pfna粗隆間骨折治療實(shí)用教案

1、Background股骨粗隆間骨折是老年人的常見(jiàn)病 美國(guó)發(fā)病率為0.034% 瑞典發(fā)病率為0.035% 中國(guó)老齡化，發(fā)病率不低于以上數(shù)字 Reference:雍宜民雍宜民. 實(shí)用骨科臨床實(shí)用骨科臨床M . 北京北京(bi jn): 科學(xué)技術(shù)文獻(xiàn)出版社科學(xué)技術(shù)文獻(xiàn)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(yè)/共36頁(yè)第一頁(yè)，共37頁(yè)。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?yàn)榕P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(guān)節(jié)損傷雜志骨與關(guān)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(yè)/共36頁(yè)第二頁(yè)，共37頁(yè)。Classification31 - A 3232：股骨干 3131：股骨

4、近端3131：股骨遠(yuǎn)端31 B31 B：關(guān)節(jié)囊內(nèi)的股骨頸骨折：關(guān)節(jié)囊內(nèi)的股骨頸骨折31 A31 A：關(guān)節(jié)囊外的轉(zhuǎn)子間骨折：關(guān)節(jié)囊外的轉(zhuǎn)子間骨折31 A31 A：關(guān)節(jié)囊內(nèi)的股骨頭骨折：關(guān)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(yè)/共36頁(yè)

5、第三頁(yè)，共37頁(yè)。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(jiǎn)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(jiǎn)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(yè)/共36頁(yè)第四頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第五頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第六頁(yè)，共37頁(yè)。 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(yè)/共36頁(yè)第七頁(yè)，共37頁(yè)。l年齡、健康狀況l骨的質(zhì)量(zhling)l骨折的幾何力學(xué)影響(yngxing)治療的因素l 復(fù)位復(fù)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(zhǔn)確的準(zhǔn)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(yè)/共36頁(yè)第八頁(yè)，共37頁(yè)。4早期完全負(fù)重早期完全負(fù)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(jiǎn)單操作簡(jiǎn)單對(duì)骨折能進(jìn)行動(dòng)力加壓對(duì)骨折能進(jìn)行動(dòng)力加壓置置入內(nèi)植物時(shí)避免造成醫(yī)源性骨折入內(nèi)植物時(shí)避免造成醫(yī)源性骨折保護(hù)骨的血供保護(hù)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(yè)/共36頁(yè)第九頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第十頁(yè)，共37頁(yè)。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(lèi)第11頁(yè)/共36頁(yè)第十一頁(yè)，共37頁(yè)。股骨(g

13、g)近端骨折生物力學(xué)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(yè)/共36頁(yè)第十二頁(yè)，共37頁(yè)。ddm = F x d m = F x d 股骨(gg)近端骨折生物力學(xué)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(yè)/共36頁(yè)第十三頁(yè)，共37頁(yè)。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(dòng)力加壓雙重功能4. 使骨折緊密結(jié)合，促進(jìn)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(yè)/共36頁(yè)第十四頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第十五頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第十六頁(yè)，共37頁(yè)。股骨頸長(zhǎng)度變短，肢體短縮股骨頸長(zhǎng)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(xiàn)位于骨折線(xiàn)位于DHS 進(jìn)針處時(shí)也不適用進(jìn)針處時(shí)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(wèn)題第17頁(yè)/共36頁(yè)第十七頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第十八頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第十九頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第二十頁(yè)，共37頁(yè)。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?chē)钦壑械膽?yīng)用股骨近端髓內(nèi)釘在股骨轉(zhuǎn)子周?chē)钦壑械膽?yīng)用. 中國(guó)骨與關(guān)節(jié)損傷雜志中國(guó)骨與關(guān)節(jié)損傷雜志, 2005, 20(4): 246-248.6. 姜磊姜磊, 等等. 閉合復(fù)位閉合復(fù)位PFN治療高齡股骨粗隆間骨折的體會(huì)治療高齡股骨粗隆間骨折的體會(huì). 中國(guó)骨與關(guān)節(jié)損傷雜志中國(guó)骨與關(guān)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(yīng)用在股骨粗隆間骨折中的應(yīng)用. 中國(guó)骨與關(guān)節(jié)損傷雜志中國(guó)骨與關(guān)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(guó)骨與關(guān)節(jié)損傷雜志中國(guó)骨與關(guān)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(guó)骨與關(guān)節(jié)損傷雜志中國(guó)骨與關(guān)節(jié)損傷雜志, 2008, 23(12): 1015-1017. 第21頁(yè)/共36頁(yè)第二十一頁(yè)，共37頁(yè)。1. 一個(gè)部件即完成了抗旋轉(zhuǎn)及成角穩(wěn)定性一個(gè)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?chē)琴|(zhì)，尤其是在末端寬大的刀面盡可能多的壓縮周?chē)琴|(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(qiáng)了穩(wěn)定性，防螺旋刀片和骨質(zhì)貼合緊密，增強(qiáng)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(xué)試驗(yàn)證明生物力學(xué)試驗(yàn)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(yè)/共36頁(yè)第二十二頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第二十三頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第二十四頁(yè)，共37頁(yè)。骨科( k)牽引床123骨

28、折基本或部分閉合復(fù)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(yè)/共36頁(yè)第二十五頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第二十六頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第二十七頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第二十八頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第二十九頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第三十頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第三十一頁(yè)，共37頁(yè)。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(yè)/共36頁(yè)第三十二頁(yè)，共37頁(yè)。Discussion生物力學(xué)：髓內(nèi)系統(tǒng)固定生物力學(xué)：髓內(nèi)系統(tǒng)固定