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股骨近端锁定钢板治疗老年股骨转子间骨折

目的 总结股骨近端锁定钢板在治疗老年股骨转子间骨折的手术经验及成功率。 方法 对2008年1月-2009年3月收治的57例老年股骨转子间骨折患者，行切开复位股骨近端锁定钢板内固定治疗。 结果 在Evans分型1~5型中手术成功率为100%，优良率为98.2%。 结论 股骨近端锁定钢板适用于老年股骨转子间骨折的各种类型。

动力髋螺钉结合拉力螺钉治疗股骨转子间骨折

目的 探讨动力髋螺钉（dynamic hip screw， DHS）结合拉力螺钉治疗股骨转子间骨折的疗效。方法 1996年4月～2005年5月，采用DHS结合拉力螺钉治疗股骨转子间骨折78例。其中男42例，女36例；年龄30～90岁，平均65岁。骨折按TronzoEvans分类：Ⅰ型2例，Ⅱ型51例，Ⅲ型16例，Ⅳ型6例，Ⅴ型3例。伤后3～12 d行手术。 结果 术后患者切口均Ⅰ期愈合。72例获随访6个月～4年，平均2年。X线片检查示骨折断端对位对线良好，8～14个月骨折线消失，骨折愈合。根据黄公怡疗效评定标准，优29例，良36例，可6例，差1例，优良率90.2%。 结论 DHS结合拉力螺钉治疗股骨转子间骨折具有固定确切、抗旋转等优点，是一种治疗股骨转子间骨折的有效方法。

外固定支架在老年股骨转子间骨折的应用

【摘 要】 目的 评价外固定支架对老年股骨转子间骨折的治疗作用。 方法 2003 年1 月－ 2005 年12 月，用外固定支架治疗高龄股骨转子间骨折60 例。其中男37 例，女23 例；年龄73 ～ 95 岁，平均83 岁。骨折至治疗时间2 ～ 15 d，平均5 d，平均12 周；按AO 分型，A1 型22 例，A2 型30 例，A3 型8 例。均合并多种内科疾病而不能耐受内固定手术。 结果 外固定架操作手术时间20 ～ 40 min，平均30 min，术中无明显出血，术中及术后未输血。所有患者均获随访8 ～ 24 个月，平均18 个月。无外固定失败者。全部骨折愈合，愈合时间10 ～ 16 周，平均12 周。无死亡者。有髋内翻畸形4 例；钉道感染8 例，经口服抗生素及局部换药等处理好转，拔除外固定钉后钉道感染痊愈。髋关节功能情况按Harris 评分系统进行评分：优35 例，良22 例，差3 例，优良率95％。 结论 外固定支架治疗股骨转子间骨折具有手术安全、创伤小、失血量少等优点，是治疗老年转子间骨折的良好选择。

股骨近端锁定钢板治疗股骨转子间骨折

目的 总结股骨近端锁定钢板（proximal femur locking plate，PFLP）微创治疗股骨转子间骨折的疗效。 方法 2007 年5 月－ 2008 年10 月，采用PFLP 微创治疗股骨转子间骨折24 例，并与同期采用动力髋螺钉（dynamic hip screw，DHS）治疗的32 例股骨转子间骨折患者临床疗效进行比较。两组患者年龄、性别、致伤原因、骨折分型（AO 分型）、骨质量Singh 分级、受伤至入院时间等一般资料比较差异均无统计学意义（P gt; 0.05），具有可比性。 结果 术后2 组患者切口均Ⅰ期愈合。PFLP 组患者均获随访，随访时间12 ～ 14 个月，平均12.6 个月。患者骨折均解剖复位，达骨性愈合。DHS 组30 例获随访，随访时间12 ～ 20 个月，平均13.5 个月。除3 例于术后1 个月发现未达解剖复位外，其余患者骨折均解剖复位，达骨性愈合。PFLP 组切口长度、手术时间、术中失血量、术后负重时间均优于DHS 组（P lt; 0.05），骨折愈合时间两组比较差异无统计学意义（P gt; 0.05）。 结论 PFLP 是治疗股骨转子间骨折一种适宜选择，相比DHS 具有手术创伤小、手术时间短、并发症少等优点。

BIOMECHANICAL COMPARATIVE STUDY ON PROXIMAL FEMORAL LOCKING PLATE AND Gamma3 FOR TREATMENT OF STABLE INTERTROCHANTERIC FRACTURE

ObjectiveTo compare the biomechanical properties between the proximal femoral locking plate and Gamma3 for fixing stable intertrochanteric fracture so as to provide a theoretical basis for selecting internal fixation in the clinical application. MethodsFive pairs of antiseptic femur specimens were selected. Specimens of each pair of matching were randomly divided into groups A and B (n=5). All specimens were made the intertrochanteric fracture of 31A1.1 type according to AO/Association for the Study of Internal Fixation (AO/ASIF) classification. Fracture was fixed with Gamma3 in group A and with proximal femoral locking plate in group B. The axial compression, destruction, and torsion tests were carried out on the mechanical testing machine. ResultsAxial compression test:The load-displacement curve of groups A and B was basically a straight line; axial stiffness of groups A and B was (621.00±36.48) N/mm and (542.55±46.94) N/mm respectively, showing significant difference (t=3.648, P=0.036). Destruction test:The maximum yield load of groups A and B was (4 394.82±450.37) N and (2 987.54±112.14) N respectively, showing significant difference (t=5.433, P=0.032). After loading maximum yield load, femoral fracture occurred again, and internal fixation and bone interface loosening were observed in group A; bending and breaking of proximal locking screw for internal fixation were found in group B, but loosening of internal fixation and bone interface was more obvious in group A than in group B. Torsion test:The torque of specimens in 2 groups increased with the increase of torsion angle (P < 0.05), the torque corresponding to the torsion angle in group B was larger than that in group A, but the difference was not significant (P > 0.05). The torsional stiffness of groups A and B was (1.78±0.16) N·mm/deg and (2.01±0.08) N·mm/deg respectively, showing no significant difference (t=-3.833, P=0.162). ConclusionProximal femoral locking plate and Gamma3 in the treatment of stable intertrochanteric fracture have good biomechanical properties, which can meet the requirements of minimal invasion, strong internal fixation, and early activity.

动力髋螺钉加防旋拉力钉治疗股骨转子间骨折

目的 总结动力髋螺钉（dynamic hip screw，DHS）加防旋拉力钉治疗股骨转子间骨折的疗效。 方法 2006 年1 月－ 2009 年1 月，收治35 例股骨转子间骨折。男25 例，女10 例；年龄16 ～ 78 岁，平均45.2 岁。致伤原因：交通事故伤16 例，摔伤19 例。均为单侧骨折，其中左侧22 例，右侧13 例。骨折按照Evans 分型标准：Ⅰ型10 例，Ⅱ型15 例，Ⅲ型8 例，Ⅳ型2 例。受伤至入院时间为1 h ～ 6 d，平均2.3 d。入院后行患肢皮牵引，对症处理合并伤，于2 ～ 7 d后行DHS 加防旋拉力钉内固定术。 结果 术后切口均Ⅰ期愈合，无下肢深静脉血栓形成等早期并发症发生。32 例获随访，随访时间12 ～ 24 个月，平均18.6 个月。X 线片检查示32 例骨折均获骨性愈合，愈合时间为6 ～ 12 个月，平均10个月。术后12 个月根据Parker 等的评定标准评价疗效：获优24 例，良5 例，中3 例。随访期间无髋内翻、内固定物松动、双下肢不等长及患肢短缩外旋畸形等并发症发生。 结论 DHS 加防旋拉力钉可有效防止股骨头旋转，患者可早期功能锻炼，是治疗转子间骨折的有效方法之一。

动力髋螺钉治疗股骨转子间骨折36例

COMPARISON OF VARIOUS KINDS OF INTERNAL FIXATIONS IN UNSTABLE INTERTROCHANTERIC FEMORAL FRACTURE

Objective To explore the effects of various kinds of internal fixations on unstable intertrochanteric femoral fractures. Methods From January 2000 to December 2004,88 cases of unstable intertrochanteric femoral fractures were treated. There were 52 males and 36 females (aged 19-86 years). Twenty-two cases were caused by fall from height, 36 by motor vehicle accident and 20 by fall and 10 by tumble. They were divided into 4 groups according to 4 kinds of internal fixations: dynamic hip screw(DHS,group A, n=42), anatomical proximal femur bone plate (group B, n=23), proximal femoral nail（PFN，group C, n=8）and dynamic condylar screw (DCS, group D, n=15). According to the modified Evan’s classification, fractures were all unstable type and were classified as follow types: group A (15 type Ⅲ, 8 type Ⅳ and 19 type Ⅴ); group B (12 type Ⅲ, 5 type Ⅳ and 6 type Ⅴ); group C (3 type Ⅲ,2 type Ⅳ and 3 type Ⅴ); and group D (10 type Ⅲ,3 type Ⅳ and 2 type Ⅴ). The data of operative time, intra-operative blood loss, intraoperative complications, fluoroscopy exposures, clinical healing time of fracture, post-operative restored function and postoperative complications were recorded and analyzed statistically using the SPSS 12.0 software package.Results All patients were followed up for 12-48 month (18 months on average). All patients achieved clinical healing. Coxa varus occurred in 3 cases of group A, in 1 case ofgroup C and in 3 cases of group D . The differences were of no statistical significance in operative time and postoperative complications between 4 groups (P＞0.05). The difference was of statistical significance in the blood loss between groups A,B and groups C,D (P＜0.05) but no statistical significance between group C and group D (P＞0.05). The difference was of statistical significance in the fluoroscopy exposures, clinical healing time of fracture and postoperative complications between group B and the other groups (P＜0.05). The difference was of statistical significance in the postoperative restored functions between group D and theother groups (P＜0.05). Conclusion The anatomical proximal femur bone plate is a useful device in the treatment of unstable intertrochanteric femoral fracture. The operative manipulation is simple and the hip functions recover well.

Proposal of a novel comprehensive classification for femoral intertrochanteric fractures

Objective To introduce a novel comprehensive classification for femoral intertrochanteric fractures, and to accommodate the clinical requirement for the world-wide outbreak of geriatric hip fractures and surgical operations. Methods On the basis of reviewing the history of classification of femoral intertrochanteric fractures and analyzing the advantages and disadvantages of AO/Orthopaedic Trauma Association (AO/OTA) classification in different periods, combined with the current situation of extensive preoperative CT scan and three-dimensional reconstruction and widespread use of intramedullary nail fixation in China, the “Elderly Hip Fracture” Research Group of the Reparative and Reconstructive Surgery Committee of the Chinese Rehabilitation Medical Association proposed a novel comprehensive classification for femoral intertrochanteric fractures, focusing on the structure of fracture stability reconstruction during internal fixation. Results The novel comprehensive classification of femoral intertrochanteric fractures incorporates multiple indicators of fracture classification, including the orientation of the fracture line, the degree of fracture fragmentation, the lesser trochanteric bone fragment and its distal extension length (>2 cm), the posterior coronal bone fragment and its anterior extension width (involving the lateral cortex of the head and neck implant entry point), transverse fracture of the lateral and anterior wall and its relationship with the implant entry point in the head and neck, and whether the cortex of the anteromedial inferior corner can be directly reduced to contact, etc. The femoral intertrochanteric fractures are divided into 4 types (type A1 is simple two-part fractures, type A2 is characterized by lesser trochanter fragment and posterior coronal fractures, type A3 is reverse obliquity and transverse fractures, type A4 is medial comminution which lacks anteromedial cortex transmission of compression force), each of which is subdivided into 4 subtypes and further subdivide into finer subgroups. In a review of 550 trochanteric hip fracture cases by three-dimensional CT, type A1 accounted for 20.0%, type A2 for 62.5%, type A3 for 15.5%, and type A4 for 2.0%, respectively. For subtypes, A2.2 is with a “banana-like” posterior coronal fragment, A2.4 is with distal cortex extension >2 cm of the lesser trochanter and anterior cortical expansion of the posterior coronal fragment to the entry portal of head-neck implants, A3.4 is a primary pantrochanteric fracture, and A4.4 is a concomitant ipsilateral segmental fracture of the neck and trochanter region. ConclusionThe novel comprehensive classification of femoral intertrochanteric fractures can describe the morphological characteristics of fractures in more detail, include more rare and complex types, provide more personalized subtype selection, and adapt to the clinical needs of both fractures and surgeries.

Treatment of AO/OTA type 31-A3 intertrochanteric fracture with proximal femoral nail antirotation combined with mini plate reconstruction of lateral femoral wall

Objective To explore the effectiveness of proximal femoral nail antirotation (PFNA) combined with mini plate for reconstruction of lateral femoral wall in the treatment of type AO/Orthopaedic Trauma Association (AO/OTA) type 31-A3 intertrochanteric fracture. Methods The clinical data of 70 elderly patients with AO/OTA type 31-A3 intertrochanteric fracture treated between January 2013 and January 2018 were retrospectively analyzed. They were divided into group A (PFNA alone, 35 cases) and group B (PFNA combined with mini plate reconstruction of lateral femoral wall, 35 cases). There was no significant difference in the general data of gender, age, side, cause of injury, time from injury to operation between the two groups (P>0.05). The operation time, intraoperative blood loss, fracture healing time, postoperative complications, and the tip apex distance (TAD) at 2 months after operation were recorded and compared between the two groups. Harris hip score was used to evaluate the function at 12 months after operation. Results Both groups were followed up 9-21 months, with an average of 16.6 months. The operation time and intraoperative blood loss in group A were significantly less than those in group B (P<0.05); there was no significant difference in TAD between the two groups at 2 months after operation (t=0.096, P=0.462). There were 5 complications (14.3%) occurred in group A, including 2 cases of blade perforating from the hip joint, 2 cases of screw back out, and 1 case of bone nonunion; only 1 case (2.9%) in group B had screw back out after operation; there was no significant difference in the incidence of complications between the two groups (χ2=2.917, P=0.088). All the fracture healed in group B, and 1 patient in group A suffered bone nonunion and eventually main nail fracture. The healing time of fracture in group A [(15.6±2.7) weeks] was significantly longer than that in group B [(12.5±2.5) weeks], showing significant difference (t=2.064, P=0.023). At 12 months after operation, according to Harris score, the results were excellent in 5 cases, good in 9 cases, fair in 13 cases, and poor in 8 cases in group A, the qualified rate (Harris score>70) was 77.14%; and the results were excellent in 7 cases, good in 11 cases, fair in 16 cases, and poor in 1 case in group B, the qualified rate was 97.14%; there was significant difference in the qualified rate between the two groups (χ2=6.248, P=0.012). Conclusion Compared with PFNA alone, the treatment of AO/OTA type 31-A3 intertrochanteric fracture with PFNA combined with mini plate reconstruction of lateral femoral wall can significantly reduce postoperative complications, promote fracture healing, and improve functional recovery of patients after operation.