趙文博,張 智,陽 波,葉永杰
(遂寧市中心醫(yī)院,四川 遂寧 629000)
克氏針輔助閉合復(fù)位微創(chuàng)防旋股骨近端髓內(nèi)釘固定治療股骨逆轉(zhuǎn)子間骨折
趙文博,張智,陽波,葉永杰
(遂寧市中心醫(yī)院,四川 遂寧629000)
[摘要]目的:探討借助克氏針閉合復(fù)位防旋股骨近端髓內(nèi)釘固定治療股骨逆轉(zhuǎn)子間骨折的手術(shù)技巧及臨床療效。方法:2014年6—9月,在術(shù)中C臂X線機(jī)透視下,采用閉合牽引床牽引、克氏針輔助復(fù)位,以股骨近端髓內(nèi)釘內(nèi)固定術(shù)治療股骨逆轉(zhuǎn)子間骨折13例,其AO分型為A3.1型5例、A3.3型8例。術(shù)后每隔4周復(fù)查X線片隨訪,確定骨性愈合時(shí)間,進(jìn)行Harris評(píng)分作出療效評(píng)定,總結(jié)術(shù)中復(fù)位技巧。結(jié)果:本組術(shù)中通過閉合牽引床牽引、克氏針輔助復(fù)位,骨折端均能得到良好復(fù)位,手術(shù)較為順利。術(shù)后13例患者均獲得4~6個(gè)月隨訪,無感染、脂肪栓塞、深靜脈血栓形成、骨折不愈合、髖內(nèi)翻及旋轉(zhuǎn)畸形等并發(fā)癥發(fā)生,無死亡病例。根據(jù)Harris標(biāo)準(zhǔn)評(píng)分,優(yōu)9例,良3例,中1例,優(yōu)良率92.31%。結(jié)論:克氏針輔助利于股骨逆轉(zhuǎn)子間骨折的閉合復(fù)位,股骨近端髓內(nèi)釘固定治療股骨逆轉(zhuǎn)子間骨折、創(chuàng)傷小、易于操作,有利于骨折復(fù)位以及保護(hù)髓外血運(yùn),療效可靠。
[關(guān)鍵詞]逆轉(zhuǎn)子間骨折;骨折內(nèi)固定;閉合復(fù)位;股骨近端髓內(nèi)釘
優(yōu)先數(shù)字出版地址:http://www.cnki.net/kcms/detail/51.1688.R.20160311.2143.034.html
股骨轉(zhuǎn)子間骨折好發(fā)于骨質(zhì)疏松的老年患者,女性多于男性,其非手術(shù)治療并發(fā)癥發(fā)生率高,現(xiàn)多主張對(duì)有條件的股骨轉(zhuǎn)子間骨折患者盡早行手術(shù)內(nèi)固定治療,減少并發(fā)癥發(fā)生[1]。不穩(wěn)定轉(zhuǎn)子間骨折選擇髓外固定并發(fā)癥多[2],首選髓內(nèi)固定。股骨近端髓內(nèi)釘(proximal femoral nail antirotation,PFNA)屬于髓內(nèi)固定系統(tǒng),用于治療股骨逆轉(zhuǎn)子間骨折時(shí)閉合復(fù)位困難,往往需切開復(fù)位,手術(shù)損傷大,對(duì)高齡且合并內(nèi)科疾病患者因其手術(shù)耐受能力問題而不易開展。我們采用克氏針撬拔輔助實(shí)現(xiàn)閉合復(fù)位微創(chuàng)PFNA內(nèi)固定治療AO:A3型股骨逆轉(zhuǎn)子間骨折,取得較好效果,現(xiàn)報(bào)告如下。
1資料與方法
1.1一般資料選擇本院2014年6—9月股骨逆轉(zhuǎn)子間骨折13例,其中:男4例,女9例;年齡53~78歲,平均64.7歲;AO分型為A3.1型者5例,A3.3型者8例,均有移位;跌傷7例,交通傷4例,高墜傷2例;術(shù)前合并高血壓2例,冠心病1例,糖尿病1例,慢性支氣管炎-阻塞性肺氣腫1例,肌間靜脈血栓2例。
1.2治療方法術(shù)前均采用骨牽引。手術(shù)采用全身麻醉?;颊咂脚P于骨科牽引床上,臀下墊薄枕,足支撐架通過會(huì)陰支柱器對(duì)抗?fàn)恳?,患肢牽引呈輕度內(nèi)收稍內(nèi)旋位。術(shù)中于C臂X線機(jī)透視下在患側(cè)股骨大轉(zhuǎn)子頂點(diǎn)上緣前側(cè)經(jīng)皮向股骨頭穿入1枚直徑為2.5 mm的克氏針,進(jìn)針深度為股骨頭直徑的1/2~2/3。把持克氏針,根據(jù)骨折移位方向撬拔股骨頭。助手于牽引床側(cè)通過牽引、內(nèi)收、內(nèi)旋、外旋、外展骨折遠(yuǎn)端,使骨折端復(fù)位。于股骨大轉(zhuǎn)子頂點(diǎn)沿股骨長軸作一約3 cm縱向切口,逐層分離,切開闊筋膜。食指觸摸大轉(zhuǎn)子頂點(diǎn)定位,在大轉(zhuǎn)子頂點(diǎn)稍內(nèi)側(cè)沿股骨長軸方向置入3.2 mm導(dǎo)針。正側(cè)位透視導(dǎo)針位于股骨髓腔內(nèi)。順導(dǎo)針方向?qū)晒墙藬U(kuò)髓,再置入PFNA主釘,深度為側(cè)位片上螺旋刀片的槽孔對(duì)準(zhǔn)股骨頭的股骨矩。先將130°瞄準(zhǔn)臂連接到手柄上,再沿瞄準(zhǔn)臂插入螺旋刀臂套筒至股骨外側(cè)皮質(zhì)。若此時(shí)近端骨折端向外側(cè)移位時(shí),平近端外側(cè)骨折端上緣約0.5 cm處經(jīng)皮置入一直徑2.5 cm克氏針。推頂復(fù)位骨折端,按套筒方向鉆入導(dǎo)針。透視確認(rèn)導(dǎo)針在正位上位于股骨頸下半部分,側(cè)位上位于股骨頸中央,針尖位于關(guān)節(jié)面下5 mm。測(cè)量長度后,擴(kuò)外側(cè)皮質(zhì),選擇螺旋刀片于解鎖狀態(tài)下捶入后鎖定刀片,據(jù)瞄準(zhǔn)器擰入近遠(yuǎn)端鎖定螺釘。C臂X線機(jī)透視確定PFNA位置良好、固定牢固后擰入尾帽,沖洗傷口,逐層關(guān)閉傷口。
1.3術(shù)后處理及康復(fù)術(shù)后均經(jīng)靜脈使用抗生素1~2 d。術(shù)后行踝泵及股四頭肌等長收縮鍛煉,術(shù)后1周離床非負(fù)重活動(dòng)。術(shù)后5~7 d出院。住院期間每天使用低分子肝素鈉(克賽)0.4 mL皮下注射抗凝。出院后每天口服拜瑞妥10 mg抗凝,至術(shù)后15 d以上。術(shù)后根據(jù)個(gè)體差異予地佐辛注射液、瑞帕昔布鈉、西樂葆、扶他林腸溶片等鎮(zhèn)痛。術(shù)后每隔4周復(fù)查X線片確定骨性愈合時(shí)間。根據(jù)Harris標(biāo)準(zhǔn)評(píng)分判斷治療效果。
2結(jié)果
本組13例術(shù)后無感染及死亡病例。13例患者均獲得4~6個(gè)月隨訪,骨折全部愈合,骨折愈合時(shí)間10~14周,平均11.5周。根據(jù)Harris標(biāo)準(zhǔn)評(píng)分,優(yōu)9例,良3例,中1例,優(yōu)良率92.31%。無脂肪栓塞、深靜脈血栓形成、骨折不愈合、髖內(nèi)翻及旋轉(zhuǎn)畸形、螺釘松動(dòng)或切割等并發(fā)癥。
3討論
3.1治療方案的確定股骨轉(zhuǎn)子間骨折治療方法分為手術(shù)治療和非手術(shù)治療。非手術(shù)治療為牽引療法。非手術(shù)療法患者臥床時(shí)間較長,易引發(fā)肺炎、壓瘡、血管栓塞、泌尿系統(tǒng)感染等并發(fā)癥,甚至導(dǎo)致患者死亡。保守治療50%能恢復(fù)獨(dú)立生活,能恢復(fù)到傷前水平的僅25%。而手術(shù)治療者80%以上患肢功能恢復(fù)滿意[3]。髖部骨折保守治療的病死率高達(dá)40%,如無絕對(duì)手術(shù)禁忌證應(yīng)積極采取手術(shù)治療[4]。
3.2內(nèi)固定的合理選擇骨折固定強(qiáng)度取決于骨質(zhì)量、骨折塊的形狀、復(fù)位質(zhì)量、內(nèi)固定器的力學(xué)性能和內(nèi)固定器的放置位置,而內(nèi)固定器的選擇是治療股骨轉(zhuǎn)子下骨折真正的獨(dú)立因素[5]。目前股骨轉(zhuǎn)子間骨折常用的內(nèi)固定物可分為髓內(nèi)固定和髓外固定2類。髓內(nèi)固定有Gamma釘、PFN、PFNA、InterTan髓內(nèi)釘?shù)龋柰夤潭ㄓ泄晒墙私馄输摪?、?jīng)皮加壓鋼板、DHS、DCS、LISS。對(duì)內(nèi)固定物的臨床療效作比較,發(fā)現(xiàn)合并有骨質(zhì)疏松的不穩(wěn)定轉(zhuǎn)子間骨折,使用DHS內(nèi)固定失敗率達(dá)50%,角鋼板治療股骨轉(zhuǎn)子間骨折失敗率高達(dá)45%,對(duì)于不穩(wěn)定股骨轉(zhuǎn)子間骨折或嚴(yán)重骨質(zhì)疏松骨折患者,髓內(nèi)固定系統(tǒng)更具優(yōu)勢(shì)[6]。Gamma釘、PFN、PFNA同屬髓內(nèi)固定系統(tǒng),均可通過閉合復(fù)位,減少髓外血運(yùn)破壞,同時(shí)減少周圍軟組織、血管和神經(jīng)的損傷。但Gamma釘股骨頸拉力螺釘為滑動(dòng)固定裝置,抗旋轉(zhuǎn)作用差,在老年骨質(zhì)疏松患者中抓持力不夠,易退釘,而且擴(kuò)髓范圍較大,會(huì)導(dǎo)致髓腔血管的嚴(yán)重破壞,術(shù)后并發(fā)癥發(fā)生率較高[7]。PFN近端雙釘承載有防旋作用,但髖螺釘和防旋釘限制了加壓螺釘和主釘之間的滑動(dòng),容易出現(xiàn)防旋螺釘切割等情況[8]。相對(duì)于PFN,PFNA用螺旋刀片鎖定技術(shù)取代了傳統(tǒng)的2枚螺釘固定,對(duì)骨質(zhì)起填壓作用,可防止旋轉(zhuǎn)和內(nèi)翻畸形。PFNA是目前治療不穩(wěn)定骨折的最佳植入物[9]。
3.3PFNA的生物力學(xué)特點(diǎn)生物力學(xué)研究表明[10],如果骨折復(fù)位不良,伴有內(nèi)翻及較大的骨折間隙,此時(shí)PFNA的滑動(dòng)功能就起作用了。另外PFNA剛性強(qiáng)度高,鎖定后角度固定牢靠,支撐作用強(qiáng),在不穩(wěn)定骨折中,PFNA承受扭矩大,抗扭轉(zhuǎn)強(qiáng)度高。PFNA的螺旋刀片能夠形成堅(jiān)強(qiáng)的錨合力固定,可以有效地減少術(shù)后螺旋刀脫落、股骨頸切割、股骨頭旋轉(zhuǎn)或內(nèi)翻等并發(fā)癥的發(fā)生[11]。
3.4克氏針輔助閉合復(fù)位操作中的優(yōu)點(diǎn)及注意事項(xiàng)克氏針經(jīng)皮穿入,對(duì)軟組織損傷小,操作簡(jiǎn)便,容易掌握。術(shù)中對(duì)股骨頭進(jìn)行撬拔和把持,復(fù)位過程中可防止股骨頭的無序旋轉(zhuǎn),并在C臂X線機(jī)輔助下,骨折端復(fù)位直觀,利于調(diào)整,可望達(dá)到解剖復(fù)位。但股骨轉(zhuǎn)子間骨折好發(fā)于老年患者,常合并有骨質(zhì)疏松癥,應(yīng)避免暴力撬拔導(dǎo)致醫(yī)源性骨折發(fā)生??耸厢樳M(jìn)針點(diǎn)于
股骨大轉(zhuǎn)子頂點(diǎn)上緣前側(cè)穿入,避免阻擋導(dǎo)針及PFNA主釘?shù)牟僮鳌?/p>
綜上所述,PFNA從生物力學(xué)角度可以滿足不穩(wěn)定型股骨轉(zhuǎn)子間骨折的內(nèi)固定要求。在克氏針輔助下實(shí)現(xiàn)閉合復(fù)位,具有創(chuàng)傷小、操作簡(jiǎn)便、復(fù)位可靠等優(yōu)點(diǎn),可避免不穩(wěn)定股骨轉(zhuǎn)子間骨折術(shù)中復(fù)位困難需改開放手術(shù)的可能,達(dá)到微創(chuàng)治療老年股骨逆轉(zhuǎn)子間骨折的目的。
參考文獻(xiàn):
[1]KITAMURA S,HASEGAWA Y,SUZUKI S,et al.Functional outcome after hip fracture in Japan[J].Clin Orthop Relat Res,1998(348):29-36.
[2]NUBER S,SCHONWEISS T,RUTER A.Stabilisation of unstable trochanteric femoral fractures[J].Dynamic hip screw(DHS)with trochanteric stabilisation plate vs.proximal femur nail(PFN).Unfallchirurg,2003, 106(1):39-47.
[3]CRONELL CN.Management of fractures in patients with osteopo-rosis[J].Orthop Clin North Am,1990,21(1): 125-141.
[4]LIN PC,CHANG SY.Functional recovery among elderly People one year after hip fracture surgery[J]. J Nurs Res,2004,12(1):72-82.
[5]MAHOMED N,HARRINGTON I,KELLAM J,et al.Biomechanical analysis of the Gamma nail and sliding hip screw[J]. Clin Orthop Relat Res,1994,304(34):280-288.
[6]KREGOR PJ,OBREMSKEY WT,KREDER HJ,et al.Unstable pertrochanteric femoral fractures[J].J Orthop Trauma,2005,19(1):63-66.
[7]MEREDDY P,KAMATH S,RAMAKRISHNAN M,et al.The AO/ASIF proximal femoral nail antirotation (PFNA):a new design for the treatment of unstable proximal femoral fractures[J].Injury,2009,40(4):428-432.
[8]WINDOLF J,HOLLANDER DA,HAKIMI M,et al.Proximal femoral nail(PFN):pitfalls and complications in the use of the proximal femoral nail[J].Langenbecks Arch Surg,2005,390(1):59-65.
[9]SIMMERMACHER RK,LJUNGQVIST J,BAIL H,et al.The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study[J].Injury,2008,39(8):932-939.
[10]ITO K,HUNGERBüHLER R,WAHL D,et al.Improved intramedullary nail interlocking in osteoporotic bone[J]. J Orthop Trauma,2001,15(3):192-196.
[11]GOFFIN JM,PANKAJ P,SIMPSON AH,et al.Does bone compaction around the helical blade of a proximal femoral nail anti-rotation (PFNA) decrease the risk of cut-out?: A subject-specific computational study[J].Bone Joint Res,2013,2(5):79-83.
Closed Replacement and Minimally Invasive Process of Kirchner Assisted Proximal Femoral Nail Antirotation in Treatment of Reversal Intertrochanteric Fracture
ZHAO Wenbo,ZHANG Zhi,YANG Bo,YE Yongjie
(Suining Central Hospital, Sichuan Suining629000,China)
[Abstract]Objective:To investigate the surgical techniques and clinical efficacy of the closed replacement and minimally invasive process of Kirchner assisted proximal femoral nail antirotation in the treatment of reversal intertrochanteric fracture.Methods:A retrospective study was conducted to analyse the replacement skills and clinical data of 13 patients who had been treated for reversal intertrochanteric fracture with minimally invasive process of Kirchner assisted proximal femoral nail antirotation in our department between June 2014 and September 2014.There were 4 males and 9 females with a mean age of 64.7 years (53-78 years).According to the AO Classification,there were 5 cases of type A3.1,8 cases of type A3.3.The Harris scores after operation were analysed.Results:No infection, fat embolism,deep vein thrombosis,nonunion and the deformity of varus and rotation of the hip occurred.No patients were dead.All patients were followed up for 4-6 months.According to the Harris criterion,9 cases were rated as excellent,3 good and 1 fair.All patients get good replacement.Conclusion:The closed replacement and minimally invasive process of Kirchner assisted proximal femoral nail antirotation are easy to operate and useful to the replacement of fractures and the protection of extramedullary blood supply. They are advisable choices for the treatment of reversal intertrochanteric fracture.
[Keywords]reversal intertrochanteric fracture;internal fixation;closed replacement;proximal femoral nail antirotation
通信作者:葉永杰,1312653816@qq.com
[中圖分類號(hào)]R683.42
[文獻(xiàn)標(biāo)識(shí)碼]A
DOI:10.11851/j.issn.1673-1557.2016.03.015
(收稿日期:2015-08-10)