Gamma nail and dynamic hip screw for the treatment of femoral trochanteric fractures 200435 Shanghai Zhabei District Shibei Hospital Department of Orthopaedics Xu Yongqiang Wang Longbin Wang Yonglu Shanghai Sixth People's Hospital orthopedics Jiang Jianxin elderly osteoporosis patients are prone to peritrochanteric fractures. Early surgical treatment has been widely accepted. It not only reduces the mortality rate, but also significantly reduces the number of complications caused by prolonged bed rest. At present, there are many surgical methods. From August 1996 to March 2001, our hospital used Gamma nail and dynamic hip screw (DHS) to treat 63 cases of femoral trochanteric fractures. The results were satisfactory. The report on the clinical application is summarized as follows.
1 Materials and Methods 11 General information The whole group of 63 patients, of which 18 patients underwent Gamma nail fixation and 45 patients underwent DHS internal fixation. According to Evans classification: 8 cases of type 1 , 15 cases of type 11 , 26 cases of Ilk type, 4 cases of melon type, 10 cases of type 1 and type 1 of type W belong to stable fracture, 111 and W type belong to unstable fracture. Gamma nail group: patients aged 51-86 years, mean 76 years old, including 8 males and 10 females; 4 stable fractures, 14 unstable fractures; average operation time 104min, average length of incision 13cm, average blood transfusion volume 212ml DHS group: patients aged 41 to 88 years, mean 72 years old, 26 males and 19 females; 5 stable fractures, 40 unstable fractures; average operation time of 125 minutes, average length of incision 15cm, average blood transfusion volume of about 425ml 1.2 Surgical methods Both operations were performed with continuous epidural anesthesia. The patient was placed in the supine position. The C-arm X-ray monitoring underwent the open or closed reduction DHS using the surgical procedure recommended by AO111. Gamma nails refer to the surgical procedure recommended by Grosse.
1.3 postoperative treatment for patients with stable fractures, the knee can be extended and flexed in the knee and hip after surgery, and muscle relaxation training. After 2 weeks, I will not take the weight off the bed and take full weight in about 3 months. Unstable fractures are generally extended by about 1 month to bed and full weight-bearing time.
2 Results A total of 58 patients were followed up. The fractures all healed. The DHS group was followed up for 6 to 50 months, with an average of 20 months and 4 cases of hip varus. According to the evaluation criteria of joint function proposed by Huang Gongyi et al. in 1984, 40 patients (93%) with excellent joint function died in hospital in the DHS group, and died of fat embolism. 1 case of lag screw and perineal pressure sore, the average hospitalization time was 25.1dGamma nail group followed up for 4~27 months, average 14 months, 1 case of hip varus, the excellent rate of joint function was 93.3%. Gamma nail One group had a femoral neck base fracture in 1 case, and a lag screw was used to cut the femoral neck in 1 case. The average hospitalization was 23.2d3. 3.1 Biomechanical characteristics DHS treatment of femoral trochanteric fractures has been adopted in many hospitals at home and abroad. It is a thick lag screw in the direction of the head and neck of the femur. The tip of the nail has a thick thread, the tail end has a sliding groove, and the side is a sleeve steel plate. The lag screw slides in the sleeve to have the dual functions of pressure and sliding. When the fracture end is compressed, the screw can retreat along the nail tail, avoiding complications such as the nail tip penetrating the femoral head.
Gamma nails have also been developed as a new alternative in recent years and are a tough intramedullary nail. Since the Gamma nail is located in the femoral shaft of the femur, it is closer to the inside than the standard DHS. Therefore, the patient's weight is transmitted closer to the femoral distance than DHS, which enhances the mechanical strength of the implant. Tests have shown that the failure load of the Gamma nail is the highest, reaching 5 000 N1*'. In addition, from the mechanical analysis, for the subtrochanteric fracture involving the medial cortical comminution, the Gamma nail avoids the need for anatomical reconstruction of the fracture, thus benefiting the anti-oblique rotor. Treatment of fractures or subtrochanteric fractures. Due to the above advantages, in the early 1990s, Gamma nails became a treatment commonly used in Europe and the United States. And in the early reports, 100% success was achieved |451, no fixation failure and non-healing cases occurred.
3.2 Complications The incidence of complications of DHS is about 3% to 15%. The main reason is that the lag screw is cut from the femoral head or neck, the screw is withdrawn, the plate is broken, and the hip is deformed. The lag screw cut is mainly related to the positional deviation, and is also related to poor reduction, neck dry angle reduction and senile osteoporosis, hip varus activity and screw material process. One patient in this group died of fat embolism 3 days after surgery, which was associated with poor general condition, large surgical trauma and long operation time. The perineal pressure sore occurs because the length of the procedure is long, and the traction force is too large to cause the perineum. The hip varus deformity is related to the bone defect of the femur and the fixation instability. This group had no screw withdrawal and other complications such as infection.
The Gamma nail has a good clinical effect, but it also has the following complications: 1 The proximal femoral fracture occurs when the Gamma nail is inserted. This iatrogenic fracture is a major complication during surgery. One case of this group was a one-year traumatic femoral neck fracture and a subtrochanteric fracture of the femur. After removing three threaded needles, it was fixed with Gamma nails. Due to the bone defect left by the previously threaded needle, the proximal bone The quality is loose, and the reaming is close to the medial side, resulting in a fracture of the base of the femoral neck. In order to prevent this iatrogenic fracture, the piriform fossa should be avoided when reaming, and the proximal femoral cavity should be at least 2mm larger than the intramedullary nail used. Absolutely prohibit violence, such as using a hammer or the like. The inner nail is inserted and the intramedullary nail must be inserted by hand. Leung et al.|6 developed the Asian-type Gamma nail and moved the lag screw hole 10mm to the distal end. At the same time, the surgical technique was improved, and the complications of reaming surgery were reduced by only 7.7%|7L and the proximal femur was significantly osteoporotic. It is best not to use this nail in patients with thinner medullary cavities. 2 lag screw is cut out in the femoral head and neck. This group cut 1 case from the femoral neck. The Gamma nail was used to move the lag screw to the femoral distance, thus reducing the incidence of lag screw detachment above the 173 intramedullary nail distal locking screw or nail tail fracture. Lacroix et al.18 confirmed by mechanical tests that when the bone cone drilled the lateral femoral cortex, it often caused cracks in the lateral cortical bone.
This type of crack on the X-ray film is not seen in most cases due to the presence of intramedullary nails, thus potentially contributing to the cause of the fracture. In addition, the mechanical load is transmitted down the Gamma nail and concentrated at the nail tail at the femoral shaft, which may also result in a femoral shaft fracture at the distal end of the intramedullary nail. For these reasons, Stapert et al. developed an extended Gamma nail that is suitable for many fractures of the proximal femur. The lengthened intramedullary nail significantly reduces the stress near the femoral trochanteric region, and there is no orphan increase in the mid-section of the femoral condyle with 5 micro-nails and nails combined with the medullary technique. And standard intramedullary nails.
The efficacy of 3.3Gamma nail and DHS The average length of hospital stay, postoperative complications and functional recovery of the femoral trochanteric fractures were similar. The Gamma nail treatment group was generally smaller than the DHS group, with a shorter operation time and less damage and bleeding. Bridle (1991) compared this nail with DHS (100 cases each). There was no significant difference between the two groups in terms of operation time, bleeding volume, wound complications, hospitalization time, and discharge status. We believe that the tibial tuberosity should be pulled before surgery, which is beneficial to ensure that the fracture end of the operation is as close as possible to the anatomical reduction, which is conducive to the internal fixation. The use of DHS in a transorbital or subtrochanteric fracture without medial support is prone to internal fixation failure. Care must be taken to either reconstruct the medial branch structure or the medial cancellous bone capping to induce early bone formation. Gamma nails can avoid the need for anatomical reconstruction of the fracture, and the scope of indications for DHS is expanded. Both of them can achieve satisfactory results in the treatment of fractures around the femoral trochanter. Different fixation methods should be selected according to the type of fracture, the condition of the surgical equipment, and the proficiency of the doctor. As a new technology, Gamma nail is a recommended treatment because of its simple operation, reliable fixation and small surgical damage.
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