Dynamic hip screw combined with trochanter stabilizing plate versus Gamma nail fixation in repair of intertrochanteric fracture

doi:10.3969/j.issn.2095-4344.2014.09.022

Abstract

Abstract:

BACKGROUND: Intertrochanteric fracture can obtain good curative effects after active effective internal fixation in early stage.
OBJECTIVE: To compare dynamic hip screw + trochanter stabilizing plate and Gamma nail fixation for treatment of Evans type IIIB and type IV intertrochanteric fracture.
METHODS: A total of 67 patients with Evans type IIIB and type IV intertrochanteric fracture, including 28 cases undergoing dynamic hip screw + trochanter stabilizing plate and 39 cases undergoing Gamma nail, were selected from Chongming Branch, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from February 2009 to November 2012. All patients received antibiotics and functional exercises after treatment. Time of therapy, intraoperative bleeding amount, fracture healing time and Harris Hip Score were retrospectively analyzed in patients of both groups.
RESULTS AND CONCLUSION: All patients were followed up for 6-45 months, averagely 21 months. (1) One patient affected infection in the dynamic hip screw + trochanter stabilizing plate group. He was healed after fixation removal half a year after drug exchange. One obese patient experienced injury again during out-of-bed activity at 3 weeks after treatment in the Gamma nail group. Fracture appeared at distal end of lock pin, and healed after replaced by Gamma nail. Trochanteric stabilizing plate was unstable in four patients of the Gamma nail group. They affected severe pneumonia after over 6 weeks of lying in bed, and healed after treatment in the medical department (2) Coxa vara appeared in two cases of the dynamic hip screw + trochanter stabilizing plate group, and three cases in the Gamma nail group. Fracture healing was achieved in all patients. (3) The time of therapy was longer, and intraoperative bleeding amount was significantly more in the dynamic hip screw + trochanter stabilizing plate group compared with the Gamma nail group (P < 0.05). No significant difference in healing time and Harris Hip Score was detected between the two groups (P > 0.05). Dynamic hip screw + trochanter stabilizing plate and Gamma nail are effective methods for treatment of Evans type IIIB and type IV intertrochanteric fracture. To choose a suitable fixator, we should aggregately analyze fracture stability, healing state and the degree of osteoporosis.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: prostheses and implants, femur, hip fractures, bone nails, fracture fixation, intramedullary, fracture healing, fracture fixation

CLC Number:

R318

Zhou Qiang, Lu Hua, Yu Si-ming, Wang Zhan-chao, Mao Yu-lun, Yao Bing, Zhang Tian-hao . Dynamic hip screw combined with trochanter stabilizing plate versus Gamma nail fixation in repair of intertrochanteric fracture[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(9): 1441-1446.

Figures/Tables 2

2 股骨转子间骨折内固定治疗方法的选择 Choice of therapeutic methods for intertrochanteric fracture 资料来源：采用检索CNKI数据库、万方数据库和Pubmed数据库的方法获取资料[10-12]。资料检索公式：资料检索时间范围从2001至2013年，中文检索词为“股骨转子间骨折；动力髋螺钉；Gamma钉；钢板”，英文检索词为“intertroehanteric fracture；dynamic hip screw；Gamma nail；steel plate”，检索出相关文献198篇。其中，CNKI数据库收录文献数量为60篇，万方数据库收录文献数量106篇，Pubmed数据库收录文献数量为32篇。最终纳入研究的文献共22篇[13-34]。入选标准：①检索结果中排除与研究目的不相关的文献。②文献的内容与动力髋螺钉、Gamma钉、钢板内固定治疗股骨转子间骨折研究相关。③检索结果中排除无全文的文献。④同一研究团队以及同一作者的相似研究，只选取其中1篇纳入结果分析。⑤检索文献体例为论著和病例报告等，均为一次性文献，排除综述类二次性文献。 2.1 动力髋螺钉和Gamma钉内固定治疗股骨转子间骨折股骨转子间骨折的治疗方法较多，目前切开或闭合复位内固定仍旧是治疗的主流方式，内固定选择方面动力髋螺钉及Gamma钉无疑分别是髓外系统及髓内系统的代表，循证医学研究表明，对于稳定的转子间骨折，髓外系统及髓内系统均可以取得良好的效果，差异并没有显著性意义[13]。国内关于动力髋螺钉和Gamma钉内固定治疗股骨转子间骨折研究的文献，见表2。由表2可见，动力髋螺钉内固定治疗的患者在治疗时间和出血量方面高于Gamma钉内固定，动力髋螺钉和Gamma钉内固定治疗股骨转子间骨折在愈合时间和Harris髋关节功能评分方面差异无显著性意义，均可以获得良好的内固定效果。 2.2 动力髋螺钉+转子稳定钢板内固定治疗股骨转子间骨折对于伴有大转子粉碎或大转子冠状面骨折的Evans ⅢB型、Ⅳ型转子间骨折往往是治疗的难点，大转子不稳定骨折往往伴有转子部外侧皮质的破裂，如何对大转子稳定固定是该类骨折治疗的关键所在。Gotfried[19]研究了24例内固定失败的股骨转子间骨折，发现所有失败的原因都是由于转子部外侧壁的破裂所致，对于大转子不稳定转子间骨折，骨科医生通常会选择动力髋螺钉+转子稳定钢板的组合方式，动力髋螺钉固定于外侧骨皮质，主要分担张应力，动力髋螺钉有固定牢靠，可有效抵抗顺转子间骨折的剪切应力的优点，其套筒式连接，具有动力加压和静力加压双重功能，非常有利于早期负重和骨折的愈合。转子稳定钢板解剖型设计，贴附性好，盖板两侧护翼型设计，保证对大转子的复位固定；多枚螺钉固定，形成牢固的钉板结构，动力髋螺钉加用转子稳定钢板固定后既减小骨折对动力髋螺钉的依赖，又可控制股骨头旋转，避免了可能出现的并发症。同时，转子稳定钢板本身可对外侧壁进行有效的重建。陆耀刚等[20]认为严重的粉碎股骨转子间骨折，可采用动力髋螺钉+转子稳定钢板重建转子部外侧壁，固定有效，使用方便，适用于重度粉碎的转子间骨折。然而由于动力髋螺钉应避免通过骨折线进入，否则它的滑动加压作用可能成为骨折移位的原因，因此对于部分大转子劈裂的转子间骨折，有时不得不小调整动力髋螺钉的进针点，调整进针点后动力髋螺钉拉力螺钉往往不能位于股骨颈最佳位置，这样往往造成股骨头旋转的扭矩增加，又使骨折断端动力加压不均匀，增加了并发症的发生率；加上髓外系统治疗创伤较大，操作时间长，力臂长，弯矩也较大，如果内侧骨皮质有缺损，易造成应力集中，引起内侧皮质压缩，钉切割股骨头，螺钉松动甚至钢板断裂等并发症，王恩时等[21]认为若股骨大转子外侧皮质粉碎，不宜应用髓外系统。 "

References

[1]Peleg E, Mosheiff R, Liebergall M, et al.A short plate compression screw with diagonal bolts--a biomechanical evaluation performed experimentally and by numerical computation.Clin Biomech (Bristol, Avon). 2006;21(9): 963-968.

[2]Lin PC, Chang SY.Functional recovery among elderly people one year after hip fracture surgery.J Nurs Res.2004;12(1): 72-82.

[3]姜磊,禹宝庆,傅青格.闭合复位PFN治疗高龄股骨粗隆间骨折的体会[J].中国骨与关节损伤杂志,2006,21(1):59-60.

[4]Stocks GW. Treatment of reverse obliquity fractures of the intertrochanteric region of the femur.J Bone Joint Surg(AM). 2002;85A(5):869-870.

[5]杨逛忠,欧阳夏辉,陈江涛.老年骨质疏松性股骨粗隆骨折的手术治疗策略[J].中国骨与关节损伤杂志,2007,22(8):635-637.

[6]吴在德,吴肇汉.外科学[M].第7版.北京:人民卫生出版社,2008: 781.

[7]赵天云,刘新成.老年股骨转子部骨折三种不同手术方法的比较[J].中国骨与关节损伤杂志,2005,20(6):417.

[8]胥少汀,葛宝丰,徐印坎.实用骨科学[M].2版,北京:人民军医出版社.2004:348.

[9]Harris WH.Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation.J Bone Joint Surg Am. 1969;51(4):737-755.

[10]CNKI.中国知网[DB/OL].2014-01-21.https://www.cnki.net

[11]万方数据库.万方医学网[DB/OL]. 2014-01-21. https://med.wanfangdata.com.cn

[12]Medline.Pubmed[DB/OL]. 2014-01-21. http://www.ncbi .nlm.nih.gov /pubmed/

[13]Kaplan K, Miyamoto R, Levine BR, et al.Surgical management of hip fractures: an evidence-based review of the literature. II: intertrochanteric fractures.J Am Acad Orthop Surg.2008;16(11):665-673.

[14]罗红军,杜迎斌,何正宏.Gamma钉、动力髋螺钉、解剖形钢板3种固定物治疗老年股骨粗隆间骨折疗效分析[J].中华民康医学,2012,24(7):782-786.

[15]刘立胜,申才良.伽马钉与动力髋螺钉治疗股骨粗隆间骨折的临床疗效对比分析[J].中国当代医药,2013,20(19):16-17.

[16]赵正据,张柘.动力髋螺钉与伽马钉治疗股骨粗隆间骨折疗效分析[J].咸宁学院学报(医学版),2012,26(4):289-291.

[17]胡阿威,喻爱喜,夏成焱,等.四种内固定方法治疗老年股骨转子间骨折的对比研究[J].中华全科医师杂志,2013,12(3):185-188.

[18]刘家瑞.老年人股骨转子间骨折三种内固定方法临床对比分析[J].岭南现代临床外科,2010,109(2):104-106.

[19]Gotfried Y.The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures.Clin Orthop Relat Res.2004;(425):82-86.

[20]陆耀刚,王子平.不稳定股骨转子间骨折的治疗[J].实用骨科杂志,2006,12(1):63-64.

[21]王恩时,韩本松,曾炳芳,等.股骨粗隆间骨折Gamma钉和DHS内固定治疗比较[J].中国骨与关节损伤杂志,2008,23(5):413-415.

[22]Bhandari M, Schemitsch E, Jönsson A, et al.Gamma nails revisited: gamma nails versus compression hip screws in the management of intertrochanteric fractures of the hip: a meta-analysis.J Orthop Trauma.2009;23(6):460-464.

[23]Osnes EK, Lofthus CM, Falch JA, et al.More postoperative femoral fractures with the Gamma nail than the sliding screw plate in the treatment of trochanteric fractures.Acta Orthop Scand.2001;72(3):252-256.

[24]谢瑞卿,张绍安,徐向峰,等.不稳定性股骨转子间骨折治疗分析[J].骨与关节损伤杂志,2004,19(7):484-485.

[25]贾燕飞,冯卫,佟雁翔.三种内固定方法治疗老年股骨转子间骨折的比较[J].中华创伤骨科杂志,2011,13(2):130-134.

[26]邱贵兴.骨科学[M].北京:人民卫生出版社,2006:344.

[27]Kim JW, Oh CW, Byun YS, et al. A biomechanical analysis of locking plate fixation with minimally invasiveplate osteosynthesis in a subtrochanteric fracture model. J Trauma.2011;70(1):E19-23.

[28]朱海明.不同手术方式对股骨粗隆间骨折的疗效比较[J].临床和实验医学杂志,2009,8(3):47-48.

[29]林国兵,沈锋,洪志群,等.动力髋螺钉内固定治疗老年粗隆间骨折[J].中国矫形外科杂志,2007,15(14):1077-1078.

[30]郑晓东,陈建平.不同手术方法治疗股骨粗隆间骨折126例疗效分析[J].基层医学论坛,2011,15(1):510-512.

[31]冯孝志,周云,江建平,等.股骨转子间骨折3种内固定方法的疗效比较[J].临床骨科杂志,2013,16(4):425-427.

[32]邱桂斌,周春晖,赵金伟,等.Gamma钉内固定治疗股骨粗隆间骨折临床疗效[J].河北医学,2010,16(9):1043-1046.

[33]彭维波,农林,韦仁战,等.Gamma钉与动力;髋螺钉治疗股骨转子间骨折的Meta分析[J].中国组织工程研究与临床康复,2011, 15(43):8108-8111.

[34]刘阳,周伟,李家庚,等.DHS结合TSP治疗Evans ⅢB、lV型股骨粗隆间骨折[J].中国骨与关节损伤杂志,2008,23(3):252-253.