股骨粗隆間骨折中文版

股骨轉(zhuǎn)子間骨折手術(shù)治療

國家211工程重點學(xué)科上海市關(guān)節(jié)外科臨床醫(yī)學(xué)中心上海交通大學(xué)醫(yī)學(xué)院附屬第九人民醫(yī)院intertrochantericfracturesfirst

openreductionandinternalfixationwasattemptedby

usingintramedullarynailingin1850.

Langenbeck

theconceptoftheslidinghipscrewwasfirstproposedin1955.

SchumpelickW,JantzenPM.

thefirstarticlereviewingtheprocedurewaspublishedin1964.

ClawsonDKClawsonDK.Trochantericfracturestreatedbytheslidingscrewplatefixationmethod.JTrauma1964;4:732—52.SchumpelickW,JantzenPM.Anewprincipleintheoperatuivetreatmentoftrochantericfracturesofthefemur.JBoneJointSurgAm1955;37A:693—8.股骨轉(zhuǎn)子間骨折手術(shù)治療發(fā)展史固定角度

1940s-1960sJewettplateMclaughlinplateAO/ASIFangleplate滑動固定1960s后RichardscrewFixionDHSMedoffplateLockedplating髓外固定股骨轉(zhuǎn)子間骨折手術(shù)治療發(fā)展史

Gamma釘，1980sPFN1990s

PFNA，2000sPFNA-II，2009s

髓內(nèi)theUnitedStates

258,000fracturesin2010.$17to$20billionin2010;289,000fracturesin.

2030,500,000fracturesin.2040,JOrthopTraumaVolume29,Number4Supplement,April2015increaseof12%.amongpeopleof65andolderhipfracturesUKApproximately70000patientsareadmittedeachyearwithhipfracturesintheUK.91500fracturesin.

2015101000fracturesin.

2020BritishOrthopaedicAssociation.Thecareofpatientswithfragilityfractures.(GuidelinerefID:BOA2007)2007.Intertrochanterichipfracturesaccountfornearlyhalfofallhipfractures47%inelderlyindividuals,subtrochanteric

injuriesoccurinapproximately25%ofhipfractures7%–34%ofallfemurfracturesBrownerBD.SkeletalTrauma:BasicScience,Management,andReconstruction.4thed.Philadelphia,PA:Saunders/Elsevier;2009.Incidence關(guān)節(jié)外骨折轉(zhuǎn)子間骨折的特點

低能量90%

年齡>65歲90%

需要內(nèi)固定骨質(zhì)疏松

大多伴有內(nèi)科疾病長期臥床極易發(fā)生并發(fā)癥骨質(zhì)疏松髖部骨質(zhì)疏松性骨折

20%一年內(nèi)死亡

25%恢復(fù)到骨折前生活質(zhì)量

55%殘留不同程度功能障礙

HighplasmaBUN(morethan20mg/dl)andcreatinine(morethan1.3mg/dl)significantlyincreasedthechanceofmortalityPredictionofMortalityinHipFracturePatients:

RoleofRoutineBloodTeststheincidenceofdeathduringthefirst3monthafterhipfracturewas24%ItmeansthatpatientswithhighplasmalevelsofBUNhaddied3timesmorethanthosewithnormalBUNandpatientswithhighcreatinineplasmalevelshaddied2.5timesmorethanthosehadnormalcreatininevalues.THEARCHIVESOFBONEANDJOINTSURGERY.VOLUME3.NUMBER1.JANUARY2015轉(zhuǎn)子間骨折骨量差的不穩(wěn)定性骨折簡單、穩(wěn)定性骨折愈合率高治療具有挑戰(zhàn)性死亡率：20~30%，一年內(nèi)48小時內(nèi)手術(shù)，可減低1年內(nèi)死亡率

如何選擇？新鮮骨折－內(nèi)固定首選骨質(zhì)疏松嚴重陳舊性骨折內(nèi)固定失敗骨關(guān)節(jié)炎｝關(guān)節(jié)置換不穩(wěn)定骨折的特點1

外側(cè)皮質(zhì)粉碎

2

后內(nèi)側(cè)大塊骨塊3逆粗隆骨折4骨折線延伸至粗隆下HaidukewychGJ.Intertrochantericfractures:tentipstoimproveresults.JBoneJointSurgAm2009;91:712e9.StableUnstableUncontrolledfactor:FracturegeometryAO/OTA31A3高度不穩(wěn)定!posteromedialcomminutionEvans,in1949OrthopTraumaVolume29,Number4Supplement,April2015IMdevicesleadtoacontrolledcollapse,arebiomechanicallySuperior

hence

arepreferredinthepresenceofposteromedialcomminutionreverseobliqueITSHSisnotrecommended(JOrthopTrauma2015;29:S4–S9)LateralWallBlow-OutIMdeviceortrochantericbuttressplate.(JOrthopTrauma2015;29:S4–S9)SHSisnotrecommendedReverseObliqueVariantlongnailisabetterchoicethanashortnail.(JOrthopTrauma2015;29:S4–S9)EvansclassificationTwotype1991BoydandGriffinclassification2partposteromedialcomminutionintertrochantericandsubtrochantericAO/OTA31StableUnstableStabletrochanteric

AO/OTAtypeA1andA2.1ActaOrthopaedica2012;83(1):26–30AnewalgorithmforhipfracturesurgeryHenrikPalmDenmarkUnstabletrochantericAO/OTAtypeA2.2,A2.3andA3ActaOrthopaedica2012;83(1):26–30股骨轉(zhuǎn)子間骨折內(nèi)固定的選擇A1.1A1.2A1.3A2.3A2.2A2.1A3.3A3.2A3.1髓外固定髓內(nèi)固定NICEGuidelinerecommendation

Useextramedullaryimplantssuchasaslidinghipscrewinpreferencetoanintramedullarynailinpatientswithtrochantericfractures(AOclassificationtypesA1

andA2).穩(wěn)定性骨折，髓外固定優(yōu)于髓內(nèi)固定

AustralianandNewZealandGuidelineforHipFractureCareConsensus-basedrecommendation

Bothextramedullaryslidinghipscrewandintramedullarynailsaresuitablefortrochantericfractures(AOclassificationtypesA1andA2).-. 髓外和髓內(nèi)固定均適合穩(wěn)定性骨折

ImprovingOutcomesinHipFractureManagementofAdultsSeptember2014Australianand

NewZealandGuidelineConsensus-basedrecommendation Useanintramedullarynailtotreatpatientswithareverseobliquefracture. -反斜形骨折，建議髓內(nèi)固定Australianand

NewZealandGuidelineEvidence-basedrecommendation Useanintramedullarynailtotreatpatientswithasubtrochantericfracture.

粗隆下骨折，建議髓內(nèi)固定STABLEINTERTROCHANTERICFRACTURES

supportstheuseofeitheraslidinghipscreworacephalomedullarydeviceinpatientswithstableintertrochantericfractures髓內(nèi)或髓外固定均適合于穩(wěn)定性骨折JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineUNSTABLEINTERTROCHANTERICFRACTURES

supportsusingacephalomedullary

deviceforthetreatmentofpatientswithunstable

intertrochantericfractures.不穩(wěn)定性骨折建議使用髓內(nèi)固定JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineSURGICALTIMING

hipfracturesurgerywithin48hours

ofadmissionisassociatedwithbetteroutcomes髖部骨折48小時內(nèi)行手術(shù)可取的良好效果JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelinePREOPERATIVETRACTION

doesnotsupportroutineuseofpreoperativetractionforpatientswithahipfracture.JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuideline不常規(guī)使用術(shù)前牽引ASPIRINANDCLOPIDOGRELLimitedevidencesupportsnotdelayinghipfracturesurgeryforpatientsonaspirinand/orclopidogrel.阿司匹林或氯吡格雷不影響髖部手術(shù)JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineANESTHESIA

Strongevidencesupportssimilaroutcomesforgeneralorspinalanesthesiaforpatientsundergoinghipfracturesurgery.全麻或腰麻對于髖部骨折手術(shù)效果類似JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineVTEPROPHYLAXIS

supportsuse

ofvenousthromboembolismprophylaxis(VTE)inhipfracturepatients.JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuideline建議使用抗血栓藥物TRANSFUSIONTHRESHOLD

supportsabloodtransfusionthresholdofnohigherthan8g/dl

inasymptomaticpostoperativehipfracturepatients.JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuideline血紅蛋白低于8g/dl，建議輸血OSTEOPOROSISEVALUATIONANDTREATMENT

supportsthatpatientsbeevaluatedandtreatedforosteoporosisaftersustainingahipfracture.術(shù)后評估骨質(zhì)疏松并治療JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineNutrition

建議術(shù)后予以支持療法建議補充維生素D和鈣JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineAAOSClinicalPractice

GuidelineonManagementofHipFracturesintheElderlymoderatestrengthusingeithercephalomedullary

implantsorslidinghipscrewsinthetreatmentofstableintertrochantericfracturesmoderatestrengthpreferentialuseofcephalomedullaryimplantsinthetreatmentofunstableintertrochantericfractures.strongrecommendationcephalomedullary

deviceforthetreatmentsubtrochantericorreverseobliquityfractureJOrthopTraumaVolume29,Number3,March2015Amonganestimated287,959patientswithasurgicallytreatedproximalfemurfractureidentifiedinthe2011Inpatientadverseeventratewas22%FTRratewas6.4%.(JOrthopTrauma2015;29:e96–e102)64,2484105myocardialinfarctionacuterenalfailurerespiratoryfailurecerebrovascularaccidentdeepvenousthrombosispulmonaryembolismembolismpneumoniabacteremia/sepsissurgicalsiteinfectionpostoperativehemorrhagemajorin-hospitaladverseevents(JOrthopTrauma2015;29:e96–e102)FailuretoRescueAfterProximalFemurFractureSurgery圍手術(shù)期注意貧血

抗凝

水電解質(zhì)平衡情況控制血糖改善心功能代謝紊亂糾正心率不齊和心肌缺血

注意胸部情況和呼吸系統(tǒng)原始疾病

Gamma釘

PFN

PFNAPFNA-II

Intertan

DHS

95°髁鋼板

人工關(guān)節(jié)置換術(shù)LISSLockedplating髓外髓內(nèi)髓外固定髓內(nèi)固定股骨轉(zhuǎn)子間骨折手術(shù)治療策略滑動髖加壓螺釘系統(tǒng)（DHS）髖髓內(nèi)釘系統(tǒng)（頭髓釘）人工關(guān)節(jié)置換滑動髖加壓螺釘系統(tǒng)適應(yīng)癥穩(wěn)定的股骨轉(zhuǎn)子間骨折若逆轉(zhuǎn)子間骨折或股骨外側(cè)壁不完整，可能出現(xiàn)股骨干內(nèi)移，推薦加用大轉(zhuǎn)子擋板或角穩(wěn)定系統(tǒng)aSHSimplantorPCCPissuitableforthemanagementof2-partintertrochanterichipfractures(AO/OTA31A1)certainunstablefracturepatterns

31A2.1thatareconsideredstableafterreductionandhaveanintactlateraltrochantericbuttressINDICATIONSFOR

PLATINGTechniquesinOrthopaedics$Volume30,Number2,2015DHS髓外穩(wěn)定型髓外固定-滑動系統(tǒng)結(jié)果穩(wěn)定骨折-效果好不穩(wěn)定骨折-固定強度不足,反粗隆—禁忌失敗原因螺釘切割釘板拔出釘板分離疲勞斷裂From:Harrington,Injury,2002不穩(wěn)定型：髓外固定—失敗率高不穩(wěn)定型-外側(cè)壁損傷

不穩(wěn)定型-外側(cè)壁損傷女78歲左術(shù)后2個月外側(cè)壁損傷DHS+PlateLCP解決方法逆粗隆骨折DHS視為禁忌！逆粗隆骨折actsasabuttresstoresistlateraldisplacementoftheproximalfemur.逆粗隆骨折髓內(nèi)LISS髓外固定Case1轉(zhuǎn)子間伴股骨頸三爪固定器

bSCREW轉(zhuǎn)子間伴股骨頸cannulatedscrewsLISS髓外固定術(shù)后23月術(shù)后27月術(shù)后13月術(shù)后13月術(shù)后3月

reverseLISSournalofclinicalorthopaedicsandtrauma5(2014)137e145PF-LCPreverseLISSproximalportionisnotsittingproperlyFailureofProximalFemoralLockingCompressionPlate

JOrthopTraumaVolume25,Number2,February2011、JOrthopTraumaVolume25,Number2Supplement,February2011PF-LCPStreubeletalreporteda37%failureratewithtreatmentof31A3intertrochantericfemurfracturesutilizingproximalfemorallockingplates7of11failuresvaruscollapsewithlockingscrewcutout,screwloosening,screwbreakage,platebreakageStreubelPN,MoustoukasMJ,ObremskeyWT.Mechanicalfailureafterlockingplatefixationofunstableintertrochantericfemurfractures.JOrthopTrauma.2013;27:22–28.Short-TermFollow-UpofPertrochantericFracturesTreated

UsingtheProximalFemoralLockingPlateanunacceptablyhighfailurerate(41.4%).JOrthopTraumaVolume28,Number5,May2014Evaluationofproximalfemorallockingplatein

unstableextracapsularproximalfemoralfracturesConclusion:PF-LCPrepresentsafeasiblealternativefortreatmentofunstableinter-orsubtrochantericfracturesjournalofclinicalorthopaedicsandtrauma5(2014)137e145髖髓內(nèi)釘系統(tǒng)（頭髓釘）適應(yīng)癥穩(wěn)定的不穩(wěn)定的股骨轉(zhuǎn)子間骨折逆股骨轉(zhuǎn)子間骨折骨折線向轉(zhuǎn)子下延伸股骨外側(cè)壁不完整Gamma釘髓內(nèi)穩(wěn)定型不穩(wěn)定型Gamma釘髓內(nèi)PFNA-II髓內(nèi)固定穩(wěn)定型31A1.2穩(wěn)定型INTERTANTechniquesinOrthopaedics$Volume30,Number2,2015INTERTAN髓內(nèi)固定不穩(wěn)定型：longcephalomedullarynail不穩(wěn)定型TechniquesinOrthopaedics$Volume30,Number2,2015INTERTANSHShadasignificantlyhigherreoperationrate

comparedtothosetreatedwithanIMnail.4and12

months

postoperativelyInjury,Int.J.CareInjured44(2013)735–742Slidinghipscrewversus

IMnailin

reverseobliquetrochantericandsubtrochantericfractures.4-12個月隨訪，髓外固定比髓內(nèi)固定的再手術(shù)率高Astudyof2716patientsintheNorwegianPFNAversus

Gamma3.Arandomisedcomparativestudyduringthefirstpostoperativeyear.nosignificantdifferenceintheoverallclinicaloutcomeandriskofcomplicationshelicalbladeandscrewproximalfemoralnailswerefoundtobesuitabletreatmentoptionsforagingpatientswithanunstableproximalfemoralfracture.Injury,Int.J.CareInjured(2012)43(S2),S47–S54術(shù)后一年內(nèi)，PFNA和gamma3在臨床效果和并發(fā)癥上無明顯差別ProspectiverandomisedstudyInconclusion,bothascrewandabladeperformedequallywellwithaSHSorIMnailstabilisationoftrochantericfracturesintheelderly.importantfactoriscarefultechniqueInternationalOrthopaedics(SICOT)(2011)35:1855–1861screwblade女，105歲女，106歲人工關(guān)節(jié)手術(shù)指征

陳舊性骨折

伴有股骨頸或股骨頭骨折嚴重骨質(zhì)疏松性骨折合并嚴重髖關(guān)節(jié)骨關(guān)節(jié)炎內(nèi)固定失敗嚴重骨質(zhì)疏松陳舊性骨折骨折伴無菌性壞死骨折伴骨關(guān)節(jié)炎內(nèi)固定并發(fā)癥內(nèi)植物斷裂螺釘穿出復(fù)位丟失內(nèi)植物松動骨不連髖內(nèi)翻骨折伴無菌性壞死骨折畸形愈合

Complication髓內(nèi)固定Complication

髓內(nèi)固定Complication髓外固定、ComplicationJOrthopTraumaVolume25,Number2Supplement,February2011髓外固定關(guān)于并發(fā)癥的形象成語一路向西一分為二勇往直前節(jié)節(jié)敗退低頭哈腰妻離子散獅子大開口為什么還有哪么多的？Kaufer.

Fiveinfluencethetimeoffixation.theimplanttype,qualityofreduction

positioningoftheimplantbonequalityandfractureconfiguration,KauferH.Mechanicsofthetreatmentofhipinjuries.ClinOrthopRelatRes1980;146:53e61patientsurgeonThesuccessofsurgicaltreatmentpatientfactorspriorhipfusion,poorbonequality,patientnoncompliance,persistentnonuniontechnicalfactorsimproperplateplacement,lackofkickstandscrew,screwlength,possiblylackofappropriatecompressionacrossthefracturesite).thefracturesite).sevenof10fixationsfailedcases內(nèi)固定并發(fā)癥的原因

內(nèi)固定選擇不當(dāng)技術(shù)應(yīng)用不當(dāng)康復(fù)不當(dāng)內(nèi)固定的關(guān)鍵

良好的復(fù)位

正確的安放技術(shù)

TAD﹤20mmJBoneJointSurgAm.2009;91:712-719.

Tip1:

注意尖頂距

Tip2:“沒有外側(cè)壁，就不能使用髖螺釘”

Tip3:要知道哪些是不穩(wěn)定型骨折，Tip4:

要清楚股骨干有向前突的弧線

Tip5:

當(dāng)使用大轉(zhuǎn)子頂點為入點的髓內(nèi)釘時，要在頂點略偏內(nèi)一點IntertrochantericFractures:TenTipstoImproveResults

Tip6:

不要對沒復(fù)位的骨折進行擴髓

Tip7:髓內(nèi)釘盡量用手旋轉(zhuǎn)手柄插入，盡量避免使用錘子打入。

Tip8:

避免骨折近端的內(nèi)翻成角畸形——注意轉(zhuǎn)子頂點和股骨頭中心點的關(guān)系

Tip9:如骨折固定后存在軸線或旋轉(zhuǎn)方向不穩(wěn)，要注意髓內(nèi)釘遠端的鎖定。

Tip10:使用髓內(nèi)定時盡量避免骨折的過度牽引IntertrochantericFractures:TenTipstoImproveResults內(nèi)固定療效

新鮮骨折絕大部分可獲得較滿意療效骨不連幾率極低（4/1052）股骨頭壞死幾率極低(2/1052)要點

牽引床復(fù)位定位（正，側(cè)位）進針點拉力螺釘位置術(shù)中插針骨折再移位

輔助復(fù)位（難復(fù)性）1

骨折復(fù)位間接復(fù)位牽引復(fù)位直接復(fù)位術(shù)中撬撥復(fù)位術(shù)中切開復(fù)位FracturereductionIn

mostcases

reductionisachievedbyclosedreduction,

longitudinaltraction,

slightabduction,gradualadduction,

slightinternalorexternalrotation

DeLeeJC.Fracturesanddislocationsofthehip.In:RockwoodJrCA,GreenDP,BucholzRW,HeckmanJD.,editors.Fracturesinadults.4thed.Philadelphia:Lippincott;1996.p.1714—39.1牽引

復(fù)位TractionG臂機

reduction牽引床髂前上棘大轉(zhuǎn)子2

定位定位3

進釘點根據(jù)主釘角度決定進針點進釘點導(dǎo)針髓腔開口插入導(dǎo)針大轉(zhuǎn)子尖或稍偏內(nèi)側(cè)擴髓

進釘點

髓腔開口主釘插入1

盡量不擴髓減少出血2

髓腔狹窄者必須擴髄3

徒手插入主釘，不敲擊股骨前弓存在，易造成骨折把持器松動造成遠端鎖釘困難插入主釘再移位拉力螺釘導(dǎo)針太長太短拉力螺釘導(dǎo)針偏前居中拉力螺釘導(dǎo)針太太長突入盆腔！髂靜脈叢損傷拉力螺釘導(dǎo)針完美Case拉力螺釘位置拉力螺釘位置Case拉力螺釘位置

拉力螺釘位置CaseFractureatthetip4

拉力螺釘位置

TAD頂尖距＜25mm(20mm)BaumgaertnerMR,CurtinSL,LindskogDM,KeggiJM.Thevalueofthetip-apexdistanceinpredictingfailureoffixationofperitrochantericfracturesofthehip.JBoneJointSurgAm1995;77:1058e64.ActaOrthopaedica2013;84(5):453–459Amicro-architectural

evaluationofosteoporotichumanfemoralheadstoguideimplantplacementinproximalfemoralfracturessummary,theboneismostdensewiththebeststructuralindicesatthecenterofthefemoralhead,ontheneckaxis,concludethatlagscrewsplacedinthisareawillachieve