Madsen J E, Naess L, Aune A K, Alho A, Ekeland A, Strømsøe K
Department of Orthopaedics, Ullevål Hospital, University of Oslo, Norway.
J Orthop Trauma. 1998 May;12(4):241-8. doi: 10.1097/00005131-199805000-00005.
To compare the results after operative treatment of unstable per- and subtrochanteric fractures with the Gamma nail, compression hip screw (CHS), or dynamic hip screw with a laterally mounted trochanteric stabilizing plate (DHS/TSP).
Prospective.
One hundred seventy patients with unstable trochanteric femoral fractures surviving six months after operation. Eighty-five patients were randomized to treatment with the Gamma nail (n = 50, Gamma group) or the compression hip screw (n = 35, CHS group) and compared with a consecutive series of eighty-five patients operated with the dynamic hip screw with a laterally mounted trochanteric stabilizing plate (DHS/TSP group)
Radiographs were analyzed for fracture classification, evaluation of fracture reduction, implant positioning, later fracture dislocation, and other complications. Pre- and postoperative functional status of the patients were recorded, with a minimum of six months follow-up.
Eighteen percent of the patients in the Gamma group, 34 percent in the CHS group, and 9 percent in the DHS/TSP group suffered significant secondary fracture dislocation during the six months follow-up, leading to a varus malunion, lag screw cutout, or excessive lag screw sliding with medialization of the distal fracture fragment. Two patients (4.0 percent) in the Gamma group suffered an implant-related femoral fracture below the nail, and one had a deep infection. The reoperation rates were 8.0 percent in the Gamma group, 2.9 percent in the CHS group, and 5.9 percent in the DHS/TSP group. All but one fracture in the Gamma and CHS groups and two fractures in the DHS/TSP group healed within six months. Approximately three-fourths of the patients had returned to their preoperative walking ability after six months, with a trend toward better functional outcome in the DHS/TSP group. Use of a TSP reduced the secondary lag screw sliding as compared with the conventional CHS, without affecting fracture healing.
The TSP may be an aid in the treatment of these difficult fractures because the problem with femoral shaft fractures using the Gamma nail is avoided and the medialization of the distal fracture fragment frequently associated with the CHS is prevented.
比较使用伽马钉、加压髋螺钉（CHS）或带外侧转子稳定钢板的动力髋螺钉（DHS/TSP）手术治疗不稳定型转子周围及转子下骨折后的结果。
前瞻性研究。
170例不稳定型股骨转子骨折患者术后存活6个月。85例患者随机分为伽马钉治疗组（n = 50，伽马组）或加压髋螺钉治疗组（n = 35，CHS组），并与连续85例采用带外侧转子稳定钢板的动力髋螺钉手术治疗的患者（DHS/TSP组）进行比较。
分析X线片以进行骨折分类、评估骨折复位、植入物定位、后期骨折脱位及其他并发症。记录患者术前和术后的功能状态，随访至少6个月。
在6个月的随访期间，伽马组18%的患者、CHS组34%的患者以及DHS/TSP组9%的患者发生了严重的继发性骨折脱位，导致内翻畸形愈合、拉力螺钉穿出或拉力螺钉过度滑动并伴有远端骨折块内移。伽马组2例患者（4.0%）发生了与植入物相关的钉下股骨骨折，1例发生深部感染。伽马组的再次手术率为8.0%，CHS组为2.9%，DHS/TSP组为5.9%。伽马组和CHS组除1例骨折外，DHS/TSP组除2例骨折外，其余均在6个月内愈合。约四分之三的患者在6个月后恢复了术前行走能力，DHS/TSP组的功能结局有更好的趋势。与传统CHS相比，使用TSP可减少拉力螺钉的继发性滑动，且不影响骨折愈合。
TSP可能有助于治疗这些复杂骨折，因为它避免了使用伽马钉治疗股骨干骨折时的问题，并防止了CHS常见的远端骨折块内移。
