本文選題：股骨粗隆下骨折 + 動(dòng)力髁螺釘�。� 參考：《承德醫(yī)學(xué)院》2017年碩士論文

【摘要】：股骨粗隆下骨折約占髖部骨折的10%-34%,過去對(duì)股骨粗隆下骨折的研究相對(duì)來說較少。隨著經(jīng)濟(jì)的發(fā)展,車輛的增多,髖部的暴力骨折逐漸增多,粗隆下骨折逐年增加,對(duì)其研究也逐漸增加。基礎(chǔ)研究通常包括股骨粗隆下的生理解剖、內(nèi)固定物的生物力學(xué)性能以及內(nèi)固定物的材料,內(nèi)固定物與骨的相互作用的研究等。臨床研究一般包括內(nèi)固定物的選擇,手術(shù)的方式方法,術(shù)中的復(fù)位,術(shù)中出血量,以及術(shù)后骨折的愈合、功能康復(fù)評(píng)估,骨折及術(shù)后影像學(xué)評(píng)估。在骨科領(lǐng)域,醫(yī)師最注重的就是內(nèi)固定材料的類型和品質(zhì)。因?yàn)椴煌膬?nèi)固定物直接影響手術(shù)的時(shí)間、術(shù)中出血量,術(shù)后的骨折愈合,后期的康復(fù)鍛煉以及并發(fā)癥的出現(xiàn)。整體來說股骨粗隆下骨折的內(nèi)固定材料分為髓內(nèi)固定和髓外固定兩類,其中髓外固定材料常用的有股骨近端解剖鋼板(Proximal Femoral Anatomic Plate)、動(dòng)力髖螺釘(Dynamic Hip Sctew,DHS)、動(dòng)力髁螺釘(Dynamic Condylar Screw,DCS)、鎖定鋼板(Locking Compression Plate,LCP)等,髓內(nèi)固定材料常用的有Gamma釘、股骨近端帶鎖髓內(nèi)釘(Proximal Femoral Nail,PFN)、股骨近端防旋髓內(nèi)釘(Proximal Femoral Nail Antirotation,PFNA)等,某些內(nèi)固定材料在接受臨床檢驗(yàn)的過程中,由于自身的缺陷,逐漸被淘汰,現(xiàn)在臨床上應(yīng)用最多的是動(dòng)力髁螺釘(DCS)、股骨近端防旋髓內(nèi)釘(PFNA)。由美國公司推出的最新一款髓內(nèi)固定系統(tǒng)股骨近端交鎖髓內(nèi)釘(InterTan)也逐漸應(yīng)用于臨床治療。早期國內(nèi)外許多期刊、雜志對(duì)股骨粗隆下骨折使用PFNA、DHS臨床效果報(bào)道較多,近年來,DCS、InterTan的臨床應(yīng)用報(bào)道也逐漸增加,但目前關(guān)于InterTan、PFNA、DCS三種內(nèi)固定材料應(yīng)用于股骨粗隆下骨折綜合比較評(píng)價(jià)的臨床報(bào)道較少,生物力學(xué)上的優(yōu)劣的報(bào)道就更罕見了。三種內(nèi)固定方式無論生物力學(xué)還是臨床治療效果誰優(yōu)誰劣,還沒有明確的定論。因此,設(shè)計(jì)本次研究,從生物力學(xué)角度和臨床角度綜合評(píng)價(jià)三種固定方式優(yōu)缺點(diǎn),從而為臨床內(nèi)固定物的選擇提供理論依據(jù)和指導(dǎo)。第一部分三種內(nèi)固定方式治療股骨粗隆下骨折的生物力學(xué)研究目的:通過生物力學(xué)實(shí)驗(yàn)探究動(dòng)力髁螺釘(dynamiccondylarscrew,dcs)、股骨近端防旋髓內(nèi)釘(proximalfemoralnailantirotation,pfna)、股骨近端交鎖髓內(nèi)釘(intertan)應(yīng)用于股骨粗隆下骨折的軸向抗壓及抗扭轉(zhuǎn)能力。方法:54根豬股骨全長標(biāo)本制成股骨粗隆下骨折(seinsheimer分型Ⅲa、Ⅲb、Ⅳ型,每型18根)模型,每型骨折分為a組、b組、c組后分別給予dcs、pfna、intertan固定,進(jìn)行軸向加壓非破壞實(shí)驗(yàn)、扭轉(zhuǎn)實(shí)驗(yàn)最后進(jìn)行軸向加壓破壞實(shí)驗(yàn)。結(jié)果:軸向加載非破壞實(shí)驗(yàn)(同等壓力下,股骨頭下沉位移mm):(1)Ⅲa、Ⅳ型骨折:c組、b組小于a組(p0.05),c組和b組接近(p0.05);(2)Ⅲb:c組小于b組、a組(p0.05),b組和a組相當(dāng)(p0.05);扭轉(zhuǎn)實(shí)驗(yàn)(扭轉(zhuǎn)相同的角度),扭矩(n·m)三型骨折均為:c組大于b組(p0.05),b組大于a組(p0.05);軸向加載破壞最大載荷,三型骨折均為:c組大于b組(p0.05),b組大于a組(p0.05)。結(jié)論:股骨粗隆下骨折,intertan、pfna軸向抗壓能力及穩(wěn)定性優(yōu)于dcs,且intertan軸向穩(wěn)定性優(yōu)于pfna;抗扭轉(zhuǎn)能力intertan優(yōu)于pfna,pfna優(yōu)于dcs。第二部分三種內(nèi)固定方式治療股骨粗隆下骨折的臨床對(duì)比研究目的:從臨床應(yīng)用角度探究動(dòng)力髁螺釘(dynamiccondylarscrew,dcs)、股骨近端防旋髓內(nèi)釘(proximalfemoralnailantirotation,pfna)、intertan內(nèi)固定系統(tǒng)等三種不同的方式應(yīng)用于股骨粗隆下骨折的優(yōu)缺點(diǎn)。方法:從2014年12月至2015年12月保定市第二醫(yī)院收治的股骨粗隆下骨折的患者有109例,使用dcs、pfna、intertan固定的分別為47例、42例、20例,將他們的入院病例,以及術(shù)后0.5、1、2、3、6、12個(gè)月的隨訪結(jié)果進(jìn)行統(tǒng)計(jì)分析,將患者從手術(shù)開始(注意不是進(jìn)入手術(shù)室的時(shí)間)到結(jié)束時(shí)的時(shí)間,術(shù)中出血量、切口長度收集,去除差異顯著的,然后計(jì)算平均值。將患者骨折愈合的時(shí)間、去拐可以完全負(fù)重的時(shí)間,這1年出現(xiàn)的各種并發(fā)癥(包括術(shù)后感染、髖內(nèi)翻、髖關(guān)節(jié)畸形、內(nèi)固定物斷裂等),以及病人自身的感受(用Harris評(píng)分標(biāo)準(zhǔn)進(jìn)行評(píng)價(jià))進(jìn)行統(tǒng)計(jì)分析,去除差異顯著的計(jì)算平均值。將這些平均值進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果:同類型骨折:使用InterTan和PFNA固定的病人的手術(shù)時(shí)間,出血量、切口長度、骨折的愈合時(shí)間、完全負(fù)重時(shí)間的均值以及術(shù)后并發(fā)癥的發(fā)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評(píng)分高于使用DCS固定的病人(P0.05);使用InterTan固定的病人在的術(shù)后并發(fā)癥的發(fā)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評(píng)分高于使用PFNA固定的病人(P0.05);使用InterTan和PFNA固定的病人在手術(shù)時(shí)間,出血量、切口長度、骨折的愈合時(shí)間、完全負(fù)重時(shí)間的均值上的差異無統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:對(duì)于絕大多數(shù)股骨粗隆下骨折的病人使用InterTan固定的效果優(yōu)于PFNA,使用PFNA固定的效果優(yōu)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..
【學(xué)位授予單位】：承德醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3

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