Bess R J, Jolly S A
Department of Orthopedic Surgery, University of Colorado Health Sciences Center, Denver, USA.
J South Orthop Assoc. 1997 Fall;6(3):173-9.
Twenty-seven peritrochanteric fractures in 27 patients were evaluated and treated prospectively. Ten fractures were internally fixed with compression hip screws (CHS) (Omega Howmedica, Rutherford, NJ) and 135 degrees, four-hole side plates. Internal fixation of the posteromedial fragment was not done. Eleven fractures were internally fixed with Gamma nails with distal screws. Six fractures were internally fixed with Gamma nails without distal screws. Each group was evaluated for surgical time, blood loss, hospital days, collapse of the fracture, infections, cut out of the lag screw from the femoral head, fracture healing, perioperative femoral shaft fractures, and implant failure. Surgery time did not differ significantly in either group. Blood loss and hospital days were less in the Gamma nail group. There were no infections, cut out of the lag screw, implant fractures, or pulmonary complications in either group. Fracture healing was the same in both groups. Those fractures treated with Gamma nails, both with and without distal screws, had 50% less collapse than those treated with CHS. There were two femoral shaft fractures in the Gamma nail group (11.76%). There were no femoral shaft fractures in the CHS group. Fractures of the femoral shaft were believed to be caused by two factors: a mismatch of the nail design and the normal geometry of the proximal femur and stress risers in the femoral shaft caused by repeatedly missing the screw hole with the drill bit. Although the Gamma nail is an excellent device for stabilizing and preventing collapse of unstable peritrochanteric fractures, the learning curve is high, and femoral shaft fractures can occur. We believe precautions outlined in this report are helpful in preventing these complications.
对27例患者的27处转子周围骨折进行了前瞻性评估和治疗。10处骨折采用加压髋螺钉（CHS，欧米茄豪美医疗公司，新泽西州卢瑟福）及135度四孔侧板进行内固定，未对后内侧骨折块进行内固定。11处骨折采用带远端螺钉的伽马钉进行内固定。6处骨折采用不带远端螺钉的伽马钉进行内固定。对每组的手术时间、失血量、住院天数、骨折塌陷、感染、拉力螺钉从股骨头切出、骨折愈合、围手术期股骨干骨折及植入物失败情况进行评估。两组的手术时间无显著差异。伽马钉组的失血量和住院天数较少。两组均未发生感染、拉力螺钉切出、植入物骨折或肺部并发症。两组的骨折愈合情况相同。采用伽马钉治疗的骨折，无论带或不带远端螺钉，其塌陷程度均比采用CHS治疗的骨折少50%。伽马钉组发生2例股骨干骨折（11.76%）。CHS组未发生股骨干骨折。股骨干骨折被认为由两个因素引起：钉的设计与近端股骨正常几何形状不匹配，以及钻头反复错过螺钉孔导致股骨干应力集中。尽管伽马钉是稳定和预防不稳定转子周围骨折塌陷的优良器械，但学习曲线较陡，且可能发生股骨干骨折。我们认为本报告中概述的预防措施有助于预防这些并发症。
