pfna粗隆間骨折治療實用教案

1、Background股骨粗隆間骨折是老年人的常見病 美國發(fā)病率為0.034% 瑞典發(fā)病率為0.035% 中國老齡化，發(fā)病率不低于以上數(shù)字 Reference:雍宜民雍宜民. 實用骨科臨床實用骨科臨床M . 北京北京(bi jn): 科學技術(shù)文獻出版社科學技術(shù)文獻出版社, 1999: 188-198.Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, G

2、uangdong Academy of Medical Sciences 第1頁/共36頁第一頁，共37頁。Background 病死率較高，大約10%20%在骨折(gzh)后1年內(nèi)死亡主要死因為臥床后出現(xiàn)的內(nèi)科并發(fā)癥有心血管疾病和高齡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.張慶明張慶明, 沈惠良沈惠良, 雍宜民雍宜民, 等等. 經(jīng)皮鈦合金空心釘治療經(jīng)皮鈦合金空心釘治療(zhlio)高齡老年

3、人粗隆間骨折高齡老年人粗隆間骨折. 骨與關節(jié)損傷雜志骨與關節(jié)損傷雜志, 2002, 17(5) : 332-334. Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第2頁/共36頁第二頁，共37頁。Classification31 - A 3232：股骨干 3131：股骨

4、近端3131：股骨遠端31 B31 B：關節(jié)囊內(nèi)的股骨頸骨折：關節(jié)囊內(nèi)的股骨頸骨折31 A31 A：關節(jié)囊外的轉(zhuǎn)子間骨折：關節(jié)囊外的轉(zhuǎn)子間骨折31 A31 A：關節(jié)囊內(nèi)的股骨頭骨折：關節(jié)囊內(nèi)的股骨頭骨折AOAODepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第3頁/共36頁

5、第三頁，共37頁。A 1A 1A 2A 2A 3A 331-A31-ADepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Classification - AOA1：順粗隆間簡單的兩部分骨折，內(nèi)側(cè)有良好的骨皮質(zhì)支撐：順粗隆間簡單的兩部分骨折，內(nèi)側(cè)有良好的骨皮質(zhì)支撐A2：粗隆間粉

6、碎性骨折，內(nèi)側(cè)和后方破裂，外側(cè)骨皮質(zhì)完好：粗隆間粉碎性骨折，內(nèi)側(cè)和后方破裂，外側(cè)骨皮質(zhì)完好(wnho)A3：外側(cè)骨皮質(zhì)破裂，逆轉(zhuǎn)之間骨折：外側(cè)骨皮質(zhì)破裂，逆轉(zhuǎn)之間骨折第4頁/共36頁第四頁，共37頁。Classification - AODepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sci

7、ences A1A1A2A2A3A3第5頁/共36頁第五頁，共37頁。31 A2/331 A 131 A 1穩(wěn)定(wndng)的骨折不穩(wěn)定(wndng)的骨折第6頁/共36頁第六頁，共37頁。 Background 手 術(shù) 治 療保守(boshu)治療牽引保守(boshu)治療防旋鞋Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong

8、 Academy of Medical Sciences 第7頁/共36頁第七頁，共37頁。l年齡、健康狀況l骨的質(zhì)量(zhling)l骨折的幾何力學影響(yngxing)治療的因素l 復位復位l 內(nèi)植物內(nèi)植物(zhw)(zhw)的選擇的選擇l 內(nèi)植物內(nèi)植物(zhw)(zhw)的準確的準確放置放置不可控制因素不可控制因素可控制因素可控制因素第8頁/共36頁第八頁，共37頁。4早期完全負重早期完全負重在骨質(zhì)疏松骨有很好的抓持力在骨質(zhì)疏松骨有很好的抓持力操作簡單操作簡單對骨折能進行動力加壓對骨折能進行動力加壓置置入內(nèi)植物時避免造成醫(yī)源性骨折入內(nèi)植物時避免造成醫(yī)源性骨折保護骨的血供保護骨的血供216

9、345Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 理想(lxing)的內(nèi)植物所需的條件第9頁/共36頁第九頁，共37頁。1854Langenbeck1878Trendelenburg1907Delbet1925Smith-Petersen1932Johannsen/Je

10、rusalem1934Moore1937Thorton1940Kntscher: fem.neck nail1942Brittain1950Lezius1952Jewett1954Kntscher: Y-nail1955Pohl1955Pugh-Massie1955Ender1965AO: angled blade plates1967Kntscher1967Simon-Weidner/Ender1967Zickel1970Teubner: double T plate1980AO: DHS1988Kempf : Gamma-Nail1996Friedl: gliding nail1996 A

11、O: PFN股骨(gg)近端骨折內(nèi)植物使用的歷史Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第10頁/共36頁第十頁，共37頁。Department of Orthopedics , Guangdong General Hospital, Guangdong Acade

12、my of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 髓內(nèi)固定(gdng)髓外固定(gdng)l Proximal Femoral Nail ( PFN )l Gamma - Naill Intramedullary Hip Screwl ACE - Naill 股骨(g(gg g) )髁角鋼板l DHS, CHS, DCS DHS, CHS, DCS股骨近端骨折內(nèi)植物分類第11頁/共36頁第十一頁，共37頁。股骨(g

13、g)近端骨折生物力學正常正常(zhngchng)情況情況下下Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第12頁/共36頁第十二頁，共37頁。ddm = F x d m = F x d 股骨(gg)近端骨折生物力學Department of Orthopedics ,

14、Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第13頁/共36頁第十三頁，共37頁。1. DHS是最具代表性的髓外釘板系統(tǒng)2. 適合于大多數(shù)股骨粗隆間骨折 3. 靜力加壓與動力加壓雙重功能4. 使骨折緊密結(jié)合，促進骨折愈合 Department of Orthopedics , Guangdong General Hospit

15、al, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Dynamic Hip Screw - DHS第14頁/共36頁第十四頁，共37頁。Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Gu

16、angdong General Hospital, Guangdong Academy of Medical Sciences Dynamic Hip Screw - DHS第15頁/共36頁第十五頁，共37頁。Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Dynamic

17、 Hip Screw - DHS第16頁/共36頁第十六頁，共37頁。股骨頸長度變短，肢體短縮股骨頸長度變短，肢體短縮 1粉碎性不穩(wěn)定骨折，后內(nèi)側(cè)骨質(zhì)缺損粉碎性不穩(wěn)定骨折，后內(nèi)側(cè)骨質(zhì)缺損 2骨折線位于骨折線位于DHS 進針處時也不適用進針處時也不適用 3Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Med

18、ical Sciences DHS手術(shù)(shush)存在的問題第17頁/共36頁第十七頁，共37頁。DHS失敗(shbi)病例Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第18頁/共36頁第十八頁，共37頁。DHS失敗(shbi)病例Department of Orth

19、opedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第19頁/共36頁第十九頁，共37頁。DHS失敗(shbi)病例Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepart

20、ment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第20頁/共36頁第二十頁，共37頁。31A131A1：DHSDHS31A231A2：PFNPFN31A331A3：PFNPFNDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital,

21、 Guangdong Academy of Medical Sciences 1. Boldin C, et al. The proximal femoral nail (PFN)-a minimal invasive treatment of unstable 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 e

22、valuation of an intramedullary fixation device for intertrochanteric fractures. J Trauma, 1993, 35: 23-27.3. Sadowski C, et al. 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.

23、張經(jīng)緯張經(jīng)緯, 等等. 股骨轉(zhuǎn)子間骨折不同手術(shù)方法比較股骨轉(zhuǎn)子間骨折不同手術(shù)方法比較.中華骨科雜志中華骨科雜志, 2005, 25: 7- 11. 5. 盧華定盧華定, 等等. 股骨近端髓內(nèi)釘在股骨轉(zhuǎn)子周圍骨折中的應用股骨近端髓內(nèi)釘在股骨轉(zhuǎn)子周圍骨折中的應用. 中國骨與關節(jié)損傷雜志中國骨與關節(jié)損傷雜志, 2005, 20(4): 246-248.6. 姜磊姜磊, 等等. 閉合復位閉合復位PFN治療高齡股骨粗隆間骨折的體會治療高齡股骨粗隆間骨折的體會. 中國骨與關節(jié)損傷雜志中國骨與關節(jié)損傷雜志, 2006, 21(1): 59-60.7. 祝敬華祝敬華, 等等. DHS與與PFN在股骨粗隆間骨折

24、中的應用在股骨粗隆間骨折中的應用. 中國骨與關節(jié)損傷雜志中國骨與關節(jié)損傷雜志, 2006, 21: 63-64.8. 范忠明范忠明, 等等. PFNA治療老年股骨粗隆間骨折治療老年股骨粗隆間骨折. 中國骨與關節(jié)損傷雜志中國骨與關節(jié)損傷雜志, 2009, 24(2): 151-153.9. 周建華周建華, 等等. PFNA治療老年不穩(wěn)定性股骨轉(zhuǎn)子間骨折治療老年不穩(wěn)定性股骨轉(zhuǎn)子間骨折. 中國骨與關節(jié)損傷雜志中國骨與關節(jié)損傷雜志, 2008, 23(12): 1015-1017. 第21頁/共36頁第二十一頁，共37頁。1. 一個部件即完成了抗旋轉(zhuǎn)及成角穩(wěn)定性一個部件即完成了抗旋轉(zhuǎn)及成角穩(wěn)定性 2.

25、 末端寬大的刀面盡可能多的壓縮周圍骨質(zhì)，尤其是在末端寬大的刀面盡可能多的壓縮周圍骨質(zhì)，尤其是在骨質(zhì)疏松的情況下，具有更好的抓持力骨質(zhì)疏松的情況下，具有更好的抓持力 3. PFNA螺旋刀片和骨質(zhì)貼合緊密，增強了穩(wěn)定性，防螺旋刀片和骨質(zhì)貼合緊密，增強了穩(wěn)定性，防止旋轉(zhuǎn)和內(nèi)翻畸形止旋轉(zhuǎn)和內(nèi)翻畸形 4. 生物力學試驗證明生物力學試驗證明: 螺旋刀片顯著提高抗切出能力螺旋刀片顯著提高抗切出能力PFNA PFNA 螺旋螺旋(luxun)(luxun)刀片刀片Department of Orthopedics , Guangdong General Hospital, Guangdong Academy o

26、f Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences PFN-A vs PFN第22頁/共36頁第二十二頁，共37頁。CArm 必不可少(b b k sho)Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong Gener

27、al Hospital, Guangdong Academy of Medical Sciences 第23頁/共36頁第二十三頁，共37頁。骨科( k)牽引床Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第24頁/共36頁第二十四頁，共37頁。骨科( k)牽引床123骨

28、折基本或部分閉合復位向健側(cè)傾斜，掌握前傾角內(nèi)收、內(nèi)旋患肢，糾正畸形Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences 第25頁/共36頁第二十五頁，共37頁。Department of Orthopedics , Guangdong General Hospital, Guan

29、gdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Intraoperative 第26頁/共36頁第二十六頁，共37頁。52 歲歲，男性，男性(nnxng)12 monthsDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orth

30、opedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Case 1第27頁/共36頁第二十七頁，共37頁。鄧鄧X X，F(xiàn)emaleFemale，81Y81YDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Med

31、ical Sciences Case 2第28頁/共36頁第二十八頁，共37頁。丁XXXX，MaleMale，74Y74YDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences Case 3第29頁/共36頁第二十九頁，共37頁。Department of Orthopedics

32、, Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences MaleMale，74Y74YCase 5第30頁/共36頁第三十頁，共37頁。Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepart

33、ment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences MaleMale，81Y81YCase 8第31頁/共36頁第三十一頁，共37頁。Department of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical SciencesDepartment of Orthopedics , Guangdong General Hospital, Guangdong Academy of Medical Sciences MaleMale，70Y70YCase 9第32頁/共36頁第三十二頁，共37頁。Discussion生物力學：髓內(nèi)系統(tǒng)固定生物力學：髓內(nèi)系統(tǒng)固定