Gupta Rakesh Kumar, Gupta Vinay, Gupta Navdeep
Department of Orthopedics, Physical Medicine, Paraplegia and Rehabilitation, Postgraduate Institute of Medical Sciences, Rohtak, India.
Indian J Orthop. 2012 Nov;46(6):640-5. doi: 10.4103/0019-5413.104193.
Dynamic hip screw (DHS) has been the standard treatment for stable trochanteric fracture patterns, but complications of lag screw cut out from a superior aspect, due to inadequate bone anchorage, occur frequently in elderly osteoporotic patients. Polymethylmethacrylate (PMMA) has been used as an augmentation tool to facilitate fixation stability in cadaveric femora for biomechanical studies and in pathological fractures. However, there are very few reports on the utilization of PMMA cement to prevent these complications in fresh intertrochanteric fractures. A prospective study was conducted to evaluate the outcome and efficacy of PMMA augmented DHS in elderly osteoporotic patients with intertrochanteric fractures.
The study included 64 patients (AO type31-A2.1 in eight, A2.2 in 29, A2.3 in 17 patients, and 31-A3.1 in five, A3.2 in three, and A3.3 in two patients) with an average age of 72 years (60 - 94 years) of which 60 were available for final followup. PMMA augmentation of DHS was performed in all cases by injecting PMMA cement into the femoral head with a custommade gun designed by the authors. The clinical outcome was rated as per the Salvati and Wilson scoring system at the time of final followup of one year. Results were graded as excellent (score > 31), good (score 24 - 31), fair (score 16 - 23), and poor (score < 16).
Fracture united in all patients and the average time to union was 13.8 weeks (range 12 - 16 weeks). At an average followup of 18 months (range 12 - 24 months), no incidence of varus collapse or superior screw cut out was observed in any of the patients in spite of weightbearing ambulation from the early postoperative period. There was no incidence of avascular necrosis (AVN) or cement penetration into the joint in our series. Most of the patients were able to regain their prefracture mobility status with a mean hip pain score of 8.6.
Cement augmentation of DHS appears to be an effective method of preventing osteoporosis related complications of fracture fixation in the trochanteric fractures. The technique used for cement augmentation in the present study is less likely to cause possible complications of cement augmentation like thermal necrosis, cement penetration into the joint, and AVN hip.
动力髋螺钉（DHS）一直是治疗稳定型转子间骨折的标准方法，但由于骨锚固不足，拉力螺钉从上方穿出的并发症在老年骨质疏松患者中频繁发生。聚甲基丙烯酸甲酯（PMMA）已被用作一种增强工具，以促进尸体股骨生物力学研究和病理性骨折固定的稳定性。然而，关于使用PMMA骨水泥预防新鲜转子间骨折这些并发症的报道非常少。本研究旨在评估PMMA增强DHS治疗老年骨质疏松性转子间骨折的疗效和结果。
本研究纳入64例患者（AO分型：31-A2.1型8例，A2.2型29例，A2.3型17例，31-A3.1型5例，A3.2型3例，A3.3型2例），平均年龄72岁（60-94岁），其中60例可进行最终随访。所有病例均采用作者设计的特制枪将PMMA骨水泥注入股骨头，对DHS进行PMMA增强。在最后一年随访时，根据Salvati和Wilson评分系统对临床结果进行评分。结果分为优（评分>31）、良（评分24-31）、中（评分16-23）、差（评分<16）。
所有患者骨折均愈合，平均愈合时间为13.8周（12-16周）。平均随访18个月（12-24个月），尽管术后早期即负重行走，但未观察到任何患者出现内翻塌陷或上方螺钉穿出。本系列中无缺血性坏死（AVN）或骨水泥进入关节的情况发生。大多数患者能够恢复骨折前的活动状态，平均髋关节疼痛评分为8.6。
DHS骨水泥增强似乎是预防转子间骨折骨质疏松相关骨折固定并发症的有效方法。本研究中用于骨水泥增强的技术不太可能引起骨水泥增强可能的并发症，如热坏死、骨水泥进入关节和AVN髋关节。
