Mittal Krishna Kumar, Agarwal Apoorva, Raj Nishant
Department of Orthopaedics, Krishna Hospital and Trauma Centre, J 85 Patel Nagar I, Ghaziabad, Uttar Pradesh 201001 India.
Krishna Hospital and Trauma Centre, Ghaziabad, India.
Indian J Orthop. 2021 Mar 19;55(3):636-645. doi: 10.1007/s43465-020-00318-w. eCollection 2021 Jun.
Subtrochanteric fractures are challenging to treat because of their anatomical and biomechanical behaviours. Non-unions of this region become much more difficult to treat because of the previous surgical scar, fibrosis, mal-reduction, presence of an implant, compromised soft tissue, and osseous vascularity, bone-mass loss etc. The aim is to provide a stable mechanical environment by PF-LCP, augmented by LCP (dual plating) where biology can work uneventfully. Biology is re-initiated by decortication (shingling) and autologous cancellous bone graft.
Twelve cases of failed aseptic subtrochanteric non-union either with intact or broken implant were included in this study in a period of 3 years from August 2016 to July 2019. The interposing fibrous tissue resected in patients with mal-aligned fragments. The mechanical stabilization is achieved by orthogonal dual plating. PF-LCP on lateral and 4.5 mm LCP anteriorly, decortication, and cancellous graft applied before applying for the anterior plate. Patients were encouraged for a toe-touch walk with walking-frame from 3rd post-operative day. Functional outcomes were assessed using Parker Mobility Score (PMS).
All fractures united in 7 ± 1.53 months. ROM at the knee remained unchanged but improved at the hip after revision surgery. Average PMS improved to 7.58 from pre-revision 1.75 validating the efficacy of this protocol.
Adequate stability by dual-plate construct and re-initiation of cellular and biochemical processes by decortication and cancellous bone-graft reunited ununited subtrochanteric fractures. This particular combination of plates and decortication has not been employed earlier as per our review of the literature.
To offer a new paradigm for the management of surgically failed subtrochanteric non-unions.
转子下骨折因其解剖学和生物力学特性，治疗颇具挑战性。由于存在既往手术瘢痕、纤维化、复位不良、植入物、软组织受损以及骨血管受损、骨质流失等情况，该区域的骨不连治疗难度更大。目标是通过动力加压锁定钢板（PF-LCP）提供稳定的力学环境，并辅以锁定加压钢板（LCP，双钢板固定），以使生物学过程能够顺利进行。通过去皮质（鱼鳞状切开）和自体松质骨移植重新启动生物学过程。
2016年8月至2019年7月的3年间，本研究纳入了12例无菌性转子下骨不连失败病例，这些病例的植入物或完整或已断裂。对骨折块对线不良的患者切除其间的纤维组织。通过正交双钢板固定实现力学稳定。外侧使用PF-LCP，前方使用4.5mm LCP，在应用前方钢板之前进行去皮质和松质骨移植。鼓励患者术后第3天借助步行架进行足尖触地行走。使用帕克活动评分（PMS）评估功能结果。
所有骨折均在7±1.53个月内愈合。翻修手术后，膝关节活动度保持不变，但髋关节活动度有所改善。平均PMS从翻修前的1.75提高到7.58，证实了该方案的有效性。
双钢板结构提供的足够稳定性以及去皮质和松质骨移植对细胞和生化过程的重新启动，使不愈合的转子下骨折得以愈合。根据我们对文献的回顾，这种特定的钢板组合和去皮质方法此前尚未被采用。
为手术失败的转子下骨不连的治疗提供一种新的模式。
