三种内固定方式治疗股骨粗隆下骨折的生物力学及临床研究

发布时间：2018-05-28 11:58

本文选题：股骨粗隆下骨折 + 动力髁螺钉　；参考：《承德医学院》2017年硕士论文

【摘要】：股骨粗隆下骨折约占髋部骨折的10%-34%,过去对股骨粗隆下骨折的研究相对来说较少。随着经济的发展,车辆的增多,髋部的暴力骨折逐渐增多,粗隆下骨折逐年增加,对其研究也逐渐增加。基础研究通常包括股骨粗隆下的生理解剖、内固定物的生物力学性能以及内固定物的材料,内固定物与骨的相互作用的研究等。临床研究一般包括内固定物的选择,手术的方式方法,术中的复位,术中出血量,以及术后骨折的愈合、功能康复评估,骨折及术后影像学评估。在骨科领域,医师最注重的就是内固定材料的类型和品质。因为不同的内固定物直接影响手术的时间、术中出血量,术后的骨折愈合,后期的康复锻炼以及并发症的出现。整体来说股骨粗隆下骨折的内固定材料分为髓内固定和髓外固定两类,其中髓外固定材料常用的有股骨近端解剖钢板(Proximal Femoral Anatomic Plate)、动力髋螺钉(Dynamic Hip Sctew,DHS)、动力髁螺钉(Dynamic Condylar Screw,DCS)、锁定钢板(Locking Compression Plate,LCP)等,髓内固定材料常用的有Gamma钉、股骨近端带锁髓内钉(Proximal Femoral Nail,PFN)、股骨近端防旋髓内钉(Proximal Femoral Nail Antirotation,PFNA)等,某些内固定材料在接受临床检验的过程中,由于自身的缺陷,逐渐被淘汰,现在临床上应用最多的是动力髁螺钉(DCS)、股骨近端防旋髓内钉(PFNA)。由美国公司推出的最新一款髓内固定系统股骨近端交锁髓内钉(InterTan)也逐渐应用于临床治疗。早期国内外许多期刊、杂志对股骨粗隆下骨折使用PFNA、DHS临床效果报道较多,近年来,DCS、InterTan的临床应用报道也逐渐增加,但目前关于InterTan、PFNA、DCS三种内固定材料应用于股骨粗隆下骨折综合比较评价的临床报道较少,生物力学上的优劣的报道就更罕见了。三种内固定方式无论生物力学还是临床治疗效果谁优谁劣,还没有明确的定论。因此,设计本次研究,从生物力学角度和临床角度综合评价三种固定方式优缺点,从而为临床内固定物的选择提供理论依据和指导。第一部分三种内固定方式治疗股骨粗隆下骨折的生物力学研究目的:通过生物力学实验探究动力髁螺钉(dynamiccondylarscrew,dcs)、股骨近端防旋髓内钉(proximalfemoralnailantirotation,pfna)、股骨近端交锁髓内钉(intertan)应用于股骨粗隆下骨折的轴向抗压及抗扭转能力。方法:54根猪股骨全长标本制成股骨粗隆下骨折(seinsheimer分型Ⅲa、Ⅲb、Ⅳ型,每型18根)模型,每型骨折分为a组、b组、c组后分别给予dcs、pfna、intertan固定,进行轴向加压非破坏实验、扭转实验最后进行轴向加压破坏实验。结果:轴向加载非破坏实验(同等压力下,股骨头下沉位移mm):(1)Ⅲa、Ⅳ型骨折:c组、b组小于a组(p0.05),c组和b组接近(p0.05);(2)Ⅲb:c组小于b组、a组(p0.05),b组和a组相当(p0.05);扭转实验(扭转相同的角度),扭矩(n·m)三型骨折均为:c组大于b组(p0.05),b组大于a组(p0.05);轴向加载破坏最大载荷,三型骨折均为:c组大于b组(p0.05),b组大于a组(p0.05)。结论:股骨粗隆下骨折,intertan、pfna轴向抗压能力及稳定性优于dcs,且intertan轴向稳定性优于pfna;抗扭转能力intertan优于pfna,pfna优于dcs。第二部分三种内固定方式治疗股骨粗隆下骨折的临床对比研究目的:从临床应用角度探究动力髁螺钉(dynamiccondylarscrew,dcs)、股骨近端防旋髓内钉(proximalfemoralnailantirotation,pfna)、intertan内固定系统等三种不同的方式应用于股骨粗隆下骨折的优缺点。方法:从2014年12月至2015年12月保定市第二医院收治的股骨粗隆下骨折的患者有109例,使用dcs、pfna、intertan固定的分别为47例、42例、20例,将他们的入院病例,以及术后0.5、1、2、3、6、12个月的随访结果进行统计分析,将患者从手术开始(注意不是进入手术室的时间)到结束时的时间,术中出血量、切口长度收集,去除差异显著的,然后计算平均值。将患者骨折愈合的时间、去拐可以完全负重的时间,这1年出现的各种并发症(包括术后感染、髋内翻、髋关节畸形、内固定物断裂等),以及病人自身的感受(用Harris评分标准进行评价)进行统计分析,去除差异显著的计算平均值。将这些平均值进行统计学分析。结果:同类型骨折:使用InterTan和PFNA固定的病人的手术时间,出血量、切口长度、骨折的愈合时间、完全负重时间的均值以及术后并发症的发生率都小于使用DCS固定的病人(P0.05),使用InterTan和PFNA固定的病人的Harris评分高于使用DCS固定的病人(P0.05);使用InterTan固定的病人在的术后并发症的发生率小于使用DCS、PFNA固定的病人(P0.05);使用InterTan固定的病人的Harris评分高于使用PFNA固定的病人(P0.05);使用InterTan和PFNA固定的病人在手术时间,出血量、切口长度、骨折的愈合时间、完全负重时间的均值上的差异无统计学意义(P0.05)。结论:对于绝大多数股骨粗隆下骨折的病人使用InterTan固定的效果优于PFNA,使用PFNA固定的效果优于DCS。
[Abstract]:The subtrochanteric fracture of the femur accounts for about 10%-34% of the hip fracture. In the past, the study of the femoral subtrochanteric fracture was relatively less. With the development of the economy, the increase of the vehicle, the increase of the violent fracture of the hip, the increase of the subtrochanteric fracture year by year, and the increase in its research. The basic research usually includes the physiological anatomy of the trochanter and internal fixation. Biomechanical properties and internal fixation materials, internal fixation materials, internal fixation and bone interaction. Clinical studies generally include the selection of internal fixations, methods of operation, intraoperative reduction, intraoperative bleeding, postoperative fracture healing, functional rehabilitation assessment, fracture and postoperative imaging evaluation. In Department of orthopedics, medicine The most important thing is the type and quality of the internal fixation material. Because different internal fixators directly affect the time of operation, the amount of intraoperative bleeding, the healing of the fracture after the operation, the later rehabilitation exercises, and the occurrence of complications. The internal fixation materials of the femoral subtrochanteric fracture are divided into two types, intramedullary fixation and extramedullary fixation. Proximal Femoral Anatomic Plate, dynamic hip screw (Dynamic Hip Sctew, DHS), dynamic condylar screw (Dynamic Condylar Screw, DCS), locking plate, etc., are commonly used in fixed materials. L, PFN), the proximal femoral nail (Proximal Femoral Nail Antirotation, PFNA). Some internal fixation materials are gradually eliminated because of their own defects in the process of clinical examination. Now, the most widely used clinical application is the dynamic condylar screw (DCS) and the proximal femoral anti rotation intramedullary nail (PFNA). The interlocking intramedullary interlocking intramedullary nail (InterTan) of the proximal femur of the internal fixation system is also gradually applied to clinical treatment. Many periodicals at home and abroad have used PFNA for the femoral subtrochanteric fracture, and the clinical effect of DHS has been reported more. In recent years, the clinical application of DCS and InterTan has gradually increased, but there are three internal fixation materials for InterTan, PFNA, DCS. There are few clinical reports on the comprehensive comparative evaluation of subtrochanteric fracture of the femur. The report on biomechanics is more rare. There is no definite conclusion on the three internal fixation methods, no matter who is superior to the biomechanics or the clinical treatment effect. Therefore, this study is designed to evaluate three kinds of solid from the mechanical and clinical perspectives. In order to provide theoretical basis and guidance for the selection of clinical fixtures, the biomechanical study of three internal fixation methods in the treatment of subtrochanteric fractures in the first part: dynamiccondylarscrew (DCS), and proximal femoral intramedullary nail (proximalfemoralnailantirotat Ion, PFNA), the axial compression and anti torsional ability of proximal femoral interlocking intramedullary nail (intertan) for subtrochanteric fracture of the femur. Methods: 54 total femur femur specimens were made into subtrochanteric fracture of femur (seinsheimer type III A, III B, type IV, and each type 18). Each type of fracture was divided into a group, B group, and C group, respectively, DCS, PFNA, intertan fixed, into intertan, into intertan fixed, into intertan, into intertan fixed, into intertan. Axial compression non destructive experiment and axial compression failure experiment at last. Results: axial loading non destructive test (under the same pressure, femoral head subsidence mm): (1) III A, type IV fracture: Group C, group B less than group A (P0.05), C group and B group (P0.05); (2) III b:c group is less than B group, a group and group equivalent; torsion real The torsion (n m) type three fractures were all: Group C was greater than group B (P0.05), group B was larger than group A (P0.05), axial loading destroyed the maximum load, and type three fracture was greater than B group (P0.05), B group was greater than that of group (P0.05). Qualitatively superior to PFNA; anti torsional ability intertan is superior to PFNA, and PFNA is superior to dcs. second in three internal fixation methods for the treatment of subtrochanteric fracture of the femur. Objective: To explore the dynamic condylar screw (dynamiccondylarscrew, DCS), proximal femoral intramedullary nail (proximalfemoralnailantirotation, PFNA), intertan within the clinical application. Methods: 109 cases of femoral subtrochanteric fractures were treated from December 2014 to December 2015 in second hospitals in Baoding City, 109 cases were treated with DCS, PFNA, and intertan fixation in 47 cases, 42 cases, 20 cases, their hospitalization cases, and 0.5,1,2,3,6,12 after operation. The results of the month's follow-up were statistically analyzed, and the patients from the operation began (notice not the time in the operation room) to the end of the operation, the amount of bleeding, the length of the incision was collected, the difference was statistically significant, and the average value was calculated. The time of the patient's fracture healing was completely weighed, and the complications occurred in the 1 years. Including postoperative infection, coxa varus, hip joint deformity, internal fixation fracture, and patient's own feelings (evaluated by Harris scoring criteria) for statistical analysis and removal of significant calculated mean values. These mean values were statistically analyzed. Results: the same type of fracture: the operation of patients with InterTan and PFNA fixation. The amount of bleeding, the length of the incision, the time of the healing of the fracture, the mean time of complete weight loading, and the incidence of postoperative complications were less than that of patients with DCS fixation (P0.05). The Harris score of patients with InterTan and PFNA fixation was higher than that of DCS fixed patients (P0.05); the postoperative complications of InterTan fixed patients were observed. The rate less than DCS and PFNA fixed (P0.05); the Harris score of patients with InterTan fixation was higher than that of PFNA fixed patients (P0.05); there was no significant difference in the mean difference between the time of operation time, the amount of bleeding, the length of the incision, the healing time of the fracture, the time of complete weight loading with the InterTan and PFNA fixed patients (P0.05). For most patients with femoral subtrochanteric fracture, the effect of InterTan fixation is better than that of PFNA, and the effect of PFNA fixation is better than DCS..
【学位授予单位】：承德医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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