Abstract: [Objective] To observe the clinical efficacy of closed reduction and proximal femoral anti rotation intramedullary nail (PFNA) internal fixation in the treatment of intertrochanteric fractures of the femur, and to explore its surgical techniques. [Method] From April 2010 to January 2014, 32 cases of intertrochanteric fractures of the femur were treated with closed reduction and PFNA internal fixation. As a result, 32 cases in this group were followed up for 6-24 months, with an average of 18 months. Postoperative X-ray examination of the hip joint in both the anterior and lateral positions showed satisfactory reduction and fixation of the fracture. A patient with severe osteoporosis experienced local pain after surgery due to premature weight-bearing walking. A follow-up X-ray showed loose spiral blades. After bed rest and treatment with anti osteoporosis drugs, the fracture was delayed in healing. 31 cases of fractures all healed in one stage. At the last follow-up, the efficacy was evaluated based on Harris hip joint function score: 28 cases were excellent, 4 cases were good, and the excellent rate was 100%. Conclusion: Closed reduction with PFNA internal fixation for the treatment of intertrochanteric fractures of the femur has the advantages of minimal trauma, reliable fixation, anti rotation, anti cutting, allowing early hip joint function recovery exercise, effectively reducing mortality and complications, especially suitable for elderly patients who cannot tolerate long-term bed rest treatment.
Keywords: intertrochanteric fracture of femur; Proximal femoral anti rotation intramedullary nail; Internal fixation; Surgical techniques
Femoral intertrochanteric fractures are more common in the elderly, and surgical treatment is beneficial for early activity, promoting functional recovery, reducing mortality and complications. Therefore, in the absence of surgical contraindications, active surgical treatment should be performed. From April 2010 to January 2014, the author used closed reduction and proximal femoral anti rotation intramedullary nail (PFNA) internal fixation to treat 32 cases of intertrochanteric fractures of the femur, achieving satisfactory treatment results. The report is as follows:
1. Data and Methods
1.1 General Information
There were 32 cases in this group, including 24 males and 8 females; The age range is 62 to 83 years old, with an average of 69 years old. 14 cases on the left and 18 cases on the right. Causes of injury: 28 cases of falls, 2 cases of car accidents, and 2 cases of other injuries. All fractures are closed, and local pain, swelling, and loss of limb function occur after injury. The injured limb is shortened, and subcutaneous bruising can be seen on the outer side of the hip. All patients have standard hip scans taken
Joint anteroposterior and lateral X-ray examination. According to AO classification, there were 8 cases of A1 type, 18 cases of A2 type, and 6 cases of A3 type fractures. There were 2 cases with other fractures, 8 cases with hypertension, 5 cases with diabetes, and 3 cases with coronary heart disease. The time from injury to surgery is 1-7 days, with an average of 3 days.
1.2 Surgical Methods
After successful anesthesia, the patient is placed in a supine position with a wedge-shaped pad placed on the injured side of the lumbar and sacral region. The C-arm X-ray machine is used to perform satisfactory traction reduction (recovery of the neck angle in the upright position), and routine disinfection is performed to a distance from the knee joint and sterile single leg below the middle and lower segments. Make a longitudinal incision 3~5cm long above the great trochanter of the femur, cut the skin and subcutaneous tissue, electrocoagulation and hemostasis, cut the fascia lata along the incision line to expose the great trochanter of the femur, take the inner edge of the great trochanter tip at about 2 transverse fingers from the rear edge of the great trochanter as the needle entry point, use a pyramid to open along the direction of the femoral medullary cavity to the proximal end of the femur, insert the guide needle, fluoroscopy confirms that the guide needle is located in the femoral medullary cavity and far from the fracture end, use the medullary cavity file to properly expand the trochanter entrance, in case of medullary cavity stenosis, use the elastic drill to expand the medullary cavity, select a main nail with appropriate length and diameter to install it on the handle of the sight, and insert it along the direction of the guide needle In the medullary cavity of the proximal femur, adjust the anteversion angle after the fluoroscopy depth is appropriate (the insertion point of the spiral blade guide needle is on the outer midline of the proximal femur, the coronal plane of the femoral shaft is taken as the reference plane, and the anteversion angle is about 15 °), pull out the medullary cavity guide needle, Insert a guide needle into the femoral neck through the proximal locking sleeve of the sight, with the forward perspective guide needle located at the junction of the middle and lower one-third of the femoral neck. The tip of the guide needle points towards the center of the femoral head and just reaches 1cm below the cartilage surface of the femoral head. The standard lateral perspective guide needle is located on the midline of the femoral head neck, and a hollow drill is used to drill a hole along the direction of the guide needle (note that only the outer cortex of the femur is drilled). The selected spiral blade is inserted along the direction of the guide needle. After the position and length of the forward perspective spiral blade are satisfactory, drill a hole through the distal locking hole of the sight and insert one suitable length distal locking nail. Count the equipment and gauze, soak the incision in iodine disinfectant for 3 minutes, rinse it clean with physiological saline, and suture the incision layer by layer.
1.3 Postoperative Management
After surgery, symptomatic supportive treatment such as antibiotics and prevention of thrombosis should be applied. After anesthesia, patients are encouraged to take a semi recumbent position and perform early quadriceps stretching and contraction activities, ankle joint and toe flexion and extension exercises. After 3-5 days of postoperative incision pain relief, patients are guided to perform hip and knee joint functional exercises. Two weeks after surgery, the incision line is removed and the range of motion of the affected limb and hip joint is gradually increased. After discharge, X-ray films should be reviewed once a month. If the fixation is confirmed, walking with a crutch under the armpit can be considered after 2 months. After clinical healing of the fracture (X-ray examination shows good callus growth and blurred fracture line), it is generally possible to walk away from the axillary staff 6 months after surgery.
2. Results
32 cases in this group were followed up for 6-24 months, with an average of 18 months. The postoperative standard hip joint X-ray re examination showed satisfactory reduction and fixation of the fracture (Figure 1). A patient with severe osteoporosis experienced local pain due to premature weight-bearing walking after surgery, and the X-ray showed loose spiral blades. After bed rest and treatment with anti osteoporosis drugs, the fracture was delayed in healing. 31 cases of fractures all healed in one stage, without complications such as incision and lung infection, pressure ulcers, deep vein thrombosis, and hip inversion. At the last follow-up, the efficacy was evaluated based on Harris hip joint function score: 28 cases were excellent, 4 cases were good, and the excellent rate was 100%.
The picture shows X-ray images before and after closed reduction and PFNA internal fixation surgery for intertrochanteric fracture of femur
3. Discussions
3.1 Biomechanical Characteristics of Intertrochanteric Fractures of Femur
Older people have varying degrees of osteoporosis. When falling from a height or falling, the femur may experience different types of intertrochanteric fractures due to excessive abduction or adduction, or direct impact of external forces on the greater trochanter of the femur. Femoral intertrochanteric fractures can be classified into two types based on the integrity of the femoral distance: stable and unstable. According to the direction of the fracture line, they can be further divided into two types: the fracture line from the outer upper to the inner lower type (stable type: the femoral distance remains intact or still embedded; unstable type: the femoral distance has completely fractured and lost its stability); From the outer lower to the inner upper type, this type belongs to the unstable category. The biomechanical characteristics of unstable intertrochanteric fractures of the femur are:
① Inverted displacement
② Loss of support on the inner side
③ The outer side loses tension
④ Shortened injured limb
The principle and purpose of surgical treatment for intertrochanteric fractures of the femur is to restore the normal biological anatomical relationship between the femoral neck and the trochanter, which requires satisfactory reduction and strong internal fixation to allow for early functional recovery, exercise, and mobilization, reduce complications, and lower mortality rates.
3.2 Advantages of Closed Reduction and PFNA Internal Fixation in the Treatment of Femoral Intertrochanteric Fractures
The unique combination design of the main nail and spiral blade fully conforms to the local anatomical and physiological characteristics of the femoral trochanter. The PFNA main nail has a 60 ° external angle, making it easy to insert from the top of the femoral trochanter. The longest tip and groove design not only facilitates insertion but also avoids local stress concentration. The wide surface area of the spiral blade tip can effectively fill and compress bone, thereby obtaining good anchoring force, especially suitable for elderly osteoporosis patients, which can better prevent rotation, loosening, and femoral head cutting phenomena; PFNA is suitable for osteoporosis patients with various types of intertrochanteric and subchondral fractures of the femur, as well as combined femoral shaft fractures. The best indication for PFNA is unstable intertrochanteric fractures in elderly patients with osteoporosis [3]. Adopting closed reduction and intramedullary fixation for fractures results in minimal interference to the fracture ends and a high rate of fracture healing; The central intramedullary fixation shortens the force arm of the fixation nail, reduces the bending stress on the internal fixation compared to the steel plate, and reduces the incidence of internal fixation fracture; The blade and main nail have automatic locking devices, which have stronger anti rotation ability. At the same time, biomechanics has shown that spiral blades can significantly improve their anti cutting ability, thus meeting the requirements of firm fixation and early functional exercise. PFNA internal fixation, as a new technique, conforms to both biomechanical characteristics and minimally invasive concepts [4], and allows for early postoperative weight-bearing [5].
3.3 Surgical Points and Precautions
① For patients with splitting and displacement of fracture blocks at both the greater and lesser trochanters of the femur, especially for fractures with detachment of the lesser trochanter, excessive pursuit of anatomical reduction of the medial structure should not be pursued. Closed reduction can be performed as long as the neck shaft angle is restored to normal, shortening correction is achieved, and the fracture block function is reduced [6].
② Choose the correct needle insertion point. Incorrect needle insertion point can directly cause deviation and displacement of the proximal fracture fragment. The insertion of the guide needle during surgery should be at least 15cm or more to check the position of the fracture end before, after, inside, and outside.
③ Grasping the up and down position of the spiral blade guide needle. During the operation, ensure that the upright fluoroscopy guide is located at the intersection of the middle and lower one-third of the femoral neck, with the tip of the guide pointing towards the center of the femoral head and just 1cm below the cartilage surface of the femoral head. The lateral fluoroscopy guide is located in the center of the femoral head neck. This position allows the spiral blade to pass through the femoral distance after insertion, achieving maximum biomechanical fixation strength.
④ Grasping the forward tilt angle of the spiral blade guide needle. Ensure that the insertion point of the spiral blade guide needle is on the lateral midline of the proximal femur during the operation, with the coronal plane of the femoral shaft as the reference plane, and tilt backwards by about 15 °. Excessive or insufficient forward tilt angle will cause the spiral blade to penetrate the femoral head and neck forward or backward after insertion, resulting in serious consequences such as internal fixation failure.
⑤ The spiral blade head is located 10mm below the femoral head. Tightening the tail nut to lock and pull the spiral blade can maximize the gripping force, anti rotation force, and compressive stress of the rotating blade head, enhance the stability of internal fixation, and avoid the spiral blade cutting out the femoral head [7].
⑥ Preoperative preparation should be sufficient, and patients should undergo a comprehensive physical examination, inquire about their medical history in detail, and grasp their underlying diseases and medication situation; Invite medical consultation to actively treat hypertension, diabetes, coronary heart disease, anemia and other medical complications; Fully cooperate with the anesthesiology department, carefully evaluate the surgical risks and safety, and once the patient’s overall condition is adjusted to ideal, surgery should be performed as soon as possible.
Source: Chinese Journal of Bone and Joint Injuries
Published on 2015-12-03 11:45
Updated on 2015-12-03 11:21
Reference
[1] Xu Shaoting, Ge Baofeng, Xu Yinkan, etc Practical Orthopedics [M] Version 3 Beijing: People’s Military Medical Press, 2005: 708-719
[2] Wu Kejian, Hou Shuxun Practical Orthopedic Fixation Techniques [M] Beijing: People’s Military Medical Press, 2007:1044-1093
[3] Tao Ran, Liu Yao, Zhou Zhenyu, etc Preliminary study on the treatment of intertrochanteric fractures with anti rotation proximal femoral nail [J] Chinese Journal of Orthopedics and Traumatology, 2009, 11 (2): 191-193
[4] Wan Yuchun, Mao Jiaming, Liu Jianxin, etc Surgical treatment of peri trochanteric fractures of femur [J] Chinese Journal of Bone and Joint Injury, 2008, 23 (5): 417-418
[5] Yin Yong, Zhou Xianjie Proximal femoral anti rotation intramedullary nail (PFNA) for the treatment of unstable intertrochanteric fractures in elderly patients [J] Chinese Journal of Bone and Joint Injury, 2011, 26 (8): 733-734
[6] Hong Jiayuan, Lian Kejian, Guo Linxin, etc Analysis of 27 causes of complications in the treatment of intertrochanteric fractures with Richard nail [J] Journal of Bone and Joint Injuries, 2001, 16 (3): 233-234
[7] Ye Xiuzhang, Gu Xiuzhang, Zhou Chenghuan, etc Analysis of the therapeutic effect of DHS and PFNA internal fixation on intertrochanteric fractures of femur [J] Chinese Journal of Bone and Joint Injury, 2013, 28 (4): 346-347
Disclaimer: Copyright belongs to the original author. If you have any questions, please contact us.
Post time: Aug-21-2024