal fixation. Parker et al [17] that its advantages are simple operation, trauma, quicker recovery, the effect is similar with the sliding hip screw. However, due to affect the postoperative functional exercise, and pin tract infection and other complications are not properly resolved, external fixation in intertrochanteric fractures of the scope of smaller and smaller. Links in the paper for download http://www.studa.net
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