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PRELIMINARY CLINICAL EFFECT OF PROXIMAL FEMORAL NAIL ANTI-ROTATION TO TREAT FEMORALINTERTROCHANTERIC FRACTURES

Objective To evaluate the primary cl inical effect of proximal femoral nail anti-rotation (PFNAR) in treating femoral intertrochanteric fractures, to summarize operation skills and to analyze correlated curative effective influentialfactors. Methods From July 2006 to May 2007, 19 cases of intertrochanteric fractures (including 8 males, 11 females, aged45-87 years old) were treated with closed reduction and PFNAR fixation. Fractures were caused by fall ing. The locations were left sides in 10 cases and right sides in 9 cases. According to AO classification, there were 14 cases of type A2 and 5 cases of type A3. Operative time, volume of blood loss and weight bear time were analyzed, the condition of fracture union was observed and the hip function was evaluated using Harris criterion after 9 months of follow-up. Results Operative time ranged 23-78 minutes with an average time of 47 minutes, the volume of blood loss ranged 50-120 mL with an average volume of 85 mL, getting-outof- bed time ranged 2-14 days with an average time of 7.4 days; the weight bearing time ranged 10-14 weeks with an average time of 12.4 weeks. No intra-operative femoral fractures and no regional or deep infection occurred during hospital ization period. Seventeen cases were followed up from 3 months to 12 months with an average time of 9.4 months, and achieved bone heal ing within 15-18 weeks with an average time of 16.5 weeks. No compl ications such as delay heal ing, coxa vara or coxa valga, cut-out and screw extraction occurred. Fifteen cases were followed up over 9 months; according to the Harris criterion for evaluation, the results were excellent in 13 cases, good in 1 case and fair in 1 case, the excellent and good rate was 93.3%. Conclusion PFNAR has the advantages of micro invasion, easy-to-perform, less blood loss, less bone loss and stable fixation in treatment of unstable comminuted intertrochanteric fracture, especially in old patients with osteoporosis.

Assessment of the Curative Effects of DHS(Dynamic Hip Screw)Plus Bone Cement in Treating Intertrochanteric Fractures in the Elderly

:目的:探讨DHS+骨水泥治疗老年股骨粗隆间骨折的疗效。方法:回顾分析2001年1月～2006年4月48例70岁以上老年股骨粗隆间骨折病例的临床资料,对其骨折类型、骨质疏松程度、合并症及临床疗效进行分析。结果:本组术后32例获得1～4年随访,无螺钉松动、髋内翻、感染或骨折延期愈合,髋关节功能评价优良率93％。结论:DHS+骨水泥治疗老年股骨粗隆间骨折具有手术时间短、创伤小、内固定牢靠、符合生物力学分配、能早期得到功能锻炼、减少术后并发症等优点;适合各种类型老年股骨粗隆间骨折的治疗。

不同方法治疗股骨粗隆间骨折

【摘 要】 目的 探讨不同方法治疗股骨粗隆间骨折的手术适应证及疗效。 方法 1999 年1 月－ 2006 年12 月，收治176 例股骨粗隆间骨折患者。男103 例，女73 例；年龄34 ～ 91 岁，平均63.5 岁。交通伤31 例，高处坠落伤11 例，跌倒伤134 例。按AO 分型：31A1 型79 例，31A2 型18 例，31A3 型7 例，31B 型15 例，32A 型34 例，32B 型12 例，32C型11 例。病程2 h ～ 7 d。35 例采用非手术治疗，83 例采用动力髋螺钉（dynamic hip screw，DHS）固定，23 例采用股骨近端髓内钉（proximal femoral nails，PFN）固定，27 例采用动力髁螺钉（dynamic condyle screw，DCS）治疗，8 例采用解剖钢板手术治疗。 结果 患者均获随访6 个月～ 7 年，平均15.2 个月。非手术治疗组3 例骨折不愈合，均放弃治疗。解剖钢板手术治疗组1 例术后10 周发生钢板断裂，予对症处理骨折愈合。余患者于术后10 ～ 15 周骨折达临床愈合。6 个月后髋关节功能根据Brumback 评价标准评定，非手术治疗者优9 例，良18 例，差8 例；DHS 手术治疗者优68 例，良12例 ，差3 例；PFN 手术治疗者优18 例，良5 例；解剖钢板手术治疗者优5 例，良1 例，差2 例；DCS 手术治疗者优15 例，良11 例，差1 例。 结论 股骨粗隆间骨折首选手术治疗，手术方案应综合考虑骨折类型、内固定器材特点以及患者病情，采取个性化的治疗方案。

人工股骨头置换术在高龄股骨粗隆间骨折中的应用

目的 总结人工股骨头置换术治疗高龄患者股骨粗隆间骨折的方法和疗效。方法 2002年2月～2005年12月，采用骨水泥型双极人工股骨头置换治疗高龄股骨粗隆间新鲜骨折19例。其中男7例，女12例；年龄78～102岁，中位年龄83.3岁。摔伤13例，车撞伤6例。损伤至手术时间2～10 d。合并糖尿病9例，高血压病9例，慢性支气管炎1例（缓解期），脑梗塞后遗症2例（骨折侧肌力在Ⅳ级以上）。术前患髋Harris评分均为差；骨折按Evan’s分型：Ⅱ型2例，Ⅲ型9例，Ⅳ型8例。结果 19例获6～41个月随访，患髋均无明显疼痛。12例恢复术前行走功能，5例行走能力下降需要扶助，2例不能独立行走。术后并发下肢深静脉血栓1例，泌尿道感染1例，一过性精神障碍2例，7例术后8~37个月分别死于心肌梗死，心衰、脑出血、肺内感染等。结论 人工股骨头置换术治疗高龄患者股骨粗隆间骨折短期疗效满意，可以显著提高患者的生活质量，但应严格掌握适应证。

Evidence-Based Treatment for an Elderly Patient with Intertrochanteric Fractures

Objective To identify an evidence-based treatment for an elderly patient with intertrochanteric fractures. Methods Clinical problems were presented on the basis of the patient’s conditions, and evidence was collected from the NGC (2000 to 2009), The Cochrane Library (Issue 4, 2009), TRIP Database, PubMed (1966 to 2009) and CBM (1978 to 2009). Treating strategies were formulated in terms of the three-combination principle (best evidence, the doctor’s professional knowledge and the patient’s desire). Results Three guidelines and sixteen studies were included. The current evidence indicated that surgery was the preferred solution to intertrochanteric fractures of the elderly patient. The sliding hip screw (SHS) appeared superior to others. There was insufficient evidence to support the routine use of closed suction drainage in orthopedic surgeries. Early surgery was associated with shorter hospital stay and improved mortality. Antibiotic prophylaxis significantly reduced infections. In order to lower the risk of venous thromboembolism, pharmacological prophylaxis should be carried out when the patient was admitted to hospital and be assisted with mechanical prophylaxis after surgery. Nutritional supplementation was conducive to the recovery of the patient. Rehabilitation ought to be performed as soon as possible. Considering the patient’s condition, the treatment option was established according to the available evidence and guidelines. Short-term follow-up showed a good outcome. Conclusion Through the evidence-based method, an individual treatment plan could obviously improve the treatment effect and prognosis.

老年粗隆间骨折动力髋螺钉内固定术的改进

股骨粗隆间骨折内固定并发症原因分析

目的 总结股骨粗隆间骨折内固定手术引起的常见并发症和产生的原因。 方法 2002 年1 月－2007 年10 月，股骨粗隆间骨折内固定手术后17 例出现并发症。其中男15 例，女2 例；年龄31 ～ 82 岁。均为闭合性骨折；新鲜骨折16 例，陈旧性骨折1 例；粉碎性骨折15 例。Evan’s 分型Ⅰ型2 例，Ⅱ型5 例，Ⅲ型7 例，Ⅳ型3 例。伤后至就诊时间1 ～ 6 h，平均2.5 h。采用动力髋螺钉固定7 例，动力髁螺钉固定6 例，股骨近端交锁髓内钉固定1 例，2 枚空心钉固定2 例，外院转入麦氏鹅头钉固定1 例。 结果 术后出现断钉后髋内翻3 例、头颈钉突出股骨头5 例、骨折复位不良4 例、感染导致慢性骨髓炎内固定失败1 例、患肢短缩3 例、患肢延长1 例。无股骨干骨折、股骨头坏死等并发症。 结论 股骨粗隆间骨折内固定术后并发症，主要由于内固定方式选择不当，术中骨折复位不良、固定不牢靠、术后处理不当等引起。

Comparison of proximal femoral nail anti-rotation operation in traction bed supine position and non-traction bed lateral position in treatment of intertrochanteric fracture of femur

ObjectiveTo compare the effectiveness of proximal femoral nail anti-rotation (PFNA) in the treatment of intertrochanteric fracture of femur in traction bed supine position and non-traction bed lateral position.MethodsA retrospective analysis of 102 elderly patients with intertrochanteric fracture of femur who met the selection criteria between January 2013 and April 2018 was made. According to the different operative positions, the patients were divided into two groups: group A (50 cases, PFNA internal fixation in traction bed supine position) and group B (52 cases, PFNA internal fixation in non-traction bed lateral position). There was no significant difference in age, gender, fracture side, cause of injury, AO classification, complications, and time from injury to operation between the two groups (P>0.05). The preoperative preparation time, incision length, operation time, intraoperative blood loss, intraoperative X-ray fluoroscopy times, fracture healing time, and complications were recorded and compared between the two groups, and the effectiveness was evaluated by Harris hip score at 1 year after operation.ResultsThere was no significant difference in incision length between groups A and B (t=1.116, P=0.268). In addition, the preoperative preparation time, operation time, intraoperative blood loss, and intraoperative X-ray fluoroscopy times in group A were significantly greater than those in group B (P<0.05). Both groups were followed up 12-14 months, with an average of 13 months. There were 3 postoperative complications in group A and group B respectively. In group A, there were 2 cases of hip joint pain and 1 case of local fat liquefaction (healed after dressing change); in group B, there were 2 cases of hip joint pain and 1 case of deep vein thrombosis in lower extremity; there was no significant difference in the incidence of postoperative complications between the two groups (P=0.642). The patients of the two groups had a good result of fracture reduction and the internal fixation quality, and there was no main nail loosening, screw fracture, spiral blade cutting, withdrawal, and the nail breakage occurred, and no nonunion of bone, coxa vara, and other complications occurred. X-ray showed that the fracture healed in both groups, and there was no significant difference in fracture healing time between the two groups (t=1.515, P=0.133). There was no significant difference in Harris hip score between the two groups at 1 year after operation (t=0.778, P=0.438).ConclusionCompared with the traction bed supine position, PFNA internal fixation for intertrochanteric fracture of femur in the non-traction bed lateral position has the advantages of short preparation time, short operation time, less intraoperative blood loss, less X-ray fluoroscopy times, and satisfactory postoperative recovery effect.

EFFECTIVENES OF ANTEROLATERAL C-SHAPED APPROACH IN TREATMENT OF INTERTROCHANTERIC FRACTURE OF FEMUR IN ELDERLY PATIENT

Objective To study the effectiveness of anterolateral C-shaped approach in the treatment of intertrochanteric fracture of the femur in elderly patient by comparing with traditional anterolateral approach. Methods Between April 2010 and November 2011, 66 patients with intertrochanteric fracture of the femur were analyzed retrospectively. Of 66 patients, 37 underwent improved anterolateral C-shaped approach combined with fixation of dynamic hip screw (DHS) (improved group), and 29 underwent traditional anterolateral approach combined with fixation of DHS (conventional group). There was no significant difference in gender, age, injury cause, side, disease duration, fracture type, and complication between 2 groups (P gt; 0.05). The operation time, intraoperative blood loss, postoperative drainage volume, and hospitalization time were recorded; and X-ray films were taken to observe the fracture healing. The hip function was evaluated according to self-established criterion. Results The operation was successfully completed in all patients, and primary healing of incision was achieved. All patients were followed up 12-24 months (mean, 17.8 months). Bone union was achieved in both groups; the fracture healing time was 3-6 months (mean, 4.8 months). No loosening or breaking of internal fixation was observed during follow-up period. The operation time and postoperative drainage volume of improved group were significantly less than those of conventional group (P lt; 0.05); no significant difference was found in intraoperative blood loss and hospitalization days between 2 groups (P gt; 0.05). According to self-established criterion, improved group was significantly better than conventional group in recovery of hip joint motion and function at 6 and 12 months after operation (P lt; 0.05). Conclusion Anterolateral C-shaped approach combined with DHS could minimize muscle injury and scar formation, which is beneficial to surgical exposure and early postoperative rehabilitation.

TREATMENT OF UNSTABLE FEMORAL INTERTROCHANTERIC FRACTURE IN ELDERLY PATIENTS WITH REBUILD SEPTUM BRONCHIALE IN ARTIFICIAL FEMORAL HEAD REPLACEMENT

Objective To investigate the operative procedure and the therapeutic effects of unstable femoral intertrochanteric fracture in elderly patients with rebuild septum bronchiale in artificial femoral head replacement. Methods From October 2005 to October 2007, 113 elderly patients with unstable femoral intertrochanteric fracture were treated with artificial femoral head replacement with fixation of femoral greater trochanter and smaller trochanter in the help of bone cement in 58 cases (test group) and with γ-type bone nail in 55 cases (control group). In test group, there were 21 males and 37 females with an average age of 75 years, including 10 cases of type IIIA, 16 cases of type IIIB and 32 cases of type IV according to Evans-Jenson standard. In control group, there were 17 males and 38 females with an average age of 72.5 years,including 13 cases of type IIIA, 14 cases of type IIIB and 28 cases of type IV according to Evans-Jenson standard. All fractures were caused by fall damage. The disease course was 3 hours to 7.5 days (mean 1.4 days). The patients of two group compl icated with osteoporosis, and compl icated by one or several compl ications of coronary heart disease, hypertension, diabetes and chronic bronchitis. And all patients did not had fracture at other sites. There was no significant difference in general data between two groups (P gt; 0.05). Results The operations were successful, the incision healed by first intention. There were significant differences in operation time, operative blood loss and blood-transfusion between two groups (P lt; 0.05). The two group were followed 12-36 months. There were significant differences (P lt; 0.05) in the incidence rate of compl ication and the excellent and good rate of hip function (by Harris standard) between the test group (3.4% and 93.1%) and the control group (16.4% and 70.9%) 12 months after operation. Conclusion The aged patients with intertrochanteric fracture can get good result through caput femoris replacement, and rebuild septum bronchiale is of great significance.