| Part one 3D CT based morphological study of unstable intertrochanteric fracture mapObjective By mapping posterior medial and anterolateral wall fracture map of unstable intertrochanteric fracture,distribution characteristics and rules of fracture lines in posterior medial and anterolateral wall of unstable intertrochanteric fracture were discussed.Methods Patients with femoral unstable intertrochanteric fracture treated in The Affiliated Hospital of Chengdu University from January 2009 to October 2018 were analyzed retrospectively,collect their CT and three-dimensional reconstruction data.According to the fracture line involving the wall,the patients were divided into anterolateral wall group and posterior medial wall group.Through the specific markers such as femoral shaft,lesser trochanter and tip of greater trochanter were compared and 3D CT was superimposed and orientated to intertrochanteric and posterior lateral wall and anterolateral standard models to map the fracture.The parameters such as width,height,area,and fracture line of posterior lateral and anterolateral wall and fracture zone were measured to describe shape of fracture line.Results Among the 236 patients with unstable intertrochanteric fracture,there were 185 cases of type A2 and 51 cases of type A3.There were 178 cases of lateral wall injury:132 cases of A2 fracture and 46 cases of A3 fracture.The lateral wall fracture line width was(16.15±9.14))mm(range7.12～48.49 mm),fracture height(29.42±12.74)mm(range 10.19～65.98 mm),fracture area was(519.66±273.18)mm2(range 116.83～2911.82 mm2),and the fracture line alignment angle was(60.11°±20.63°)(range 2.08°～89.49°).Features of the fracture map of the lateral wall:the fracture lines are densely distributed in the posterior and upper part of the lateral wall.The fracture line of type A2 was concentrated in the posterior and upper part of the lateral wall,and the lateral femoral muscle crest was sparse.The damage in the upper area of the lateral wall is relatively serious,the fracture lines in the central and lower areas near the fracture stem are relatively sparse,and the lateral wall is relatively complete and stable.The fracture lines of type A3 were densely distributed in the central area and below the lateral wall near the femoral shaft.The fracture line is in the anterior and upper part of the lateral wall,and the muscular crest area of the lateral femur is relatively sparse.The fracture line involves the area of the femoral shaft,the lateral wall is relatively incomplete,and the stability is poor compared with type A2.There were 136 cases of posterior medial wall involved by fracture line:101 cases of A2 fracture and 35 cases of A3 fracture.The posterior wall fracture height was(48.76±4.11)mm,width was(29.78±3.29)mm,fracture area was(1 468.47±75.26)mm2,and deviation angle was 49.93°±13.05°.The fracture area ratio(fracture area)The area/posterior sidewall area ratio was 38.34%±16%;the characteristics of posterior medial wall fracture map were:fracture line was densely distributed in small rotor area and in front of it.In the A2 type fracture,posterior wall fracture line was mostly concentrated in small trochanter and below,and fracture line is oblique from anterior to posterior to inferior to calcar femorale.The A3 fracture line is concentrated in small trochanter and its upper area.The fracture line is oblique from anterior to posterior upper part of calcar femorale.Conclusion The fracture map can improve visual understanding of unstable intertrochanteric fracture of posterior lateral and anterolateral wall injury,and improve description of distribution of posterior lateral and anterolateral wall fracture line of A2\3 type in AO classification.Part two Selection of Auxiliary Fixation with Intramedullary Nail for unstable Intertrochanteric fracture and its fracture map studyObjective To compare the clinical effect of treatment of unstable femoral trochanteric fracture with lateral locking plate and wire fixation.By drawing a fracture map,explore the correlation between the fracture line distribution area and compare the choice of two auxiliary fixation methodsMethods Retrospective analysis of the data of 83 patients with unstable femoral trochanteric fractures admitted to The Affiliated Hospital of ChengDu University from March 2015 to December 2018,who were treated with intramedullary nail fixation and auxiliary lateral wall fixation,including 41 males and 42 females.Injury mechanism:15 cases of high fall injury;32 cases of traffic accident injury;Tumble injury 36 cases.AO type A2:41 cases,A3 type:42 cases.Osteoporosis was found in 45 cases(52.22%).According to different methods of auxiliary external wall fracture fixation,39 cases were divided into proximal femoral locking plate group(group A)and 44 cases were divided into cerclage wire group(group B).The amount of blood loss during surgery,hospitalization days,cost of full weight bearing time,fracture healing time and surgical-related complications were observed in the two groups respectively.Harris functional score was used in the last follow-upResult Follow-up was 12 to 24 months,with an average of 16 months.The locking plate group had a longer operation time(p=0.001<0.05)and higher cost(p=0.000<0.05)than the Cerclage wire group,but complete weight bearing time was short(p=0.005<0.05),fracture healing time was short(p=0.001<0.05),and difference was statistically significant.In the locking plate group,there was 1 case of nonunion of posterior medial wall fracture,2 cases of plate screw retreat,2 cases of hip varus In the cerclage wire group,there were 2 cases of fracture nonunion,1 case of femoral head necrosis and 3 cases of hip varus.There was no significant difference in operative complications(p=1.000>0.05).Two groups of AO classification(p=0.963>0.05),hospitalization days(p=0.386>0.05),blood loss(p=0.604>0.05)no statistical differences.Harris score at multiple time points was analyzed for repeated measurement of variance,and the Harris score in the steel plate group was higher than that in the steel wire group 3 months after surgery,with statistically significant difference(p=0.023<0.05).There was no significant difference in Harris scores between the two groups at 6 months(p=0.564>0.05)and 12 months(p=0.197>0.05).Anova of the groups(steel plate group and steel wire group),p=0.133>0.05,Harris score between steel plate group and steel wire group,no significant difference.The width of the lateral wall fracture in the 39 cases with locking plate group was(32.19±9.05)mm(range 14.53～49.73 mm),the fracture height was(43.09±10.32)mm(range 20.04～61.41 mm),the fracture area was(1378.82±519.50)mm(range 628.13～2180.28 mm),and the fracture contour Angle was(45.19°±14.56°)(range 3.43°～74.61°).Morphological results of the fracture line of the lateral wall in the wire ring binding group of 44 cases showed that the fracture width of the lateral wall was(30.06±9.19)mm(range 9.56～51.80 mm),fracture height was(41.19± 13.41)mm(range 16.30～70.84 mm),fracture area was(1254.25±652.03)mm(range 267.49～3291.25 mm),fracture line deformation Angle was(35.89°±16.73°)(range 4.56°～80.86°).Characteristics of fracture map and frequency distribution in plate group:the fracture line is densely distributed in the lower part behind the outer wall,while the lateral femoral muscular crest is relatively sparse.The fracture line is dense below the lateral wall and involves the femoral shaft.Characteristics of fracture map and frequency distribution in steel wire group:fracture line was densely distributed behind the outer wall.The fracture line is dense above the lateral wall and relatively sparse below.The fracture line is not obviously involved in the femoral shaft.The fracture line distribution area of the steel plate group and the steel wire group was different,there was a statistical difference,x2=12.340,p=0.006.There is a correlation between the auxiliary fixation method and the distribution area of the fracture line,and the correlation is large,γ=-0.404,p=0.012,which is statistically significantConclusion In auxiliary fixation of unstable trochanteric fracture with intramedullary nail,the advantage of cerclage wire is that operation time is short and operation cost is relatively low.Proximal femoral locking plate can shorten time of full weight bearing and fracture healing,and improve hip function.The distribution area of the lateral fracture line is related to the choice of intramedullary nail-assisted fixation... |
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