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    股骨近端髓內PFN治療股骨粗隆下骨折
    關鍵字:治療,EF,GH,CD,AB,wx,yz,IJ,KL,ST, 發布時間:2011-08-20

    論著?臨床論壇 CHJNESSCoM¨u~}TYDOCTOPs 股骨近端髓內PFN治療股骨粗隆下骨折 張暉 462000河南漯河醫學高等專科學校第三 附屬醫院骨科 摘要目的:探討股骨近端髓內釘治療 股骨粗隆間骨折的臨床療效及其相關問 題。方法:回顧性分析采用PFN治療的 22例股骨粗隆問骨折患者的術后骨折愈 合及并發癥情況。結果:均得到隨訪:隨 訪時間平均10個月,骨折全部愈合,功能 恢復按黃公怡標準,優8例,良12例,可2 例,優良率85%。結論:PFN具有內固定 牢固、應力分散、防旋轉功能強、手術操作 簡單等優點。 關鍵詞股骨粗隆下骨折PFN系統治 療 doi:10.3969/j.issn.1007—614x.2010. 26.00l 資料與方法 本組老年股骨轉子間骨折22例中, 男16例,女6例;年齡22~78歲,平均 41.3歲。致傷原因:機動車撞傷8例,跌 摔傷9例,墜落傷3例,重物砸傷2例。 按Seinheimer氏5型分類方法:Ⅱ型4 例,Ⅲ型9例,Ⅳ型5例,V型4例。 手術方法:手術開始前半小時使用抗 生索。手術采取連續硬膜外麻醉,患者取 健側臥位。轉子外側縱形小切口顯露骨 折處,清理斷端及嵌壓的軟組織,對骨折 端附近的軟組織不予剝離,保留骨膜的完 整性。直視下骨折復位,顯銘大轉子頂 點,用定位導針從大轉子尖端內側進入到 股骨中上交界處,然后用開口器鉆孔,患 者平臥于骨科牽引床上,c形臂x線機透 視下行牽引閉合復位,透視復位滿足后, 于大粗隆頂端作長約5em切口,剝離四 周肌肉后觸及大轉子,在其頂點偏內側以 開髓器開口后,不擴髓直接將卡釘推入髓 腔,在大粗隆下緣,經定位器和套管打人 2枚導針,經股骨頸進入股骨頭內,電視 透視滿足后,經導向器擰入近端拉力螺釘至 股骨頭關節面下0.5cm,再擰入防旋螺釘, 使其末端與拉力螺釘及大粗隆頂點在一條 直線上,同理擰入兩枚遠端交鎖螺釘。 結果 手術時間75~135分鐘,平均100分 鐘,術中出血60一lOOmJ,平均80ml。本 組切I:l均一期愈合,無感染及下肢靜脈血 栓形成。l例PFN近端鎖釘穿破股骨頸, 術后患髖活動度良好,骨折愈合后2個月 拆除內固定物,功能恢復良好。3例位置 稍高,l例位置偏低但均未穿破皮質。負 重時間最早為3天,最晚12周,經l一1.5 年隨訪,骨折全部愈合,其中ll例已取出 內同定,患肢活動功能滿意。無骨折不愈 合或髖內翻,無斷釘及折斷等并發癥發 生。 討論 PFN的手術適應證:PFN固定適應股 骨轉子間各種類型骨折,特別是對骨質疏 松的老年人,內固定物在早期活動和負重 時不易退出,符合生物力學要求,r口r降低 髖內翻發生幾率。早期負重功能練習,可 以改善髖天節功能,減少并發癥的發生, 降低病死率,尤其對粉碎型骨折,不易造 成骨折塌陷,肢體縮短。 PFN設計特點:首先,采用股骨頸內 雙釘承載,具有平衡、防旋轉、穩定的功 能。其次,增加鎖釘孔與釘尾的距離,并 將鎖孔改為橢圓彤,允許縱向滑動,最大 限度地減小應力集中。第三,該髓內釘的 直徑減小,較細的釘體無須在髓腔內廣泛 擴髓,減少了出血及脂肪栓塞等并發癥的 發生。第四,近端llcm處有1個6的外 翻角,與股骨的解剖形態相符,使主釘能 順利插入髓腔。 防止術中股骨近端骨折和術后股骨 骨折:因老年人骨質較脆,PFN內固定術 中和術后有發生粗隆間骨折加重及般骨 近端骨質劈裂的危險。其多為操作不當 所致。故術中選準進釘點,以免t釘位置 不佳,導致術中進釘闌難和主釘插入后與 股骨的生理前弓不吻合,增加股骨骨折的 危險。同時,插釘前要充分擴髓,操作動 作要輕柔,均可避免發生股骨粗隆問及股 骨十劈裂。 穩定的復位是維持內固定效果的必 要條件。有人通過實驗表明穩定的復位 同時行內固定要比單純內固定物本身的 強度增加30%。獲得穩定的復位,術前、 術中必須充分牽引,術中C臂機透視,必 要時于骨折斷端作小切口輔助復位,盡可 能少破壞斷端四周血運情況。 髓腔開口應足夠大,使PFN進入髓 腔時可用手推入,避免用鐵錘擊入髓內釘 可能發生變形,與體外定位發生誤差,導 致鎖釘進入困難,延長操作時間;股骨中 段外側星弧形,鉆頭打孑L時易使導向套管 偏離中心位置,因此術中應扶好導向器, 避免導向失準以致鎖釘放置失敗。 預防螺釘退出或切割股骨頭:老年人 有不同程度的骨質疏松,拉力螺釘在股骨 頭頸內把持力較差,尤其嚴鶯粉碎性骨 折,負重時拉力螺釘有切割股骨頭或脫出 的可能。因此,手術定位要準確,置人拉 力螺釘需一次成功,避免更改釘道,導致 螺釘固定不牢。拉力螺釘應與股骨頸平 行且靠近股骨距,側位與股骨頸平行且位 于其中心,尖端達股骨頭軟骨下約 0.5cm,即堅硬的軟骨下骨內,增強同定 牢固程度。骨質疏松較重或粉碎性骨折 者,適當延遲下床及負重,嚴密隨訪,定期 復查x線片。 控制髖內翻畸形:髖內翻足各種方法 治療股骨粗隆問骨折常見并發癥之一。 小粗隆郎骨折,使內側弓骨皮質缺損,力 學支撐破壞,有發生髖內翻的趨勢,大粗 隆部粉碎性骨折,進一步加重矢狀面不穩 定,同時,如卞釘人釘點偏外,常推擠股骨 頭頸,導致髖內翻及骨折移位術后易出現 髖內翻畸形。術中插入主釘后注意透視 頸f角是否正常,如不正常,應進行相應 調整,必要時將患肢適度外展,避免髖內 翻位打入股骨頸螺釘,術中骨折復位應注 意糾正股骨頭頸的旋轉。粉碎性骨折患 者術后應延遲負蘑和限制老年人臥位的 髖內收活動,町減少或減輕髖內翻畸形的 發生。本組3例5。~10。的內翻和1例 10。一150的內翻,占19%。但一般認為< 10。的髖內翻是可以接受的。 術后處理:首先,要繼續控制內科疾 患;其次,加強護理,防止發,董褥瘡、墜積 性肺炎等并發癥;第三,指導并督促患者 進行功能鍛煉,降低下肢深靜脈血栓形 成、髖膝關節僵硬及肌肉萎縮等并發癥的 發生;第四,對骨質疏松明顯及不穩定的 患者,術后患肢過早負蕈會大大增加手術 失敗的可能,應根據患者的年齡、骨折類 型、骨質疏松情況及X線片骨痂生長情 況決定F地行走的時間。 綜上所述,本同定有系統操作簡便、抗 旋轉確實,更符合生物力學,固定牢靠,手術 創傷小、H{血少,臨床并發癥少等特點。由 于堅強的內同定使患者町以早期進行功能 鍛煉,降低骨折并發癥的發生率。 參考文獻 l董紀元,李困宏,胡永成,等.老年人股骨轉 子問骨折圍丁.術期的治療分析.中華骨科 雜志,2000,20(8):476—479. 2王亦璁.骨與關節損傷.北京:人民衛生出 版社。2001:867—868. 3郝世忠,郭向東.PFN治療股骨轉子間骨折 45例.中國骨與關節損傷雜志,2005,20: 698. 70中國社區醫師?E判k20lo年第26期<J12卷總第251期) 萬方數據 換頁

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