Internal fixation strategies for different lateral wall types
of intertrochanteric fractures of the femur

doi:10.3969/j.issn.2095-4344.2453

Abstract

Abstract:

BACKGROUND: The importance of the lateral wall of the femoral trochanter in the intertrochanteric fracture has been paid more and more attention. The research on the classification of the external wall in guiding clinical operation has become a hot issue.

OBJECTIVE: To review the treatment strategies of different lateral wall types of intertrochanteric fractures, and the selection of the built-in materials, provide reference and help for future clinical research.

METHODS: The first author searched the Chinese database of Wanfang and China National Knowledge Infrastructure with the keywords of “intertrochanteric fracture of femur; lateral wall of femoral trochanter; fracture classification; fracture fixation, internal; implant; intramedullary fixation; extramedullary fixation; complications; elderly; prognosis”. Meanwhile, PubMed English database was retrieved with the keywords “intertrochanteric fracture of femur; lateral wall of femoral trochanter; fracture classification; fracture fixation, internal; implant; intramedullary fixation; extramedullary fixation; complications; elderly; prognosis”. The retrieval time was from May 2009 to May 2019. A total of 166 literatures were retrieved. According to the inclusion and exclusion criteria, 47 literatures were selected as the research object and summarized.

RESULTS AND CONCLUSION: (1) During the surgical treatment of intertrochanteric fracture of the femur, intramedullary fixation system and extramedullary fixation system have their own advantages and disadvantages. After full analysis of lateral femoral trochanter wall classification and reasonable preoperative evaluation, it is a combination of theory and practice. Signing, correctly assessing the severity of fractures and judging the prognosis, and fully preoperative evaluation can greatly help the patient’s treatment effect and prognosis. (2) It is a basic quality of doctors and a responsible attitude towards patients to formulate different treatment plans according to their economic conditions and physical qualities. “Individualization” has become the future development trend. (3) There are still many disputes in the treatment of intertrochanteric fractures. More clinical research and data support are needed in the future to solve and improve it.

Key words: intertrochanteric fracture, external wall, intramedullary fixation, extramedullary fixation, dynamic hip screw, proximal femoral anti-rotation intramedullary nail, proximal femoral locking plate, large trochanter stabilization plate, percutaneous compression plate

CLC Number:

Guo Tianqing, Xue Fei, Feng Wei. Internal fixation strategies for different lateral wall types of intertrochanteric fractures of the femur[J]. Chinese Journal of Tissue Engineering Research, 2020, 24(6): 917-923.

Figures/Tables 2

2.1 外侧壁概念提出及完善手术能够达到骨折的满意复位，并且提供牢固的固定，能使患者摆脱卧床，早期下地进行日常生活。长久以来，人们认为想要达到股骨转子间骨折内固定的稳定，关键因素在于复位后内侧的骨折块，认为包含了股骨距、小转子的后内侧骨折块是决定复位稳定性并能提供牢固固定的关键所在，很久以前EVANS[3]就提出了这一观点。1980年，JENSEN[4]提出了前内侧骨皮质能够维持骨折复位的稳定，从而使骨折端继发移位降低。进入20世纪90年代，1995年BAUMGAERTNER等[5]提出了顶尖距的概念，报道了头颈钉在股骨头内的距离对骨折稳定的重要性。1996年，PAKER[6]研究并发现了股骨大转子外侧骨皮质的完整有利于提高股骨转子间骨折内固定的稳定性，因其连接股骨干并能对股骨干的内移起到阻止作用。新的概念不断提出，也丰富了人们对影响股骨转子间骨折内固定稳定性因素的认识。直到2004年，GOTFRIED[7]首次提出了股骨转子外侧壁对于骨折内固定稳定性的重要性，并认为外侧壁的影响要远大于顶尖距对于术后疗效的影响，但是Gotfried并没有具体的给出外侧壁的概念和范围。2005年IM等[8]通过回归分析发现，股骨转子间骨折复位丢失的显著与否与股骨外侧壁是否完整息息相关。紧接着2007年PALM等[9]提出，在二次手术翻修中是否发现继发外侧壁骨折是最重要的预测因素。IM等[8]和PALM等[9]相继通过实验证实了股骨转子外侧壁的作用所在，并且提出了外侧壁在解剖学上的范围：上至股外侧肌嵴，与大转子相接，下至小转子中点平面的股骨近端外侧皮质，见图2[10]。2013年，ABRAM等[11]对大转子入针点、顶尖距和外侧壁3点固定稳妥的病例进行生物力学研究，提出了相对于入针点和顶尖距，外侧壁的完整性作为术后疗效的预测指标更有意义也更重要。同年，HSU等[12]通过回顾性研究预测骨折内固定稳定的可靠因素，在考虑患者的年龄、骨折类型、性别、外侧壁厚度、顶尖距等诸多因素中，外侧壁厚度成为最关键的因素。股骨外侧壁这一概念在提出后，经过IM等[8]、PALM等[9]、ABRAM等[11]、HSU等[12]的不断完善，改变了长久以来人们对于前内侧骨皮质、后内侧骨块在骨折内固定稳定性起决定性作用的大局，对外侧壁影响股骨转子间骨折内固定稳定性因素进行了补充，使认识更全面、更利于手术治疗。2018年，通过CT三维重建技术，GAO等[13]重新定义了外侧壁的范围：上至股骨外侧嵴，下至股骨外侧皮质与股骨颈下缘骨皮质切线的焦点。 "

2.2 股骨转子间骨折的手术治疗方式手术治疗股骨转子间骨折时，主要采用动力髋螺钉、经皮加压接骨板、股骨近端解剖锁定钢板、股骨近端锁定加压钢板、倒置微创内固定系统钢板等髓外固定系统，以及Gamma钉、股骨近端髓内钉、股骨近端防旋髓内钉、亚洲型股骨近端防旋髓内钉、股骨近端联合加压交锁髓内钉系统、股骨近端可膨胀髓内钉等髓内固定系统。理想的内置物要求：能够提供更坚强的内固定，以利于患者早期的负重功能锻炼；更容易的植入技术，使年轻医生的学习曲线减短，使手术操作更顺畅；更低的股骨头切割率、内置物的术后松动及其他器械相关并发症的发生率；更有力的加压技术，能够促进骨折更快的愈合；更微创的操作，减少手术操作期间并发症的发生率；更低廉的费用，减轻患者及家属的负担。 2.3 外侧壁的重要意义患者进入手术室麻醉后以仰卧位平躺于牵引床上，双下肢置于足部支架被牢牢固定，临床医生通过外展位沿着患侧下肢的长轴方向牵引试行手法复位，在透视照射下观察正位片应见内侧皮质骨接触良好，侧位片亦应见后侧皮质骨接触良好。若内侧后侧等有重叠或者裂纹，可适当的内外旋患肢并调整牵引，以达到标准复位的目的。无论是在髓内固定还是在髓外固定中，头颈钉入针点都是在股骨外侧肌嵴的下方2 cm左右区域的外侧骨皮质，打入股骨头的位置。所以外侧壁的完整性对于内置物在该区域进针至关重要。GAO等[13]回顾性分析了2004年5月至2015年4月间99例接受股骨近端骨折(股骨外侧壁骨折)手术治疗成年患者的医疗记录，以确定植入失败的相关因素。得出结论为大转子与股骨外侧壁交界处的游离骨碎片和穿过股骨外侧壁的横向骨折线，是股骨近端骨折合并股骨外侧壁骨折时植入失败的预测因子，股骨外侧壁的完整性与股骨近端骨折的预后相关，对于股骨近端骨折伴股骨外侧壁骨折的有效治疗可能需要股骨外侧壁重建。CIUFO等[14]研究发现，完整的外侧壁可有效地支撑头颈处的碎骨块，为近端骨碎片提供强有力的外侧支撑作用，使骨块之间相互接触并相互嵌入，不仅可促进骨折的愈合，而且进一步加强了稳定。如果外侧壁的完整性遭到了破坏，无法从外侧对近端骨碎片进行支撑就会造成骨质的塌陷。完整的外侧壁同样是股骨干近端的延续，能很好的对抗股骨干的内移，若外侧壁破裂，就相当于在生物力学上形成了转子下骨折，远端的骨块相比于近端的骨块更容易向内侧移动，当移位量大于1/3时就会导致髋部力学的改变，骨折复位产生丢失，髋关节变得外展无力，力矩变得短缩，从而引发肢体短缩，患者术后基本步态发生改变，骨盆平衡能力丧失，甚至丧失行走能力。外侧壁的完整防止了头颈骨块之间的旋转与内翻，为内固定的植入提供了支持，并且在生物力学上分散了应力，减少了螺钉所承受的应力，有效防止头颈螺钉的后退切出，并且在一定程度上减轻了主钉与头颈钉连接接口处的杠杆产生的应力，不仅防止了主钉的弯曲断裂，而且对头颈钉的过度滑移起到防止作用，为头颈钉提供了3点受力外侧作用力，从而降低使内固定的失败率[14]。术前要充分对外侧壁的完整性进行评估分析，根据不同外侧壁的状态来决定不同的骨折分型[15]，在术前明确并选择合适的内固定方式，术中可根据具体情况及时更改术前设计的方案，避免造成医源性的二次骨折。 2.4 外侧壁分型依据外侧壁的结构是否完整，GOTFRIED[7]、PALM[9]、SUN等[16]提出了关于外侧壁的3种分型：①外侧壁稳定型骨折：顺向的稳定骨折，包含了A1的3个亚型和A2.1亚型，其中A1的3个亚型是简单的2部分骨折，单条的骨折线延伸至内侧的骨皮质，其复位较简单，复位后能够承担大部分的负荷，A2.1亚型为小转子无移位大转子完整的骨折；②外侧壁危险型：顺向的不稳定骨折，包含了A2.2和A2.3亚型，是累及了小转子和部分大转子的骨折；③外侧壁破裂型：同样也是不稳定骨折，为原发性外侧壁破裂，包含了A3的3个亚型，后内侧与外侧的支撑结构遭到破坏(累及外侧壁)，骨折线从股外侧肌嵴以远穿出。该分型是在AO分型的基础上整理得出，体现了骨折的稳定与否。 "

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