Chinese Journal of Tissue Engineering Research ›› 2021, Vol. 25 ›› Issue (36): 5838-5843.doi: 10.12307/2021.352
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Wu Zhonghan, Xu Xinzhong, Zhang Jisen, Zhao Yao, Ye Shuming, Yu Shuisheng, Sun Jian, Jing Juehua
Received:
2021-03-12
Revised:
2021-03-15
Accepted:
2021-04-15
Online:
2021-12-28
Published:
2021-09-18
Contact:
Jing Juehua, MD, Professor, Chief physician, Doctoral supervisor, Department of Orthopedics, Second Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
About author:
Wu Zhonghan, Master candidate, Department of Orthopedics, Second Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
Supported by:
CLC Number:
Wu Zhonghan, Xu Xinzhong, Zhang Jisen, Zhao Yao, Ye Shuming, Yu Shuisheng, Sun Jian, Jing Juehua. One-stage reconstruction of the lateral wall of comminuted reverse oblique intertrochanteric fractures: how to improve the biomechanical stability of bone after repair[J]. Chinese Journal of Tissue Engineering Research, 2021, 25(36): 5838-5843.
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2.1 粉碎性逆转子间骨折的特点与外侧壁的临床意义 2.1.1 粉碎性逆转子间骨折的特点 国际内固定研究协会/美国骨创伤协会在2018年对股骨转子间骨折的分型进行了第2次更新,新修订的AO/OTA分型当中,依骨折线的走向依旧分为3大类9小类:A1型为骨折线经转子的简单骨折(内外侧骨皮质均完好),A2型为骨折线经转子的粉碎性骨折(伴有内后方骨皮质破裂),A3型为逆转子间骨折(此时内外侧骨皮质均破裂)[7]。逆转子间骨折又包含3个亚型:依次为简单斜行骨折、简单横行骨折以及粉碎性骨折,因此粉碎性逆转子间骨折即定义为A3.3型骨折。依据外侧壁是否完整,又能对转子间骨折的各AO/OTA分型进行归纳,其中A1-A2.1亚型属于外侧壁完整型,A2.2-A2.3亚型属于外侧壁危险型,最后A3的3个亚型属于原发性外侧壁骨折型;依据骨折端是否稳定又可将外侧壁完整型转子间骨折定性为稳定性转子间骨折,而外侧壁危险型和原发性外侧壁骨折型通常被定性为不稳定性转子间骨折[8]。 粉碎性逆转子间骨折既为原发性外侧壁骨折型,又为不稳定性骨折型,该类型的骨折具有特有的股骨近端结构和生物力学特性[9]。第一,骨折线累及前壁:从三维CT冠状位上可以清晰地看到,逆转子间骨折线将股骨近端区域分为骨折近端及远端,同时股骨前壁断裂,前壁支撑作用减弱[10];第二,骨折线累及外侧壁及后内侧壁:外侧壁的破裂将带来股骨头颈部骨块旋转和髋内翻畸形,内侧壁的破裂将导致阳性支撑作用丧失和骨折不稳定性剧增[11],髓内钉的主钉部分可以弥补内外侧壁不足对生物力学稳定带来的部分影响[12];第三,不稳定性骨折多发生于骨质疏松的老年患者,其成骨能力降低,导致骨折愈合往往减缓[13]。因此,单独使用髓内固定装置进行内固定,其内固定失效率及并发症发生率仍居于高值,临床医师一直在寻求对传统髓内固定作用予以加强的方法[14]。 2.1.2 外侧壁的临床意义 近年来,随着对股骨近端结构认识的逐渐加深,股骨外侧壁已经上升到与股骨后内侧壁同等重要的地位。外侧壁的概念由著名学者Gotfried于2004年提出,是对股骨近端结构延续部分的概括,国内外学者陆续根据X射线片及CT三维重建结果丰富其内容[15]。外侧壁的范围一直以来极具争议,2016年以来张世民、周方等学者指出了现今较适用的外侧壁界定范围:高度上至股外侧肌嵴,下至股外侧皮质与下股骨颈切线的交点,宽度一般指向股骨头打入螺旋刀片或拉力螺钉时进针点处的股骨干前后壁间水平长度,厚度通常以大转子无名结节下端3 cm作沿斜向股骨头135°角的斜线,测量从此点至骨折线前壁与后壁距离的均值作为厚度值[16-18]。 外侧壁的作用至关重要,其主要表现在:①完整的股骨外侧壁为头颈部骨块提供侧向支撑作用,避免骨块旋转并阻止股骨干内移,维持内固定的稳定性[19];②股骨外侧壁的完整与否是股骨转子间骨折是否需要二次手术的重要预测因 素[20],外侧壁的完整提示骨折稳定,其破裂将导致髋外展无力、内翻畸形、头颈部结构塌陷,最终导致内固定失效,需要二次手术[21];③外侧壁是否完整是区别A2与A3型股骨转子间骨折的重要依据,部分经转子的粉碎性骨折(31A2.2型及31A2.3型骨折)由于术中操作不当,致股骨外侧壁骨折,易转变为逆转子间骨折(31A3型骨折)或股骨转子下骨折[22]。 由于外侧壁的独特作用,其对内固定装置的选择有着重要影响。完整的外侧壁作为斜向135°向股骨头打入螺旋刀片或拉力螺钉的位置,在髓内钉内固定过程中能显著降低股骨头与主钉相接处的内翻应力,避免主钉断裂,阻挡螺钉切出[23]。故当外侧壁发生破裂时,应预备外侧壁修复器械,有效重建外侧壁,防止各种并发症的发生。 2.2 内固定方式 2.2.1 髓外固定 (1)动力髋螺钉+大转子稳定钢板内固定术:动力髋螺钉主要由滑动拉力螺钉和带套筒的侧方钢板组成。动力髋螺钉的加压螺钉具有滑动加压的作用,既能维持骨块稳定,又能降低骨折端的内翻应力和剪切力[24-25]。陈宇翔等[26]学者指出,尽管应用动力髋螺钉对于骨折线进行动态加压被认为是股骨转子间骨折的最佳治疗方案,但由于其偏心固定的缘故,当骨折类型不稳定时,单独应用动力髋螺钉的内固定失效率远高于髓内钉固定[27-28]。动力髋螺钉主要适用于稳定性转子间骨折,单纯动力髋螺钉内固定并不适用于逆转子间骨折,由此应际而生了大转子稳定钢板。大转子稳定钢板为动力髋螺钉基础上设计的新型内固定装置,作为改良后的髓外钢板,其暂时稳定了外侧壁,同时又通过散在的螺钉分散了应力,部分弥补了动力髋螺钉应力集中的不足之处,由此将适应证扩大到不稳定性转子间骨折。 新的手术方式具有以下3个突出特点:①操作简便,该系统和股骨近端防旋髓内钉 ( proximal femoral nail antirotation, PFNA)均适用于外侧壁不完整的股骨转子间骨折,因而适用于粉碎性逆转子间骨折[29];②动力髋螺钉+大转子稳定钢板固定在手术时间和术中失血方面表现优于PFNA固 定[30];③该系统不仅能够重建股骨外侧壁,同时防止头颈部骨块旋转,在临床工作中应用广泛并取得了良好的影像学结果和功能转归[31]。虽然动力髋螺钉+大转子稳定钢板内固定在治疗粉碎性逆转子间骨折上能取得和PFNA内固定相当的手术效果[32],但应力集中作为髓外装置生物力学上的根本缺陷并不能完全消除,疲劳断裂、骨块移位、继发性骨折脱位等并发症仍有发生,同时由于稳定钢板的存在,增加了植入物对软组织的刺激和残留疼痛[33]。 动力髋螺钉+大转子稳定钢板作为目前粉碎性逆转子间骨折的常用手术方式之一,对外侧壁重建效果良好,是一种可接受的治疗方案,但生物力学不稳定、存在软组织刺激性是其不足之处,其对于粉碎性逆转子间骨折的综合疗效有待与其他手术方式之间进行进一步比较。 (2)经皮加压钢板(percutaneous compression plate,PCCP) 螺钉内固定技术:经皮加压钢板固定系统由以色列的著名骨科学家Gotfried于20世纪90年代提出,率先应用于转子间骨折的治疗[34]。股骨转子区PCCP系统由加压钢板和5枚螺钉构成(其中2枚为股骨颈拉力螺钉,其他3枚为骨皮质螺钉),通常在闭合复位下进行内固定,然后依次沿股外侧肌深部插入钢板,拧入螺钉,因此该系统具有双轴设计抗旋更强、手术方式微创、术后疼痛较轻等特点[35]。 一项研究分析指出,在治疗转子间骨折的过程中,PCCP在术中疗效和术后并发症方面表现均优于动力髋螺钉;并且相较PFNA固定,手术时间明显缩短,输血单位明显减少是其优势[36];同时,置入钢板的小直径特点和特殊的钻孔方式可以保护股骨外侧壁,避免转子区外侧壁的二次损伤。Arirachakaran等[37]学者认为,就术中操作和术后并发症而言,老年股骨转子间骨折患者适合首选PCCP内固定技术。 值得注意的是,一直以来PCCP的主要适应证为稳定性股骨转子间骨折尤其是A1型转子间骨折,不稳定的转子间骨折更适合髓内钉固定[38]。故而针对粉碎性逆转子间骨折,PCCP的综合疗效相对有所降低,股骨干内翻移位、螺钉滑动、螺钉切出等并发症发生率相对更高[39]。再者,与PFNA相比,PCCP技术在提高髋关节功能方面的作用短板仍比较明显[40];研究显示,患者术后末次随访Harris髋关节评分较低,平均仅为84.1分[41],但合格率达88.89%,仍稍高于动力髋螺钉+ 大转子稳定钢板组的87.50%[32]。 在粉碎性逆转子间骨折的内固定方式选择中,PCCP内固定技术仍是备选的治疗方式之一,优于动力髋螺钉+大转子稳定钢板内固定术,但一般不作为首选;另外,在髓外钉板系统中,股骨近端锁定加压钢板内固定术后并发症较多,一般也不作为首选治疗方式[42]。 2.2.2 髓内+髓外固定 (1)PFNA+钢丝/钛缆捆扎技术:对于不稳定的股骨转子间骨折,髓内钉的综合疗效要优于髓外钉板系统或关节置换术,主要表现在其术后关节功能好、手术时间短、总死亡率低,近年来已得到广泛使用[43-44]。但是单纯应用髓内钉治疗粉碎性逆转子间骨折时,易出现复位困难、置钉遇阻以及外侧骨块把持障碍等多个问题,从而延长手术时间,增加隐性失血及髋内翻概率[45];同时,相较其他内固定方式,单纯髓内固定术后再次骨折发生率没有明显降低[46]。针对粉碎性逆转子间骨折端移位特点,在置入髓内钉前采用髓外固定装置辅助复位并牢固把持外侧多个骨块、维持位置,可以取得良好的术中及术后效果,利于术中精准开口、防止术中再移位、避免髋内翻等并发症的发生[47]。 能够坚强固定外侧骨块并维持复位的常用方法包括PFNA联合钢丝/钛缆捆扎和PFNA联合外侧壁钢板固定。放置内固定器械时,通常先使用一两根环扎钢丝捆扎固定,再置入合适规格的PFNA,然后依次锁钉,这种联合固定系统主要适用于股骨转子下骨折,对伴外侧壁骨折的转子间骨折亦疗效独到。 相较于使用复位工具如顶棒、骨拨(骨膜剥离器)及复位钳等,此种手术方式具有以下几点优势:①术中复位时间缩短,避免术中多次透视,减少复位困难所带来的部分隐性失血及降低此过程中的潜在感染可能[48];②术中复位良好,相比两种髓外固定,不仅修复了股骨外侧壁,同时维持了内侧壁的完整性[49];③术后髋关节功能结果改善明显, MOHAMED JAFARULLAH等[47]学者随访了49例外侧壁骨折患者,辅助以钢丝重建,选取Harris髋关节评分作为评价指标,优良率超过82.35%。就优良率而言,相比动力髋螺钉+ 大转子稳定钢板组的59.38%和PCCP组的87.5%有大幅提 高[32,47]。而不足之处同样存在:首先,因手术切口较大,该手术在一定程度上对软组织及血运有所破坏[50],但由于生物力学恢复良好,骨折愈合率高于81.81%,因而软组织及血运破坏 对骨折端愈合的影响可以忽略[51];其次,KARAYIANNIS等[52]学者观察到,由于钢丝松动断裂等而重返手术室的概率在近年来有上升的趋势,由3.4%上升到9.1%,同时股骨头缺血性坏死、股骨干内翻塌陷、螺钉切出、骨不连、浅表感染等并发症仍时有发生,因此在复位质量明显改善时使用更为合适。 PFNA联合钛缆/钢丝内固定术可以视为粉碎性逆转子间骨折重建外侧壁合适的治疗方法,其操作简便,对下肢生物力学恢复及外侧壁重建效果的兼顾优于单纯髓外固定或单纯髓内固定,关节功能改善明显;但并发症亦不可忽视,一般而言建议在复位困难时使用,将明显改善复位质量。 (2)PFNA+小钢板内固定术:由于一些难复性股骨转子间骨折的性质复杂,必要时需要切开复位,从而也促使髓内髓外联合固定有了多种多样的形式。辅助复位工具除钢丝钛缆外,应用较多的还有小钢板,因此股骨外侧小钢板辅助下进行PFNA内固定成为一种可供选择的手术方式[53]。 对于髓内部分仍然选用PFNA,髓外部分选用股骨外侧壁纵行支撑钢板,以直型锁定重建钢板最为常用。而其置入顺序与钢丝有别,联合钢板内固定术的手术过程中一般在牵引复位后首先置入髓内钉,再剥离股骨外侧肌肉置入外侧锁定钢板。 时至今日,单纯髓内固定治疗不稳定的股骨转子间骨折,其术后内固定失效率及并发症发生率仍居高不下[54]。PFNA联合钢板主要针对各型不稳定的转子间骨折,尤其是伴有外侧壁损伤的骨折类型进行固定,对股骨转子下骨折也有良好效果。在外侧钢板辅助下对粉碎性逆转子间骨折进行PFNA内固定存在以下4点优势:①相较单纯髓内固定,由于外侧壁重建可靠、骨折端复位良好、对头颈部骨块的支撑抗旋作用到位,术后PFNA退钉、螺钉松动等并发症明显减少[55];②相较PFNA+钢丝/钛缆捆扎内固定术,复位优良率更高,骨折愈合时间缩短,术后下地活动时间提前近1周(WANG等[56]报道83例不稳定性股骨转子间骨折,应用两种方式手术,术后辅助钢板组复位优良率为71.79%,愈合时间为14.28周;辅助钢丝组复位优良率为45.45%,愈合时间为13.35周),而术后半年两者的关节功能评分及并发症发生率则没有太大差异;③相较单纯髓外固定髋关节功能明显提高(术后Harris髋关节评分合格率为97.14%),同时达到术后早期负重的目的[57];④相较关节置换术,其创伤相对更小、骨质流失更少,故而有条件施行内固定手术者应优先施行内固定手术[58]。 由于附加重建钢板时需在大转子至小转子下水平作前外侧小切口,手术时间和术中出血量不可避免有所增加[59]。由此应运而生的髓内+有限髓外固定改进了这一不足,主要代表为PFNA+微创经皮钢板内固定术,其可最大程度降低手术创伤,保护股骨近端血运,螺钉切出、骨折不愈合、退钉等并发症发生率与翻修概率显著降低,这也揭示了内固定手术微创化发展的趋势[60]。 相较于PFNA联合钢丝/钛缆捆扎,PFNA联合股骨外侧小钢板固定对粉碎性逆转子间骨折的骨折端及外侧骨块的复位稳定性更好、术后下地更早,而两种联合固定方式术后髋关节功能及术后并发症发生率无明显差异。对于劈裂严重、骨块不规则或粉碎严重的骨折类型,若支撑钢板操作困难且对骨块把持能力弱,可换用操作更为简便的钢丝或钛缆捆 扎[61]。 "
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