老年股骨粗隆间骨折不同分型的内固定治疗选择

目的：探讨老年股骨粗隆间骨折不同分型内固定治疗选择。方法：老年股骨粗隆间骨折62例，男40例，女22例；年龄60～82岁，平均71岁。按Evans分型：Ⅰ型16例，Ⅱ型13例，Ⅲ型17例，Ⅳ型10例，V型6例。其中Ⅰ、Ⅱ型29例采用空心钉内固定治疗，Ⅲ、Ⅳ、Ⅴ型33例采用动力加压髋螺钉治疗（DHS）治疗。结果：经1-4年随访，平均2．5年．根据疗效评定的标准，EvansⅠ、Ⅱ型（即稳定型骨折）29例，优13例，良11例，差5例；EvansⅢ、Ⅳ、Ⅴ型（即不稳定型骨折）33例，优18例，良12例，差3例。结论：老年股骨粗隆间骨折不同的分型，分别采用了两种不同的内固定治疗，对EvansⅠ、Ⅱ型的稳定性骨折，多采用了空心钉内固定的治疗，而对EvansⅢ、Ⅳ、Ⅴ的不稳定性骨折，则以动力加压髋螺钉（DHS）内固定为首选。     

下肢

股骨头坏死的关节镜下表现及分析,手术治疗老年股骨转子间骨折66例体会,复杂股骨粗隆间骨折的内固定治疗,缝匠肌骨瓣移植术与加压螺纹钉联合治疗中青年股骨颈骨折,螺旋刀片交锁髓内钉治疗股骨粗隆下骨折[编者按]     

微创股骨近端锁定加压钢板治疗老年股骨粗隆间骨折

目的探讨微创锁定加压钢板(LCP)治疗老年股骨粗隆间骨折的疗效。方法应用股骨近端LCP内固定治疗老年股骨粗隆间骨折21例,骨折按AO分类:A1型8例,A2型9例,A3型4例。结果切口长度4～6cm,手术时间40～75min,术中出血50～200ml。21例获3～14个月随访,骨折愈合时间2～4个月,无髋内翻、骨不连和内固定失效。结论微创股骨近端LCP治疗老年股骨粗隆间骨折创伤小,固定可靠,有利于老年患者全身状况和肢体功能恢复。     

PFNA-Ⅱ微创内固定治疗股骨粗隆间骨折

目的 探讨PFNA-Ⅱ微创内固定治疗股骨粗隆间骨折的固定强度及疗效.方法 回顾性分析116例应用PFNA-Ⅱ微创内固定治疗股骨粗隆间骨折的临床效果.结果 PFNA-Ⅱ拉力钉在股骨颈中的固定强度:中1/3＞中上2/5＞中下1/3;侧位在中轴线上最强、偏后的最差.结论 PFNA-Ⅱ微创内固定治疗股骨粗隆间骨折是简单有效的方法,拉力钉应置于股骨颈中1/3或中上2/5,且侧位在中轴线上.     

下肢

高龄股骨粗隆间骨折手术治疗的风险与防范；股骨粗隆周围骨折内固定治疗的选择；微侵袭法DHS治疗EvansⅠ、Ⅱ型粗隆间骨折36例分析；股骨近端髓内钉治疗股骨转子周围部骨折的并发症及防治；粉碎性股骨干骨折带锁髓内钉内固定术中旋转及成角畸形的预防。     

GammaⅢ型钉内固定治疗老年股骨粗隆间骨折

目的探讨GammaⅢ型钉内固定治疗老年股骨粗隆骨折的疗效。方法采用GammaⅢ型钉内固定治疗35例股骨粗隆间骨折。结果 35例均获3~12个月随访,平均9个月。髋关节功能按Harris评分:优24例,良8例,可3例,优良率91.4%;拉力螺钉切割1例,股骨颈缩短2例。结论 GammaⅢ型钉内固定手术操作简单、创伤小、固定牢固,是治疗老年股骨粗隆间骨折的有效方法。     

多功能股骨近端重建钉治疗老年人股骨粗隆间骨折

目的探讨多功能股骨近端重建钉(MFN)治疗股骨粗隆间骨折的临床疗效。方法322例股骨粗隆间骨折行MFN内固定治疗并观察其术后疗效,其中Evan’sⅠ型36例,Ⅱ型120例,Ⅲ型131例,Ⅳ型35例。结果术后随访1～3.5年,322例骨折均愈合,优良率98%。结论MFN治疗股骨粗隆间骨折,复位好,固定稳,是治疗股骨粗隆间骨折较为理想的方法。     

闭合复位加压螺纹钉内固定治疗股骨粗隆问骨折36例

自1999年起笔者采用闭合复位可折断式加压螺纹钉内固定治疗股骨粗隆间骨折36例，并得到了2年以上随访，现将临床观察结果报告如下。     

股骨粗隆间骨折不同内固定物生物力学实验研究

探讨不同内固定物在治疗股骨粗隆间骨折中的作用，以新鲜尸体股骨做成Ⅲα型粗隆间骨折，分别用经股骨矩四枚斯氏针，三枚斯氏针，加压螺纹钉，加压滑动鹅头钉固定。在实验机上一次性承压，扭转，测定其分离位移和扭转位移变化。     

中老年股骨近端骨折内固定方式的选择

目的探讨中老年人股骨近端骨折不同解剖部位及骨折类型的最优内固定方式。方法 56例股骨颈骨折采用股骨近端防旋髓内钉（PFNA）内固定8例、空心钉内固定10例、动力髋螺钉（DHS）内固定10例,DHS＋空心钉内固定23例,DHS＋空心钉＋带旋髂深动脉髂骨瓣治疗5例,88例股骨粗隆间骨折采用PFNA内固定42例、Gamma钉内固定12例、股骨近端解剖钢板内固定13例、DHS＋空心钉内固定21例,38例股骨粗隆下骨折采用PFNA内固定18例、解剖钢板内固定12例、DHS内固定8例。结果 182例均获得随访6-38个月,平均24.2个月。股骨颈骨折DHS＋空心钉内固定组及股骨粗隆间、粗隆下骨折PFNA内固定组髋关节功能Harris评分优良率高于其他组,差异有统计学意义（P〈0.05）。结论DHS＋空心钉内固定治疗中老年股骨颈骨折具有优势,而PFNA内固定是治疗股骨粗隆间骨折及粗隆下骨折的较佳选择。     

Transpedicular screw fixation

Spinal fixation employing transpedicular screws has recently been the focus of increased attention at various institutions throughout the world, but concerns about the safety and efficacy of transpedicular screws linger. This study was undertaken to address some of these concerns. The study included evaluation of the internal and external morphology of the vertebral pedicles, which revealed that adequate bone stock is generally available at T2, T7, T12, and L1-L5 spinal levels to accept screws in the 4-7-mm diameter range. The pedicle was observed to be composed of abundant cancellous bone internally with relatively thick cortical walls. The method of pilot hole preparation for pedicle screws was also examined. Screws inserted in pilot holes prepared with a 3.4-mm blunt probe (ganglion knife) resulted in higher pullout forces in eight of 10 trials as compared with those with pilot holes prepared using a 3.2-mm drill. Furthermore, the probes afford greater control of hole depth and alignment. Fatigue studies on three screw designs revealed a graduation of strength between a 7.0-mm pedicle screw, a 5.5-mm pedicle screw, and a modified 6.5-mm cancellous lag screw. The modified cancellous lag screw has an inherent stress riser that affected fatigue life. It was noted that extreme care must be exercised to prevent bending of the pedicle screws during implantation. If bending occurs one can expect a 50% reduction in the number of cycles to failure.     

Scarf osteotomy without screw fixation

The scarf osteotomy is now well recognised as reliable and effective to contribute to the correction of the majority of hallux valgus. The challenge remains for the correction of severe deformities with metatarsus varus angle >18° and Distal Metatarsal Articular Angle (DMAA) >15°. In order to significantly improve in ₃D the metatarsal head displacements, our scarf design became more oblique, shorter and if necessary a medial wedge removal from the plantar fragment was done to supinate the head. And gradually, with the amount of the horizontal translation, there was no space left for any screw. A bone cerclage with an absorbable suture in order to obtain distally a constrained fixation, and proximally an impacted autologus bone grafting (distal wedge of the dorsal M1 fragment) have been done. The immediate weight-bearing ambulation allowed with always a sole of total contact cast for two weeks (only this method is able to decrease the weight on the foot <20 Mpa), followed by post-operative shoe wearing for a month, have not been changed. The M1P1 angle, the M1M2 angle and the DMAA angle had been measured after bone fusion on a weight-bearing dorsoplantar X-ray, on the different series of moderate and severe hallux valgus. Results: For the two screws series (1993–1995) 49 cases: M1P1 = 12.67° +−7.22°, M1M2 = 7.93° +− 2.61°, DMAA = 13.5° =− 4.5°. For the one screw series (1996–1998) 37 cases: M1P1 =13.11°+− 6.67°, M1M2 = 7.44°=−2.51°, DMAA= 6.89°+−4.27°. For the “no screw series” (since 1999) 33 cases: M1P1 = 7.07° +− 4.84°, M1M2 = 6.51° +− 2.36°, DMAA = 7° +− 3.8°. It appears that the correction is better without screw fixation, especially for M1P1 and M1M2 angles.     

Interference screw fixation using bioabsorbable screw as void filler

We evaluated interference screw fixation in a plug-tunnel construct using bioabsorbable screws as void fillers with different percentages of the screw removed. Nine-millimeter tunnels in a closed-cell foam block were filled with a 10-mm bioabsorbable screw, and 10-mm revision tunnels were placed in parallel with tunnel overlap resulting in removal of 10%, 25%, or 50% of the screw diameter. Synthetic bone plugs were fashioned to fit 10-mm tunnels. In all groups, the plugs were secured in standard interference fixation with a 9-mm metal screw between the void-filling bioabsorbable screw and plug. Failure loads for the control group (no revision tunnel) averaged 926 +/- 44 N, 10% (1024 +/- 129 N) and 25% (932 +/- 129 N) groups were not significantly different; failure load in the 50% diameter group (780 +/- 72 N) was significantly lower than all other groups (p < 0.001). Using a bioabsorbable screw as void filler provided mean load to failure not different from that of standard reconstruction when 10 and 25% of the diameter of the void-filling screw was removed. Load to failure was significantly lower when 50% of the void-filling screw diameter group was removed. This may be applicable in anterior cruciate ligament reconstruction where a previous tunnel void has to be addressed.     

寰枢椎后路经关节螺钉固定术

目的评价参照枢椎椎管内壁行寰枢椎后路经关节螺钉固定（Naged技术）的可行性。方法2002年1月～2005年1月，对31例寰枢椎不稳患者行后路经关节螺钉内固定术，男18例，女13例；平均年龄36．8岁。螺钉置入方法：紧贴枢椎椎管内壁确定距离中线的距离，以枢椎椎板下缘上2帅为进针高度，两线交叉点即为螺钉进针点。螺钉平行矢状面，指向寰枢关节面后缘高度，通过C型臂机侧位像确认螺钉向上倾斜角度。术后结合正、侧位x线片、螺旋CT三维重建及断层扫描图像，评价螺钉置入准确程度。根据螺钉与寰枢椎关节面的位置关系分为A、B、C三区，A区螺钉通过寰椎下关节面；B区螺钉在关节面的前方或后方（前方为B1，后方为B2）；C区为螺钉在关节面的内侧或外侧（内侧为C1，外侧为C2）。结果共置入60枚螺钉。术中无椎动脉、颈脊髓、颈神经根及颅神经损伤。所有患者获得6～18个月（平均9个月）的随访，植骨融合时间为3～12个月，平均5个月，颈脊髓及神经根症状改善明显者3例，部分改善者5例，无改善者1例，无神经症状加重患者。枕颈部疼痛完全缓解者8例，部分缓解者6例，无缓解者2例。60枚螺钉中，A区58枚（96．7％），B1区2枚（3．3％），无B2及C区螺钉。结论参照枢椎椎管壁行寰枢椎后路经关节螺钉固定是安全可靠的。     

Complications of the variable screw plate pedicle screw fixation

In this study, 124 consecutive cases of posterior spinal fusion with variable screw plate fixation were reviewed. In 33 patients (27%), 41 complications were identified. Urinary tract infection without sequelae developed in 13 patients. Dural tear occurred in seven patients and wound hematoma in five. Wound infection developed in three patients; one was subfascial requiring instrument and graft removal. Neurologic deficit developed in seven patients (6%), in five of whom the deficit was due to manipulation and reduction of neural elements. Two of the seven deficits were believed to be caused by misplaced pedicle screws. Variable screw plate fixation is a formidable procedure with a significant complications rate.     

Prediction of fixation failure after sliding hip screw fixation

Cut-out of the lag screw is the commonest cause of fixation failure after sliding hip screw fixation of extracapsular hip fracture. A number of technical aspects of surgery have been used to asses the risk of cut-out. This study was to determine which of these indicators was the most reliable predictor of cut-out. The anterior-posterior and lateral post-operative radiographs of 23 cases of cut-out were compared with those of 77 cases of uneventful fracture healing. The tip-apex distance with correction for magnification was found to show the most significant difference between patients with cut-out against those without (P = 0.001), followed by the lag screw position on the lateral radiographs (P = 0.0095 and 0.014), reduction of the fracture on the anterior-posterior radiograph (P = 0.011 and 0.016) and the uncorrected tip-apex distance (P = 0.019). We recommend that for audit and research purposes the corrected tip-apex distance, fracture reduction and implant positioning methods should be used. For routine clinical practice, the uncorrected tip to apex distance, which is sum of the distance from the tip of the lag screw to the apex of the femoral head on anterior-posterior and lateral radiograph, and fracture reduction angle on the anterior-posterior radiograph are recommended.