| Backgrounds:Intertrochanteric fractures are the most common among comminuted fracture of the proximal femur. Boyd and Griffin proposed the concept of subtrochanteric lower fracture in1949. It is treated as variation type of intertrochanteric fractures. If we use internal fixation surgery mode of intertrochanteric fractures for treatment of intertrochanteric lower fracture, higher internal fixation failure rate and nonunion rate can be generated. Subtrochanteric lower fractures are different from intertrochanteric fractures in the aspects of biomechanics, treatment, prognosis and the like with gradual deepening of clinical and basic research, and intertrochanteric fracture is viewed as a separate type of fracture at present. Intertrochanteric fracture is defined as follows after being evolved over the years:it mainly occurs between small rotor of the femur and femoral shaft isthmus (between small rotor and the part5cm far away from it). Intertrochanteric fracture occurs mainly in elderly patients with osteoporosis, and mainly belongs to low energy injury. Only a small part occurs among young people and belongs to high-energy injuries. The high-energy injury of the proximal femur is more and more common with the progress of society. Clinical high-energy subtrochanteric lower fractures are more common than before, and the disease is also more complex. Since the energy of the injury is large, the fracture line is usually extended to the femoral small rotor beyond10cm or more, and even up to20cm, and it reaches the femur cadres. It is easy to lead to the complex cortical bone long segment comminuted fracture The blood supply damage of the fracture block is greater. Therefore, subtrochanteric lower long segment comminuted fracture is more likely to cause failure of internal fixation and fracture nonunion in treatment. Its treatment is different from traditional intertrochanteric lower fractures.Scholars believe that:intertrochanteric lower area is the site with high concentration stress after biomechanical research for many years. It not only bears the axial load of the body weight, but also bears strong buckling stress caused by eccentric load acting on the femoral head. The buckling stress causes enormous pressure stress which is forced on subtrochanteric lower medial cortical bone, while the lateral cortical bone is subject to tensile stress, thereby the part is prone to failure of internal fixation, nonunion and other complications. Subtrochanteric lower area has strong attachment of the muscles, including the adductor muscles, hip abductors, supinator and flexor. Powerful forces of the muscles increase the stress strength of the rotor lower area. Once fracture occurs, the original balance of each muscle would be destroyed, and complex fracture displacement appears. Fractures proximal end is draught by gluteus to cause abduction, draught by iliopsoas to cause flexion, and draught by external rotation muscle to cause external rotation. Meanwhile, the fracture end causes adduction due to the powerful stretch of the adductor. Even if the fracture reduction is made during surgery, further displacement also can be easily caused. Subtrochanteric region, especially the area5cm under the rotor, mainly has hard cortical bone. If high-energy injury occurs, it is prone to subtrochanteric lower long segment comminuted fracture, and bone defect and reset difficulties can be caused. Rotor lower bone of the young patients is relatively hard, and most of fractures are caused by high energy injury. The femur cadres are located in the area5cm under the small rotor. They belong to cortical bone. Complex long segment comminuted fracture of cortical bone under high energy injury, such as falling injury, traffic injury, noon injury etc.. Small rotor fracture can be caused during most intertrochanteric lower fractures. The lower inside part of the rotor can lost supporting role of the bone, and unstable fractures can be formed. Hip varus can be caused easily due to improper treatment, thereby generating serious impact on hip function.There are many methods to treat subtrochanteric lower fractures in clinics. The patients should make appropriate choices based on specific situation, including traditional traction therapy, outer mounting brackets, side steel plate, proximal femur intramedullary nail, minimally invasive LISS internal fixation system for fixation and the like. The force lines and length of the limbs must be restored to guarantee the limb distal non-rotating shift regardless of treatment method selected by the patient. The damage to the blood supply on the fracture should be minimized, and the time in bed should be reduced as soon as possible. Patients should walk on ground and early rehabilitation exercises can be conducted as early as possible, thereby ultimately promoting fracture healing. The orthopedic department in Yuebei People’s Hospital of Shantou University diagnosed and treated many patients with intertrochanteric lower long segment comminuted fracture (fracture is classified as Russell-Taylor I A and I B, the fracture line is extended to small rotor between5cm and20cm) from September2007to January2012. The used internal fixation method refers to femoral proximal locking compression steel plate and proximal fomaral nail antiritation. The method achieved satisfactory results.Objective:To discuss the indications and clinical efficacy of treating subtrochanteric lower long segment comminuted fracture with proximal femur locking compression plate and proximal fomaral nail antiritation.Materials and methods:A retrospective study was conducted on40patients with intertrochanteric lower long segment comminuted fracture (the fracture line is extended to small rotor between5cm and20cm) in orthopedic department in Ebei People’s Hospital of Shantou University from September2007to January2012, including25male patients and15female patients. Their ages are from16to58years old with an average of32.4years of age.36cases have high energy injury, and two case have low-energy injury.26cases belong to Rusell-Taylor I A type,14belong to I B type.20cases belong to left lower limb injury, and20cases belong to right lower extremity fractures. Wherein, two cases belong to pathological fractures. All patients belong to closed fractures without important organ injury and simultaneous bilateral lower extremity fracture. They all belong to fresh fractures without limb neurovascular injury as well as medicine basis disease and osteoporosis. The preoperative limb traction time was4d-11d after injury. The treatment methods were divided into the follows:20cases in the treatment group adopted proximal femur locking compression plate (LCP) and20cases in the treatment group adopted PFNA. Postoperative patients were followed up for more than12months. The related indicators were compared through recording the related data of two groups of patients before surgery, after surgery, two weeks,2months,6months, and12months after surgery, and the like. The indicators included operation time, operative bleeding, wound length, fracture healing time after surgery, postoperative early and late complications, time for patients to get out of bed and walk, hip function score and the like. The advantages and disadvantages of two internal fixation modes were compared through the study, and respective adaptations were pointed out to guide the clinical treatment.Results:All40cases were followed up. The time for patients to get out of end, and the time of fracture healing before surgery,2weeks, two months,6months and12months after surgery, Harris ratings, Lyshonlm-rating and other indicators were recorded. The fracture healing time of each patient after surgery were recorded. Value P was greater than0.05and had no statistical significance among the comparison of all preoperative data in the LCP group and PFNA group, including age, preoperative Harris rating, Lyshonlm rating and the like. The two groups had no difference, and are comparable. One patient had postoperative wound infection, and two cases had nonunion among20patients adopting LCP treatment. The average healing time was9.79months. One case had knee stiffness in the review12months after surgery. Other patients did not have internal fixation fracture, plate far fractures, limb deep vein thrombosis, femoral head necrosis, hip varus and other complications. One patient had rotor bone splitting, two cases had postoperative wound infection, and one case had nonunion among20patients adopting PFNA treatment. The average healing time was7.54months. All patients did not have internal fixation loosening, fracture, limb deep vein thrombosis, femoral head necrosis, hip varus, knee stiffness and other complications in the review12months after surgery. Time for patients of LCP group to get out of bed was shorter than one of PFNA group, but fracture healing time of LCP group was longer than one of PFNA group, comparison of them was statistically significant (P<0.0.5).Harris scores of LCP group were all lower than them of PFNA group, but Lyshonlm scores of LCP group were all higher than them of PFNA group from two months to twelve months after operations, comparison of them was statistically significant (P<0.0.5) Conclusion:In short, As for the patients with intertrochanteric lower long segment comminuted fracture discussed in the study, if the patients do not have osteoporosis and femoral canal stenosis, it is recommended to use PFNA, and the doctor should try to wear nail on the fracture end for closure. However, if the fracture is too complicated and crushed, it is recommended to use the mode of cutting and resetting the fracture end and internal fixation. Meanwhile, the patients should pay attention to immediate and effective hip and knee function exercise after surgery, which is extremely important to the final rehabilitation of limb function. |
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