股骨粗隆周围骨折内固定治疗
瑞金 王蕾,2004.11,股骨粗隆周围骨折内固定治疗的一些体会,上海第二医科大学附属瑞金医院 骨科 上海市伤骨科研究所 王 蕾,瑞金 王蕾,2004.11,AO临床资料统计结果,2010年 1520 （>65岁）78.9%的股骨近端骨折病例均为年龄>65岁的老年人股骨近端骨折发生率 (1.22.0 )股骨近端骨折中: 股骨转子间骨折 35.7% ( 31-A1/A2 ) 股骨转子间反向骨折 7.3% ( 31-A3 ) 股骨转子下骨折 3.2%,46.2%,瑞金 王蕾,2004.11,股骨近端骨折内固定的目的,尽早施行手术稳定的内固定病人早期下床活动,有报道表明：如果骨折发生至手术时间>3天，患者一年内的死亡率上升一倍。Gilchrist WJ, Newman RJ, Hamblen DL, Williams BO. Prospective randomised study of an orthopaedic geriatric inpatient service. Br Med J 1988; 297:1116-8.Tinetti ME, Baker DI, McAvay G et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994; 331: 821-7. WHO Study Group. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Technical Report no. 843. Geneva: WHO, 1994.,瑞金 王蕾,2004.11,股骨近端骨折内固定治疗内植入物的选择,骨折分类对于判断骨折稳定性的重要性骨折的复位固定方式及内植入物的选择术后治疗方案的确定,瑞金 王蕾,2004.11,Evans' classification (1949) Boyd and Griffin's classification (1949) Ramadier's classification (1956) Decoulx & Lavarde's classification (1969) Ender's classification (1970) Tronzo's classification (1973) Jensen's classification (1975) Deburge's classification (1976) Briot's classification (1980) AO classification (1981),骨折分类对于判断骨折是否稳定的重要性,瑞金 王蕾,2004.11,骨折分类对于判断骨折稳定性的重要性,Evans 分类1949 EM Evans骨折块的数量骨折移位股骨近端后外侧股骨近端内侧 （包括小转子）骨折线的走向Modified Evans 分类19751980 Jensen & Michaelson234DHS病例治疗结果分析骨折冠状面、矢状面的复位未明确转子下骨折,相对稳定,不稳定,瑞金 王蕾,2004.11,骨折分类对于判断骨折稳定性的重要性,AO/ASIF 分类1980-1987 M.Mueller et al.骨折线的方向（A1,2/A3）内侧壁及小转子骨折块的数量,相对稳定,不稳定,瑞金 王蕾,2004.11,股骨近端骨折的治疗方案和内植入物选择,股骨近端骨折,手术？,否,保守治疗,是,关节置换,内固定,髓外固定,髓内固定,DHS,DCS,角钢板,空心螺丝钉,外固定支架,其它,Gamma钉,股骨重建钉,PFN,其它,内固定失败/骨关节炎,Ender钉,瑞金 王蕾,2004.11,股骨近端骨折内植入物的选择,瑞金 王蕾,2004.11,股骨近端骨折内植入物的选择,股骨近端的生物力学,Excentrical load between head and shaftCompression versus traction forces,髓外固定: load sharingstable fracture,髓内固定: load bearingunstable fracture,张力侧,压力侧,Kim WY, Han CH, Park JI, Kim JY. Failure of intertrochanteric fracture fixation with a dynamic hip screw in relation to pre-operative fracture stability and osteoporosis. Int Orthop. 2001; 25:360-2.,瑞金 王蕾,2004.11,股骨近端骨折的整复和稳定性股骨近端内侧的支持丧失（小转子和股骨距）股骨后方骨的完整性（后侧骨皮质和大转子）股骨转子下骨折,Some authors think that medial stability is usually preserved if only the lesser trochanter is fractured, since the structure described as a “massive cancellous apophysis behind the calcar“ does not have a major weight-bearing function. Franck Mabesoone Department of Orthopaedics and Traumatology, Hôpital Pitié-Salpétrière- F-75013 Paris, France,瑞金 王蕾,2004.11,股骨近端相对稳定骨折的固定,DHS是目前髓外固定方式中首选的动力化钉板系统钝性粗大固定螺钉通过滑动产生骨折端动力加压缩短力臂的作用、降低屈曲负荷减少头钉的切割率 多发性创伤，尤其合并有肺部挫伤的患者，髓外固定首选广泛使用、标准化操作,Jacobs RR, McClain O, Armstrong HJ. Internal fixation of intertrochanteric hip fractures: a clinical and biomechanical study. Clin Orthop. 1980;146:62-70.,瑞金 王蕾,2004.11,股骨近端相对稳定骨折的固定,DHS手术操作中需要注意的问题DHS主钉固定位置？小转子是否必须复位、固定？DHS是否还能用于不稳定骨折的固定？,瑞金 王蕾,2004.11,股骨近端相对稳定骨折的固定,DHS手术操作中需要注意的问题DHS主钉固定位置？小转子是否必须复位、固定？DHS是否还能用于不稳定骨折的固定？,瑞金 王蕾,2004.11,Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77:1059,TAD- Tip Apex Distance,主钉必须尽可能到达软骨下区域主钉应位于股骨头的中心,DHS主钉固定位置？,瑞金 王蕾,2004.11,股骨近端相对稳定骨折的固定,DHS手术操作中需要注意的问题DHS主钉固定位置？小转子是否必须复位、固定？DHS是否还能用于不稳定骨折的固定？,瑞金 王蕾,2004.11,Some authors think that medial stability is usually preserved if only the lesser trochanter is fractured, since the structure described as a “massive cancellous apophysis behind the calcar“ does not have a major weight-bearing function. Franck Mabesoone Department of Orthopaedics and Traumatology, Hôpital Pitié-Salpétrière- F-75013 Paris, France,小转子是否必须复位、固定？,我院经验：当使用DHS固定股骨近端骨折时小转子不需要进行复位和固定,瑞金 王蕾,2004.11,股骨近端相对稳定骨折的固定,DHS手术操作中需要注意的问题DHS主钉固定位置？小转子是否必须复位、固定？DHS是否还能用于不稳定骨折的固定？,瑞金 王蕾,2004.11,DHS是否还能用于不稳定骨折的固定？DHS的固定力学结构对内侧的完整性要求较高。DHS过度滑动（>15mm）临床并发症显著增加。骨折远端内移（>该部位股骨直径1/3，固定失败率上升7倍）。,张力侧,压力侧,Steinberg GC, Desai SS, Kornwitz NA, Sullivan TJ. The intertrochanteric hip fracture. A etrospective analysis. Orthopedics. 1988;11:265-73.Parker MJ, Pryor GA. Gamma versus DHS nailing for extracapsular femoral fractures. Metaanalysis of ten randomised trials. Int Orthop. 1996;20:163-8.Baixauli F, Vicent V, Baixauli E, Serra V, Sanchez-Alepuz E, Gomez V, Martos F. A reinforced rigid fixation device for unstable Intertrochanteric fractures. Clin Orthop. 1999; 361:205-15.Kim WY, Han CH, Park JI, Kim JY. Failure of intertrochanteric fracture fixation with a dynamic hip screw in relation to pre-operative fracture stability and osteoporosis. Int Orthop. 2001;25:360-2.,瑞金 王蕾,2004.11,AO/ASIF分类 A3.3型 不稳定骨折,瑞金 王蕾,2004.11,AO/ASIF分类 A3.3型 不稳定骨折,瑞金 王蕾,2004.11,股骨近端不稳定骨折的固定,股骨近端髓内钉是目前首选的髓内固定系统 （以Gamma钉和PFN为代表）主钉粗大，机械强度高，固定牢固位于髓腔中心线，有效降低髋关节和股骨机械轴心线之间的距离可以通过滑动产生骨折端动力加压（Gamma钉>PFN）手术切口小、不需扩髓、出血少,？,Mahomed N, Harrington I, Kellam J, Maistrelli G, Hearn T, Vroemen J. Biomechanical analysis of the Gamma nail and sliding hip screw. Clin Orthop. 1994;304:280-288.,
