|
什么是復雜的股骨轉子間骨折
股骨轉子間骨折復位的要求
good： 正側位皮質之間的距離均小于一個皮質的厚度 acceptable ：正位或側位皮質之間的距離小于一個皮質的厚度 poor ：無論正位側位，皮質的距離都大于一個皮質的厚度. Youngwoo Kim, et al. Hook leverage technique for reduction ofintertrochanteric fracture. Injury, (2014) 1006–1010 大約有11%左右的轉子間骨折，通過閉合復位時很難達到滿意的效果的。這個數據各家報道不一，基本上在 3% 到 17% 之間。 Gaurav Sharma, et al. Pertrochantericfractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes ofirreducibility. Injury, (2014) 1950–1957 ◆ ◆ ◆ 類型一 AO/OTA 31-A1.2 fracture 順粗隆骨折，骨折線至小粗隆上 Gaurav Sharma, et al. Pertrochantericfractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes ofirreducibility. Injury, (2014) 1950–1957 不是骨折端間有嵌插，而是近端骨折塊“鎖”在股骨干的下方，復位近端骨折塊非常困難，有時需要切斷部分髂腰肌腱。 G.Z. Said, et al. An irreducible variant ofintertrochanteric fractures: a technique for open reduction. Injury, (2005) 36,871—874 AO/OTA 31-A1.3 fracture Gaurav Sharma, et al. Pertrochantericfractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes ofirreducibility. Injury, (2014) 1950–1957 Supposed chain of causation and effect ofnail breakage after trochanteric fracture: Fixation of a stableintertrochanteric fracture in extreme valgus position (a) results in limitedcranial bone contact of the fragments and leaves a caudal bone defect (b). Lackof bony healing induces permanent full strain on the femoral nail finally leadingto nail breakage, thus resulting in the conversion of an intertrochantericfracture (A1/A2) into a reversed fracture (A3) (c) A1-3型絕對是陷阱 ◆ ◆ ◆ 類型II 矢狀位不穩(wěn) Chun et al. Technique and Early Results ofPercutaneous Reduction of Sagittally Unstable Intertrochateric Fractures.Clinics in Orthopedic Surgery . Vol. 3, 2011 AO/ASIF 分型 31 A1.3 到 31 A2.3 都可能出現矢狀位不穩(wěn)，軸向牽引力和重力只會讓近端骨折屈曲、遠端骨折向后移動，單純向上抬大腿對復位沒有幫助，如果后內側或小轉子有骨折時尤其難復。 Chun et al. Technique and Early Results ofPercutaneous Reduction of Sagittally Unstable Intertrochateric Fractures.Clinics in Orthopedic Surgery . Vol. 3, 2011 Chun et al. Technique and Early Results ofPercutaneous Reduction of Sagittally Unstable Intertrochateric Fractures.Clinics in Orthopedic Surgery . Vol. 3, 2011 如果傾斜的骨折面，在遠端骨塊上是“面向”后面的，在重力的幫助下，通過牽引和旋轉，可能獲得滿意的復位。 Chun et al. Technique and Early Results ofPercutaneous Reduction of Sagittally Unstable Intertrochateric Fractures.Clinics in Orthopedic Surgery . Vol. 3, 2011 相反，如果傾斜的骨折面，在遠端骨塊上是“面向”前面的，牽引只會加劇移位。 Chun et al. Technique and Early Results ofPercutaneous Reduction of Sagittally Unstable Intertrochateric Fractures.Clinics in Orthopedic Surgery . Vol. 3, 2011 Case：孤寡老人，男，82歲，小區(qū)滑倒 術前CT片提示轉子間粉碎性骨折，骨折線到轉子下
術中透視-復位
臨時固定、開口
置釘
術后復查
◆ ◆ ◆ 類型三 AO/OTA 31-A2.2
Gaurav Sharma, et al. Pertrochantericfractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes ofirreducibility. Injury, (2014) 1950–1957 近端骨折塊并沒有坎插到股骨干部，有向前向下移位的傾向。并且這種傾向不會因為軸向牽引而停止。 Gaurav Sharma, et al. Pertrochantericfractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: Causes ofirreducibility. Injury, (2014) 1950–1957 Case：老年女性，75歲，術前X片
術中透視-難以復位
術中透視-克氏針輔助復位
術中透視-輔助復位
術中透視-再次調整-打入導針
術中最后透視
建立骨性通道的時候復位丟失
一期復位丟失
Case：徐某，老年女性，80歲，浴室滑倒
復位、臨時固定
主釘插入困難
插入導針處理開口 ------重建骨性隧道
用手指抵住reamer
Ioannis Aktselis, et al. Intramedullarynailing of trochanteric fractures—Operative technical tips. Injury, (2012)961–965 在進行以上操作的同時必須將軟鉆向內折彎，從而可避免軟組織將鉆頭推向外側。在折彎的作用下，軟鉆具有變直的反作用力，從而可將鉆頭推向內側
Ioannis Aktselis, et al. Intramedullarynailing of trochanteric fractures—Operative technical tips. Injury, (2012)961–965 術中最后透視
近年來，對于股骨轉子間骨折合并外側壁骨折的治療方法是熱點問題
外側壁的定義 a-b為股骨頸上方切線，c-d為股骨頸下方切線，兩條直線與股骨外側的交界的區(qū)域為股骨轉子間的外側壁。
HaqRU Proximal femoral nails compared with reverse distal femoral lockingplates in intertrochanteric fractures with a compromised lateral wall; arandomised controlled trial IntOrthop. 2014 Mar 22. Tip 2: ‘‘No Lateral Wall, No Hip Screw’’
Intertrochanteric Fractures:Ten Tips toImprove Results THE JOURNAL OF BONE & JOINT SURGERY dJBJ S .ORG VOLUME 91-A d NUMBER 3 d MARCH 2009 對于轉子間骨折外側壁的厚度與再次骨折的發(fā)生也有關系 d=股骨大轉子下無名結節(jié)下3cm向上135°至骨折線的距離。
A RELIABLE PREDICTOR OF POST-OPERATIVELATERAL WALL FRACTURE IN INTERTROCHANTERIC FRACTURES。Bone Joint J 2013;95-B:1134–8. 薄壁＝外側壁損傷
外側壁損傷髓內釘作用
A3.3 unstable intertrochanteric fracture.If sliding hip screw had been chosen as the method of treatment, uncontrollablemedialisation and eventual failure would be likely. The nail acts as a buttress, due to itscentromedullary position and prevents failure 髓內釘可以重建外側壁阻止股骨近端向外滑移 Evolving concepts of stability andintramedullary fixation of intertrochanteric fractures--a reviewInjury. 2012Jun;43(6):686-93 預測因素
Inadequate ‘three-point’ proximal fixation predicts failure of the Gamma nail.BoneJoint J 2013;95-B:825–30 不穩(wěn)定型-外側壁損傷
Treatment of Complex Proximal FemoralFractures With the Proximal Femur Locking Compression Plate Erik A. Hasenboehler, MD; 近端復雜骨折
無論哪種方法固定，復位至關重要！ 大量文獻都關注于股骨轉子間骨折合并外側壁骨折的固定方法，對于外側壁粉碎骨折對固定內置物穩(wěn)定性會有影響。因此矢狀位和冠狀位的解剖復位會增加穩(wěn)定，特別是冠狀位的復位是十分重要的 Perioperative Lateral Trochanteric WallFractures: Sliding Hip Screw versus Percutaneous Compression Plate forIntertrochanteric Hip Fractures。J Orthop Trauma April 2011
男性，65歲，脊髓灰質炎多年，摔傷
術前CT片2016-06-279
術中透視-復位
術中最后透視
術后復查
術后兩個月復查
怎么辦？ 爭議
長釘固定
Treatment of Pertrochanteric Fractures:Long Versus Short Nailing Kaan S Long Versus Short Nailing ForIntertrochanteric Femur Fractures Kelly Carlberg … … 手術時間長 術中失血多 系統(tǒng)并發(fā)癥多 費用高…… OTA 28th Annual Meeting October3~6,2012 文獻
不穩(wěn)定型-外側壁損傷-累及轉子下
長髓內釘＋鋼板
一年后
Bone Mass, Structure and Quality
Diagnosis of Osteoporosis Pre UrgentSurgery
Stability of Reduction
復位第一要素！ Blade shaped weightbearing elements
PMMA Augmentation
復雜股骨轉子間骨折
|
|
|
