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1、PFNAPFNA治疗股骨粗隆骨折治疗股骨粗隆骨折Background股骨粗隆间骨折是老年人的常见病股骨粗隆间骨折是老年人的常见病 美国发病率为美国发病率为0.034% 瑞典发病率为瑞典发病率为0.035% 中国老龄化，发病率不低于以上数字中国老龄化，发病率不低于以上数字 Reference:雍宜民雍宜民. 实用骨科临床实用骨科临床M . 北京北京: 科学技术文献出版社科学技术文献出版社, 1999: 188-198.Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Scien
2、ces Background Background 病死率较高，大约病死率较高，大约10%20%在骨折后在骨折后1年内死亡年内死亡主要死因为卧床后出现的内科并发症主要死因为卧床后出现的内科并发症有心血管疾病和高龄患者的病死率比其他人高一倍有心血管疾病和高龄患者的病死率比其他人高一倍 References:Canale ST, Beaty JH. Campbells Operative Orthopaedics M. 9th ed. Harcourt: Mosby, 1998: 2182-2199.张庆明张庆明, 沈惠良沈惠良, 雍宜民雍宜民, 等等. 经皮钛合金空心钉治疗高龄老年人粗隆间骨折经
3、皮钛合金空心钉治疗高龄老年人粗隆间骨折. 骨与关节损伤杂志骨与关节损伤杂志, 2002, 17(5) : 332-334. Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences ClassificationClassification31 - A 32：股骨干：股骨干 31：股骨近端：股骨近端31：股骨远端：股骨远端31 B：关节囊内的股骨颈骨折：关节囊内的股骨颈骨折31 A：关节囊外的转子间骨折：关节囊外的转子间骨折31 A：关节囊内的股骨头骨折：关节囊内的股
4、骨头骨折AODepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences A 1A 2A 331-ADepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Classification - AOClassification - AOA1：顺粗隆间简单的两部分骨折，内侧有良好的骨皮质支撑：顺粗隆间简单的两部分骨折，内侧有良好的骨皮质支撑A2：
5、粗隆间粉碎性骨折，内侧和后方破裂，外侧骨皮质完好：粗隆间粉碎性骨折，内侧和后方破裂，外侧骨皮质完好A3：外侧骨皮质破裂，逆转之间骨折：外侧骨皮质破裂，逆转之间骨折Classification - AOClassification - AODepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences A1A2A331 A2/331 A2/331 A 131 A 1稳定的骨折稳定的骨折稳定的骨折稳定的骨折不稳定的骨折不稳定的骨折不稳定的骨折不稳定的骨折 Background
6、 Background 手手 术术 治治 疗疗保守治疗保守治疗保守治疗保守治疗牵引牵引牵引牵引保守治疗保守治疗保守治疗保守治疗防旋鞋防旋鞋防旋鞋防旋鞋Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences l年龄年龄、健康状况、健康状况l骨的质量骨的质量l骨折的几何力学骨折的几何力学影响治疗的因素影响治疗的因素l 复位复位l 内植物的选择内植物的选择l 内植物的准确放置内植物的准确放置不可控制因素不可控制因素可控制因素可控制因素4早期完全负重早期完全负重在骨质疏松
7、骨有很好的抓持力在骨质疏松骨有很好的抓持力操作简单操作简单对骨折能进行动力加压对骨折能进行动力加压置置入内植物时避免造成医源性骨折入内植物时避免造成医源性骨折保护骨的血供保护骨的血供216345Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 理想的内植物所需的条件理想的内植物所需的条件18541854LangenbeckLangenbeck18781878TrendelenburgTrendelenburg19071907DelbetDelbet19251
8、925Smith-PetersenSmith-Petersen19321932Johannsen/JerusalemJohannsen/Jerusalem19341934MooreMoore19371937ThortonThorton19401940Kntscher: fem.neck nailKntscher: fem.neck nail19421942BrittainBrittain19501950LeziusLezius19521952JewettJewett19541954Kntscher: Y-nailKntscher: Y-nail19551955PohlPohl19551955P
9、ugh-MassiePugh-Massie19551955EnderEnder19651965AO: angled blade platesAO: angled blade plates19671967KntscherKntscher19671967Simon-Weidner/EnderSimon-Weidner/Ender19671967ZickelZickel19701970Teubner: double T plateTeubner: double T plate19801980AO: DHSAO: DHS19881988Kempf : Kempf : Gamma-NailGamma-N
10、ail19961996Friedl: gliding nailFriedl: gliding nail1996 1996 AO: PFNAO: PFN股骨近端骨折内植物使用的历史Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 髓内固定髓内固定髓内固定髓内固定髓外固定髓外固
11、定髓外固定髓外固定l l Proximal Femoral Nail ( PFN ) Proximal Femoral Nail ( PFN )l l Gamma - Nail Gamma - Naill l Intramedullary Hip Screw Intramedullary Hip Screwl l ACE - Nail ACE - Naill l 股骨髁角钢板股骨髁角钢板股骨髁角钢板股骨髁角钢板l l DHS, CHS, DCS DHS, CHS, DCS股骨近端骨折股骨近端骨折内植物分类内植物分类股骨近端骨折生物力学正常情况下正常情况下Department of Orthop
12、edics , Guangdong General Hospital, Guangdong Academy of Medical Sciences ddm = F x d m = F x d 股骨近端骨折生物力学Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 1. DHS1. DHS是最具代表性的髓外钉板系统是最具代表性的髓外钉板系统是最具代表性的髓外钉板系统是最具代表性的髓外钉板系统2. 2. 适合于大多数股骨粗隆间骨折适合于大多数股骨粗隆间骨折适合于大
13、多数股骨粗隆间骨折适合于大多数股骨粗隆间骨折 3. 3. 静力加压与动力加压双重功能静力加压与动力加压双重功能静力加压与动力加压双重功能静力加压与动力加压双重功能4. 4. 使骨折紧密结合，促进骨折愈合使骨折紧密结合，促进骨折愈合使骨折紧密结合，促进骨折愈合使骨折紧密结合，促进骨折愈合 Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Dynamic Hip Screw - DHSDepartment of Orthopedics , Guangdong G
14、eneral Hospital, Guangdong Academy of Medical Sciences Dynamic Hip Screw - DHSDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Dynamic Hip Screw - DHS股骨颈长度变短，肢体短缩股骨颈长度变短，肢体短缩 1粉碎性不稳定骨折，后内侧骨质缺损粉碎性不稳定骨折，后内侧骨质缺损 2骨折线位于骨折线位于DHS 进针处时也不适用进针处时也不适用 3Department of
15、 Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences DHS手术存在的问题DHS失败病例Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences DHS失败病例Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences DHS失败病例
16、Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 31A1：DHS31A2：PFN31A3：PFNDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 1. Boldin C, et al. The proximal femoral nail (PFN)-a minimal invasive treatment of unst
17、able proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand, 2003, 74: 53-58.2. Flahiff CM, et al. A biomechanical evaluation of an intramedullary fixation device for intertrochanteric fractures. J Trauma, 1993, 35: 23-27.3. Sadowski C, et al.
18、 Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or 95 screw- plate. J Bone Joint Surg(Br), 2002, 84: 372- 381.4. 张经纬张经纬, 等等. 股骨转子间骨折不同手术方法比较股骨转子间骨折不同手术方法比较.中华骨科杂志中华骨科杂志, 2005, 25: 7- 11. 5. 卢华定卢华定, 等等. 股骨近端髓内钉在股骨转子周围骨折中的应用股骨近端髓内钉在股骨转子周围骨折中的
19、应用. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2005, 20(4): 246-248.6. 姜磊姜磊, 等等. 闭合复位闭合复位PFN治疗高龄股骨粗隆间骨折的体会治疗高龄股骨粗隆间骨折的体会. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2006, 21(1): 59-60.7. 祝敬华祝敬华, 等等. DHS与与PFN在股骨粗隆间骨折中的应用在股骨粗隆间骨折中的应用. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2006, 21: 63-64.8. 范忠明范忠明, 等等. PFNA治疗老年股骨粗隆间骨折治疗老年股骨粗隆间骨折. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2009,
20、24(2): 151-153.9. 周建华周建华, 等等. PFNA治疗老年不稳定性股骨转子间骨折治疗老年不稳定性股骨转子间骨折. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2008, 23(12): 1015-1017. 1.一个部件即完成了抗旋转及成角稳定性一个部件即完成了抗旋转及成角稳定性 2.末端宽大的刀面尽可能多的压缩周围骨质，尤其是在末端宽大的刀面尽可能多的压缩周围骨质，尤其是在骨质疏松的情况下，具有更好的抓持力骨质疏松的情况下，具有更好的抓持力 3.PFNA螺旋刀片和骨质贴合紧密，增强了稳定性，防螺旋刀片和骨质贴合紧密，增强了稳定性，防止旋转和内翻畸形止旋转和内翻畸形 4.生物
21、力学试验证明生物力学试验证明: 螺旋刀片显著提高抗切出能力螺旋刀片显著提高抗切出能力PFNA 螺旋刀片螺旋刀片Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences PFN-A vs PFNCArm 必不可少Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 骨科牵引床Department of Orthopedics , Gua
22、ngdong General Hospital, Guangdong Academy of Medical Sciences 骨科牵引床123骨折基本或部分闭合复位骨折基本或部分闭合复位向健侧倾斜，掌握前倾角向健侧倾斜，掌握前倾角内收、内旋患肢，纠正畸形内收、内旋患肢，纠正畸形Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Department of Orthopedics , Guangdong General Hospital, Guangdong A
23、cademy of Medical Sciences Intraoperative 52 52 岁岁岁岁，男性，男性，男性，男性12 12 monthsmonthsDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Case 1邓邓X，Female，81YDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Case 2丁丁XX
24、，Male，74YDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Case 3Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Male，74YCase 5Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medica
25、l Sciences Male，81YCase 8Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Male，70YCase 9Discussion生物力学：髓内系统固定强度明显优于生物力学：髓内系统固定强度明显优于DHS 1术后可以早期下床活动术后可以早期下床活动 粗隆部粉碎性骨折，进针部骨质粉碎也适用粗隆部粉碎性骨折，进针部骨质粉碎也适用2PFNAReference:1.Flahiff CM, Nelson CL, Gruenwald JM, et al
26、. A biomechanical evaluation of an intramedullary fixation device for intertrochanteric fractures. J Trauma, 1993, 35: 23-27. 2.祝敬华祝敬华, 吴柏林吴柏林, 聂海洋聂海洋. DHS与与PFN在股骨粗隆间骨折中的应用在股骨粗隆间骨折中的应用. 中国骨与关节损伤杂志中国骨与关节损伤杂志, 2006, 21:63-64.Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 术中应注意正确的颈干角、前倾角术中应注意正确的颈干角、前倾角1螺钉退出、切割股骨头螺钉退出、切割股骨头2髋内翻畸形髋内翻畸形进钉点的选择进钉点的选择3Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences PFNA手术存在的问题
