股骨转子间不稳定型骨折内固定物的选择

摘要

Femoral intertrochanteric fracture,accounting for about 50％ of hip fractures,is one of the common fracturein elderly patients and arguably the most important public health problem faced by orthopedic surgeons.Early surgical interventions,which are of benefit to early restoring limb function and reducing post-operative complications,have gradually become the optimal solution to treating femoral intertrochanteric fractures.Intramedullary andextramedullary fixation methods are two of the widely used techniques for surgical interventions.The dynamic hip screw (DHS) had been considered the standard fixation devicefor treating stable femoral intertrochanteric fractures.For unstable femoral intertrochanteric fractures,early reports suggested somesubstantial advantages in association with intramedullary devices,including a minimally invasive surgical technique,shortened operating times,improved biomechanics,greater stability of fixation,earlier patient mobilization and shorter lengths of stay.In the last 10 years we have also seen the introduction,increasing acceptance and use of the proximal femoral locking compression plate (PFL-CP) in preference to the DHS,for the treatment of unstable femoral intertrochanteric fractures.It could provide angular stable plate and optimal fixation of highly unstable fractures associated with greater sheafing and pull-out forces.However,the optimal fixation method of treating unstable femoral intertrochanteric fractures remains controversial.For the unstable femoral intertrochanteric fracture,intramedullary fixation has superiority in the biomechanics,because it more closes to the center of gravity and its force arm is shorter.Intramedullary nail can resistthe conductive stress along with calcar femoral well and can prevent the femoral shaft ingression.As the intramedullary nail provides more stability and allows for earlier weight bearing than the PFLCP when used for the treatment of unstable intertrochanteric fractures of the femur.While PFLCP are associated with a high complication rate,so intramedullary nailing was more beneficial for patients with an unstable femoral intertrochanteric fracture.%股骨转子间骨折是最为常见的老年骨质疏松性骨折,约占老年髋部骨折的1/2,其中不稳定型骨折占老年髋部骨折的50％.对于稳定型转子间骨折,滑动髋螺钉操作简便,固定坚实可靠,临床效果普遍满意,仍是手术治疗的金标准,髓内钉固定并无明确优势.而当治疗不稳定型转子间骨折时,髓内钉因髓内中心固定力臂较短且可早期承受更大负荷,已经广泛用于治疗不稳定型转子间骨折;近10年来,可提供角稳定性和内支架作用的股骨近端锁定钢板,也逐渐应用于治疗不稳定型转子间骨折并取得不错的临床效果.目前关于不稳定型转子间骨折如何合理选择固定方式,以加速术后康复、减少并发症和死亡率等方面的相关文献报道很多,且结论不尽相同一直存在争议,因此手术内固定物的选择和策略也见仁见智.对于不稳定型股骨转子间骨折,髓内固定系统在生物力学上具有优势,力臂较短更靠近重心,能更可靠的对抗沿股骨距传导的应力,并可防止股骨干内移,且临床效果相对满意和稳定,术后内植物相关并发症低.股骨近端锁定钢板因放置于股骨外侧导致力臂明显加长,术后早期负重活动存在内固定变形、断裂、骨折移位、髋内翻畸形等风险,存在相对较高的并发症发生率,且手术时间相对较长、组织剥离创伤大,增加术中失血量.因此对于不稳定型股骨转子间骨折的治疗,应主要根据患者的骨折形态类型,并综合考虑患者年龄、健康状况、骨质疏松情况及经济状况等,来制定最佳治疗方案,更符合人体生物力学特点的髓内固定应作为首选,对于股骨近端锁定钢板需谨慎使用.