股骨粗隆间骨折中文版

股骨转子间骨折手术治疗

国家211工程重点学科上海市关节外科临床医学中心上海交通大学医学院附属第九人民医院intertrochantericfracturesfirst

openreductionandinternalfixationwasattemptedby

usingintramedullarynailingin1850.

Langenbeck

theconceptoftheslidinghipscrewwasfirstproposedin1955.

SchumpelickW,JantzenPM.

thefirstarticlereviewingtheprocedurewaspublishedin1964.

ClawsonDKClawsonDK.Trochantericfracturestreatedbytheslidingscrewplatefixationmethod.JTrauma1964;4:732—52.SchumpelickW,JantzenPM.Anewprincipleintheoperatuivetreatmentoftrochantericfracturesofthefemur.JBoneJointSurgAm1955;37A:693—8.股骨转子间骨折手术治疗发展史固定角度

1940s-1960sJewettplateMclaughlinplateAO/ASIFangleplate滑动固定1960s后RichardscrewFixionDHSMedoffplateLockedplating髓外固定股骨转子间骨折手术治疗发展史

Gamma钉，1980sPFN1990s

PFNA，2000sPFNA-II，2009s

髓内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关节外骨折转子间骨折的特点

低能量90%

年龄>65岁90%

需要内固定骨质疏松

大多伴有内科疾病长期卧床极易发生并发症骨质疏松髋部骨质疏松性骨折

20%一年内死亡

25%恢复到骨折前生活质量

55%残留不同程度功能障碍

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

RoleofRoutineBloodTeststheincidenceofdeathduringthefirst3monthafterhipfracturewas24%ItmeansthatpatientswithhighplasmalevelsofBUNhaddied3timesmorethanthosewithnormalBUNandpatientswithhighcreatinineplasmalevelshaddied2.5timesmorethanthosehadnormalcreatininevalues.THEARCHIVESOFBONEANDJOINTSURGERY.VOLUME3.NUMBER1.JANUARY2015转子间骨折骨量差的不稳定性骨折简单、稳定性骨折愈合率高治疗具有挑战性死亡率：20~30%，一年内48小时内手术，可减低1年内死亡率

如何选择？新鲜骨折－内固定首选骨质疏松严重陈旧性骨折内固定失败骨关节炎｝关节置换不稳定骨折的特点1

外侧皮质粉碎

2

后内侧大块骨块3逆粗隆骨折4骨折线延伸至粗隆下HaidukewychGJ.Intertrochantericfractures:tentipstoimproveresults.JBoneJointSurgAm2009;91:712e9.StableUnstableUncontrolledfactor:FracturegeometryAO/OTA31A3高度不稳定!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股骨转子间骨折内固定的选择A1.1A1.2A1.3A2.3A2.2A2.1A3.3A3.2A3.1髓外固定髓内固定NICEGuidelinerecommendation

Useextramedullaryimplantssuchasaslidinghipscrewinpreferencetoanintramedullarynailinpatientswithtrochantericfractures(AOclassificationtypesA1

andA2).稳定性骨折，髓外固定优于髓内固定

AustralianandNewZealandGuidelineforHipFractureCareConsensus-basedrecommendation

Bothextramedullaryslidinghipscrewandintramedullarynailsaresuitablefortrochantericfractures(AOclassificationtypesA1andA2).-. 髓外和髓内固定均适合稳定性骨折

ImprovingOutcomesinHipFractureManagementofAdultsSeptember2014Australianand

NewZealandGuidelineConsensus-basedrecommendation Useanintramedullarynailtotreatpatientswithareverseobliquefracture. -反斜形骨折，建议髓内固定Australianand

NewZealandGuidelineEvidence-basedrecommendation Useanintramedullarynailtotreatpatientswithasubtrochantericfracture.

粗隆下骨折，建议髓内固定STABLEINTERTROCHANTERICFRACTURES

supportstheuseofeitheraslidinghipscreworacephalomedullarydeviceinpatientswithstableintertrochantericfractures髓内或髓外固定均适合于稳定性骨折JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineUNSTABLEINTERTROCHANTERICFRACTURES

supportsusingacephalomedullary

deviceforthetreatmentofpatientswithunstable

intertrochantericfractures.不稳定性骨折建议使用髓内固定JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineSURGICALTIMING

hipfracturesurgerywithin48hours

ofadmissionisassociatedwithbetteroutcomes髋部骨折48小时内行手术可取的良好效果JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelinePREOPERATIVETRACTION

doesnotsupportroutineuseofpreoperativetractionforpatientswithahipfracture.JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuideline不常规使用术前牵引ASPIRINANDCLOPIDOGRELLimitedevidencesupportsnotdelayinghipfracturesurgeryforpatientsonaspirinand/orclopidogrel.阿司匹林或氯吡格雷不影响髋部手术JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineANESTHESIA

Strongevidencesupportssimilaroutcomesforgeneralorspinalanesthesiaforpatientsundergoinghipfracturesurgery.全麻或腰麻对于髋部骨折手术效果类似JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineVTEPROPHYLAXIS

supportsuse

ofvenousthromboembolismprophylaxis(VTE)inhipfracturepatients.JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuideline建议使用抗血栓药物TRANSFUSIONTHRESHOLD

supportsabloodtransfusionthresholdofnohigherthan8g/dl

inasymptomaticpostoperativehipfracturepatients.JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuideline血红蛋白低于8g/dl，建议输血OSTEOPOROSISEVALUATIONANDTREATMENT

supportsthatpatientsbeevaluatedandtreatedforosteoporosisaftersustainingahipfracture.术后评估骨质疏松并治疗JAmAcadOrthopSurg2015;23:131-137AAOSClinicalPracticeGuidelineNutrition

建议术后予以支持疗法建议补充维生素D和钙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围手术期注意贫血

抗凝

水电解质平衡情况控制血糖改善心功能代谢紊乱纠正心率不齐和心肌缺血

注意胸部情况和呼吸系统原始疾病

Gamma钉

PFN

PFNAPFNA-II

Intertan

DHS

95°髁钢板

人工关节置换术LISSLockedplating髓外髓内髓外固定髓内固定股骨转子间骨折手术治疗策略滑动髋加压螺钉系统（DHS）髋髓内钉系统（头髓钉）人工关节置换滑动髋加压螺钉系统适应症稳定的股骨转子间骨折若逆转子间骨折或股骨外侧壁不完整，可能出现股骨干内移，推荐加用大转子挡板或角稳定系统aSHSimplantorPCCPissuitableforthemanagementof2-partintertrochanterichipfractures(AO/OTA31A1)certainunstablefracturepatterns

31A2.1thatareconsideredstableafterreductionandhaveanintactlateraltrochantericbuttressINDICATIONSFOR

PLATINGTechniquesinOrthopaedics$Volume30,Number2,2015DHS髓外稳定型髓外固定-滑动系统结果稳定骨折-效果好不稳定骨折-固定强度不足,反粗隆—禁忌失败原因螺钉切割钉板拔出钉板分离疲劳断裂From:Harrington,Injury,2002不稳定型：髓外固定—失败率高不稳定型-外侧壁损伤

不稳定型-外侧壁损伤女78岁左术后2个月外侧壁损伤DHS+PlateLCP解决方法逆粗隆骨折DHS视为禁忌！逆粗隆骨折actsasabuttresstoresistlateraldisplacementoftheproximalfemur.逆粗隆骨折髓内LISS髓外固定Case1转子间伴股骨颈三爪固定器

bSCREW转子间伴股骨颈cannulatedscrewsLISS髓外固定术后23月术后27月术后13月术后13月术后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髋髓内钉系统（头髓钉）适应症稳定的不稳定的股骨转子间骨折逆股骨转子间骨折骨折线向转子下延伸股骨外侧壁不完整Gamma钉髓内稳定型不稳定型Gamma钉髓内PFNA-II髓内固定稳定型31A1.2稳定型INTERTANTechniquesinOrthopaedics$Volume30,Number2,2015INTERTAN髓内固定不稳定型：longcephalomedullarynail不稳定型TechniquesinOrthopaedics$Volume30,Number2,2015INTERTANSHShadasignificantlyhigherreoperationrate

comparedtothosetreatedwithanIMnail.4and12

months

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

IMnailin

reverseobliquetrochantericandsubtrochantericfractures.4-12个月随访，髓外固定比髓内固定的再手术率高Astudyof2716patientsintheNorwegianPFNAversus

Gamma3.Arandomisedcomparativestudyduringthefirstpostoperativeyear.nosignificantdifferenceintheoverallclinicaloutcomeandriskofcomplicationshelicalbladeandscrewproximalfemoralnailswerefoundtobesuitabletreatmentoptionsforagingpatientswithanunstableproximalfemoralfracture.Injury,Int.J.CareInjured(2012)43(S2),S47–S54术后一年内，PFNA和gamma3在临床效果和并发症上无明显差别ProspectiverandomisedstudyInconclusion,bothascrewandabladeperformedequallywellwithaSHSorIMnailstabilisationoftrochantericfracturesintheelderly.importantfactoriscarefultechniqueInternationalOrthopaedics(SICOT)(2011)35:1855–1861screwblade女，105岁女，106岁人工关节手术指征

陈旧性骨折

伴有股骨颈或股骨头骨折严重骨质疏松性骨折合并严重髋关节骨关节炎内固定失败严重骨质疏松陈旧性骨折骨折伴无菌性坏死骨折伴骨关节炎内固定并发症内植物断裂螺钉穿出复位丢失内植物松动骨不连髋内翻骨折伴无菌性坏死骨折畸形愈合

Complication髓内固定Complication

髓内固定Complication髓外固定、ComplicationJOrthopTraumaVolume25,Number2Supplement,February2011髓外固定关于并发症的形象成语一路向西一分为二勇往直前节节败退低头哈腰妻离子散狮子大开口为什么还有哪么多的？Kaufer.

Fiveinfluencethetimeoffixation.theimplanttype,qualityofreduction

positioningoftheimplantbonequalityandfractureconfiguration,KauferH.Mechanicsofthetreatmentofhipinjuries.ClinOrthopRelatRes1980;146:53e61patientsurgeonThesuccessofsurgicaltreatmentpatientfactorspriorhipfusion,poorbonequality,patientnoncompliance,persistentnonuniontechnicalfactorsimproperplateplacement,lackofkickstandscrew,screwlength,possiblylackofappropriatecompressionacrossthefracturesite).thefracturesite).sevenof10fixationsfailedcases内固定并发症的原因

内固定选择不当技术应用不当康复不当内固定的关键

良好的复位

正确的安放技术

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

Tip1:

注意尖顶距

Tip2:“没有外侧壁，就不能使用髋螺钉”

Tip3:要知道哪些是不稳定型骨折，Tip4:

要清楚股骨干有向前突的弧线

Tip5:

当使用大转子顶点为入点的髓内钉时，要在顶点略偏内一点IntertrochantericFractures:TenTipstoImproveResults

Tip6:

不要对没复位的骨折进行扩髓

Tip7:髓内钉尽量用手旋转手柄插入，尽量避免使用锤子打入。

Tip8:

避免骨折近端的内翻成角畸形——注意转子顶点和股骨头中心点的关系

Tip9:如骨折固定后存在轴线或旋转方向不稳，要注意髓内钉远端的锁定。

Tip10:使用髓内定时尽量避免骨折的过度牵引IntertrochantericFractures:TenTipstoImproveResults内固定疗效

新鲜骨折绝大部分可获得较满意疗效骨不连几率极低（4/1052）股骨头坏死几率极低(2/1052)要点

牵引床复位定位（正，侧位）进针点拉力螺钉位置术中插针骨折再移位

辅助复位（难复性）1

骨折复位间接复位牵引复位直接复位术中撬拨复位术中切开复位FracturereductionIn

mostcases

reductionisachievedbyclosedreduction,

longitudinaltraction,

slightabduction,gradualadduction,

slightinternalorexternalrotation

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

复位TractionG臂机

reduction牵引床髂前上棘大转子2

定位定位3

进钉点根据主钉角度决定进针点进钉点导针髓腔开口插入导针大转子尖或稍偏内侧扩髓

进钉点

髓腔开口主钉插入1

尽量不扩髓减少出血2

髓腔狭窄者必须扩髄3

徒手插入主钉，不敲击股骨前弓存在，易造成骨折把持器松动造成远端锁钉困难插入主钉再移位拉力螺钉导针太长太短拉力螺钉导针偏前居中拉力螺钉导针太太长突入盆腔！髂静脉丛损伤拉力螺钉导针完美Case拉力螺钉位置拉力螺钉位置Case拉力螺钉位置

拉力螺钉位置CaseFractureatthetip4

拉力螺钉位置

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

evaluationofosteoporotichumanfemoralheadstoguideimplantplacementinproximalfemoralfracturessummary,theboneismostdensewiththebeststructuralindicesatthecenterofthefemoralhead,ontheneckaxis,concludethatlagscrewsplacedinthisareawillachieve