MENG XIANFENG1, WU LIN1, Д. С. БОБРОВ2, WANG XINYUE3, CUI ZHENGLI1
1центральная Больница Месторождения Нефти «Шэн Ли»
2первый Московский Государственный Медицинский Университет Имени И. М. Сеченова, Москва 3народная Больница Города Дун Ин
Целью данной работы было оценить эффективность и целесообразность использования проксимального бедренного деротационного штифта (PFNA) при лечении пожилых пациентов с межвертельными переломами бедренной кости.
Метод: Проведен анализ лечения 35 пожилых пациентов с межвертельными переломами бедренной кости с использованием малоинвазивного остеосинтеза проксимальны бедренным деротационным штифтом (PFNA) в период с сентября 2013 по апрель 2015 года.
Результаты: Проведен анализ результатов лечения 35 пациентов в период 6 и более месяцев с момента операции. Полнове восстановление функции поврежденной конечности без укорочения, смещения и несращения получено у всех 35 пациентов. У 30 пациентов получен отличный, у 5 хороший результат лечения.
Заключение: Использование технологии остеосинтеза межвертельных переломов будренной кости проксимальным бедренным антиротационным штифтом у пожилых пациентов можно назвать идеальным методом. К преимуществам метода можно отнести простоту оперативного пособия, небольшой доступ, отсутсвие интраоперационной травмы мягих тканей, быстрое восстановление, малое количество осложнений и высокая удовлетворенность пациентов результатами проведенного лечения.
Ключевые слова: малоинвазивность, проксимальный бедренный штифт, межвертельные переломы бедренной кости, интрамедуллярный остеосинтез.
Intertrochanteric fracture is a common fracture in the elderly, and the discussions on its treatment is very necessary for the early recovery of limb functions, reducing the trauma and the complications caused by prolonged bed rest and improving the quality of life. Due to osteoporosis, minor violent movements such as falls can cause fractures in the elderly. With the aging of the population in the society, there has been an increased incidence of femoral intertrochanteric fractures, (Ruecker, et al) , which is expected to double in 25 years. If not treated properly a er fracture, the conditions will seriously a ect the quality of life of the elderly patients, even endanger lives. According to the report in 1994 by Xu Jigang, among the 438 cases of femoral intertrochanteric fracture, the case fatality rate (CFR) of traction therapy was 6.1%, while the CFR of surgical treatment was 0.9%. erefore, currently, the clinical treatment for femoral intertrochanteric fractures is mainly surgical treatment for better e cacy and lower CFR.  ere a numerous various methods of the surgical treatment, and the close reduction combined with PFNA intramedullary xation has become the common practice clinically because of its bio-mechanical and technological advantages.
35 cases of di erent types of femoral intertrochanteric fractures in senile people were admitted and treated with PFNA in our hospital from September 2013 to April 2015, and the results were satisfactory.
1.1 General information: in the 35 cases of this study, 12 cases were male and 23 were female, with the average age of 78.6 years old (65-88 years old). e types of the fractures were divided with AO Classi cation of Fractures : AO Type Al-2 cases, A2.1-5 cases, A2.24 cases, A2.320 cases, A34 cases; also 10 cases with complications: high blood pressure10 cases, diabetes 3 cases. e reasons of the fractures included falling (25 cases) and being twisted (10 cases), in which 3 cases were combined with wrist fracture. All the cases were performed with elective surgery, and the operation time was generally within 3-7 days a er the injury, averagely 3.5 days.
1.2 Surgical methods: the cases with good cardiopulmonary function (30 cases) were performed with general anesthesia, and the cases with poor cardiopulmonary function and normal blood coagulation (5 cases) were given combined spinal-epidural anesthesia (CSEA). In this procedure, a er e ective anesthesia, each patient was in supine position on the orthopedic traction and surgery bed with proper traction. e injured limb was put in middle vertical position with inclination of 150 °. With the guidance of C-arm X-ray, the incision point, location and incision size were determined. A er the observation of the relocation conditions, a er satisfactory relocation, the injured limb was then xed. A er routine sterilization, with surgical drape on the patient, the vertical incision of approximately 3cm was cut 5cm proximal from the vertex of the greater trochanter, the layers were then separated, and the fascia lata was cut open. With the index nger touching and locating the vertex, and place the 3.2mm guiding needle into the femoral medullary cavity with the vertex as the entry point, con rmed with the adem position X-ray. Along the direction of the guiding needle, the proximal medullary cavity was expanded with the mating expansion device (diameter: 17mm). en the main nail of PFNA with the right diameter was inserted into the medullary cavity. A er adjustment of the depth of the main nail, drill the guiding needle in with the anteversion angle of 150°. A er con rming good location of the guiding needle at the lower 1/3 inferior the femoral head from the front and 1/2 in the femoral neck from the lateral view. A er the length of spiral blade required was measured, the right spiral blade was selected, inserted and xed. e distal xation sighting device was then installed. According to the conditions of the fracture, the distal xation screw nail was xed with static or dynamic of distal xation. For the cases of fracture of femoral sha on the same side with dissatisfactory traction treatment and obvious dislocation, a small incision was cut in the fracture part of the femoral sha to relocate the femoral sha with temporal xation. en the previous surgical procedures were performed. For the similar cases with satisfactory fraction treatment, the incision should not be performed, and the patients should be given PFNA main nail with the guiding needle directly. With the guidance of C-arm X-ray, the PFNA location was con rmed to be good, the tip cap was then installed, and the wound was rinsed and sutured layer by layer.
1.3 Postoperative process: the patients were given 24h routine postoperative infection prevention treatment. On the day3, the patients presented pain reduction and started limb function exercises in bed. Patients with better recovery cold start early activities on the oor. A er 1 month, all the patients could perform activities on the oor step by step, until the full weight-bearing.
Of all the 35 cases in this study group, the average incision size was 3cm (2.5-4cm), and the average operative time was 50min (45min-1.5h), and the average intraoperative bleeding was 150ml (100-200ml). All the patients presented primary healing of the surgical wounds, and were discharged day 12 postoperatively. ere were no cases of death, deep vein thrombosis or exacerbation of cardio-cerebral diseases. e average follow-up period was 8 months (6-12 months), and the patients all presented bone healing with no shortening or malunion, no blade withdrawal or femoral cut. According to Huang Gongyi’s Evaluation Standards , 30 cases presented excellent recovery, and 5 cases were good recovery, and the rate of good recovery was 100%.
There has been a common agreement on the treatment for femoral intertrochanteric fracture: if there is no absolute contraindication, active surgical treatment should be performed. Currently, there are 2 types of surgical treatments for intertrochanteric fracture: extramedullary and intramedullary xations. e previous method is represented by the application of dynamic hip screw (DHS), while the latter is mainly characterized by proximal femoral nail (PFN). DHS is better for stable fractures, while PFN is applicable for the severe comminuted unstable fractures. Because the bio-mechanical features of the PFN system are consistent with the biological loading line to support the majority load through the proximal femur, especially the inside. With the reduction of the compression stress of the femoral calcar area and the internal migration of the arm of force, the tension stress and compression stress at the junction of the nail is signi cantly reduced with a smaller stress shielding, so as to facilitate the healing of the fracture.
There are also some shortcomings of PNF:
1. it’s di cult to insert 2 parallel screws correctly into the femoral neck, and 2 screws can cause bone degeneration with the risk of femoral head necrosis;
2. the screw nails in the femoral neck need bigger diameter of the drilling holes with more bone damage, therefore the patients with severe osteoporosis would have poor and unstable xation;
3. the screws in the femoral neck may cause the Zigzag e ect and then the failure of the internal xation;
4. the intramedullary PFN nails with bigger radian and length are not applicable in patients with severe anterior arch of the femoral sha . PFNA is the improvement and replacement product of PFN, and its main advantage is that the stability and resistance to rotation of the xed part is achieved by the special design of spiral blades, and is applicable to various types of proximal femoral intertrochanteric fractures .
We also have the following experiences and understanding in this study:
1. the preoperative C-arm X-ray to locate the entry point can e ectively reduce the size of the incision, hence to reduce the bleeding;
2. e key procedure is to insert the main nail into the medullary cavity: locating the vertex of the greater trochanter with the guiding needle under X-ray, all in the middle of the medullary cavity front and laterally with the con rmation of the X-ray, with the expansion along the guiding needle, as well as with the patient inclination of 150°; with all these points to facilitate the procedure, the main nail can be inserted smoothly;
3. e surgeons should have mental preparation for the size of the medullary cavity before the operation, with the narrow medullary cavity during the insertion of the main nail, and the process cannot be forced through to avoid the splintered intertrochanteric-femoral sha fracture and the failure of the operation. In this situation, the main nail should be changed into one with smaller diameter with more expansion of the cavity;
4. Apply proper smooth spiral force with a small torsion during the entry of the screw blades, generally there is no risk of separation of dislocation of the femoral head and neck; if any concern, the Kirschner wire can be used for temporal xation to control the rotation;
5. e operational procedures should be followed strictly with constant observation of the location of the xations under X-ray during the operation; e blades should be xed rmly a er insertion, the internal xation will be failed if there is any withdrawal.
1. Ruecker Ah, Rupprecht M, Gruber M, et al . e treatment of intertrochanteric fractures results using an intrameduary nail with integrated cephalocervical screws and linear compression. J Orthop Trauma 2009,23: 22 30.
2. Xu Jigang. Analysis of Curative E ect of Intertrochanteric Fractures (On 438 Case Reports) Chinese Journal of Orthopaedics 1994, 14: 150 152.
3. Park SY. Yang Kh, Yoo Jh, et al. e treatment of reverse obliguity intertrochanteric fractures with the intramedullary hip nail . J Trauma 2008, 65: 852 857.
4. Zhou Qing, Shen Yun, Comparison on the Two Intramedullary Fixations for Intertrochanteric Fractures, Chinese Journal of Orthopaedic Trauma, 2005,78: 730 733.
5. Wang Manhuan, Yang Qingming, Zeng Bingfang, et al, AO Principles of Fracture Management M. Beijing: Huaxia Publishing House,2003:441 444.
6. huang Gongyi, Wang Fuquan. Curative E ect of DHS Treatment for Femoral Intertrochanteric Fractures, J, Chinese Journal of Orthopaedics , 1984,4(6):349 353.
7. Wu Kejian, hou Shuxun, Practical Orthopedic Fixation Techniques. Beijing: People’s Military Doctor Press. 2007: 1081 1093.
Информация об авторах:
Мэн Шиань Фэн – Центральная Больница месторождения нефти «шэн Ли». Заместитель деректра отделения травматологии и ортопедии. Травматолог и ортопед. Место работыул Цзинань, No.38, Дун Ин, КНР. firstname.lastname@example.org
Бобров Дмитрий Сергеевич – ГБОУ ВПО Первый МГМУ имени И.М. Сеченова, кафедра травматологии, ортопедии и хирургии катастроф. Кандидат медицинских наук, доцент. Место работы – 2-й Боткинский проезд, д.5. email@example.com
Ван Шинь Юэ – Народная Больница г. Дун Ин, КНР. Нефролог. Место работыул. Нань И, No.317, Дун Ин, КНР. Wang.firstname.lastname@example.org
Цуй Чжэн Ли – Центральная Больница месторождения нефти «шэн Ли». Заместитель деректра отделения травматологии и ортопедии. Травматолог и ортопед. Место работыул. Цзинань No.38, Дун Ин, КНР. email@example.com
SMALL INCISION PFNA FOR THE TREATMENT OF FEMORAL INTERTROCHANTERIC FRACTURES
MENG XIANFENG, WU LIN, D. S. BOBROV, WANG XINYUE, CUI ZHENGLI
Shengli Oil eld Central Hospital Sechenov First Moscow State Medical University, Moscow Dong Ying People’s Hospital
Information about the authors:
Meng Xian Feng – Shengli Oil eld Central Hospital. Associate Chief Physician of traumatic orthopeidics department. Doctor of traumatic orthopedics.Workplce – Ji Nan road, No.38, Dong ying, China. firstname.lastname@example.org
Bobrov Dmitry Sergeevich – I.M.Sechenov First Moscow State Medical University. e Department of Traumatology, Orthopedics and Disaster Surgery. PhD, Assistant professor of the Department. Workplace 2nd Botkinsky fare, 5. email@example.com
Wang Xin Yue – Dong ying People’s Hospital. Doctor of nephrologue. Workplace-Nan yi road, No.317,Dong ying,China Wang. firstname.lastname@example.org
Cui Zheng Li – Shengli Oil eld Central Hospital. Chief Physician of traumatic orthopeidics department. Doctor of traumatic orthopedics. Workplce – Ji Nan road No.38, Dong ying, China. email@example.com
Objective To explore the method and the e cacy of small incision proximal femoral nail antirotation (PFNA) in the treatment of senile femoral intertrochanteric fractures. Method 35 cases of elderly patients with femoral intertrochanteric fracture treated with small incision PFNA from September 2013 to April 2015 were selected and compared in this study. Results With the follow-up period of at least 6 months, the 35 cases in this study presented complete recovery, with no bone shortening, dislocation or malunion. 30 cases presented excellent recovery, and 5 cases were good recovery, and the rate of good recovery was 100%. Conclusion PFNA is an ideal method of treatment for senile femoral intertrochanteric fracture, because of the advantages of simple operation, small incision, less injury, quick recovery, less complications and good curative e ect satisfaction.
Key words: small incision; minimally invasive; PFNA; femoral intertrochanteric fracture; internal xation.