【作者】 刘刚；

【导师】 董纪元； 唐佩福；

【作者基本信息】 中国人民解放军军医进修学院 ， 外科学， 2010， 硕士

【摘要】 目的回顾性随访粗隆间骨折术后大粗隆移位对预后的影响,并设计新型大粗隆固定装置及生物力学分析其稳定性和可行性。方法(1)随访解放军总医院自1993年至2008年收治入院的636例粗隆间骨折患者,依据筛选标准建立样本群,统计分析各项住院治疗资料、影像资料及Harris评分,分析术后大粗隆移位与术后患者功能的关系。(2)设计了新型大粗隆固定装置,近端双钩锁定大粗隆骨折块顶端,远端双螺钉锁定。(3)运用5对人尸体股骨标本对该新型大粗隆固定装置行力学分析,通过循环力学负荷测试机器渐增的加载负荷并记录大粗隆移位数据,同时记录大粗隆移位1cm,2cm及>2cm时的负荷值,分析该固定装置的稳定性。结果(1)636例患者中,失访145例,术后死亡111例,28例拒绝手术治疗,在获得完整影像资料且存活的225例患者中,伴有大粗隆骨折的Jesen-EvansⅢ型、Ⅴ型,共109例：Jesen-EvansⅠ型、Ⅱ型、Ⅳ型、R型,共116例,伴有大粗隆骨折的Jesen-EvansⅢ型、Ⅴ型,共109例,其中术后大粗隆移位<1cm 34例；术后大粗隆移位>2cm 13例；术后大粗隆移位1.2cm 62例。Harris评分分别是89.50±8.510,80.692±7.983,85.573±7.651；两两比较p<0.05,存在差异。Jensen-EvansⅢ型、Ⅴ型,共109例患者中,有30例采用股骨头置换治疗,79例采用髓内钉治疗。比较其治疗效果示,股骨头置换组年龄稍高但无差别(78.6±5.2岁,71.4±18.5岁,p=0.357),而股骨头置换组功能恢复好且存在差别(81.6±12.9,70.4±18.5,p=0.012)。(2)所有标本,通过循环负荷检测,大粗隆移位1cm所需平均负荷值为：1600N。大粗隆移位2cm所需平均负荷值为：2400N；当负荷>2400N时,大粗隆移位>2cm。分析不同负荷下移位数值时,在700N的负荷下,大粗隆平均移位数值为：2mm,并且随着加载负荷的增加移位数值也相应增加,成线性相关。在1400N的负荷时,大粗隆平均移位数值为：5mm；在2100N的负荷时,大粗隆平均移位数值为：15mm。在2800N的负荷时,大粗隆平均移位数值>20mm。结论.(1)术后大粗隆移位可明显影响臀中肌的肌力,从而影响术后患者的行走能力并可以造成行走疼痛。对于大粗隆游离甚至大粗隆冠状面劈裂的不稳定性粗隆间骨折,术中复位并固定大粗隆是非常必要的。(2)新型大粗隆固定装置不仅较好的固定大粗隆骨折块来抵抗外力牵拉,而且同时可以在垂直方向上加压,在维持稳定性的同时促进骨折愈合。(3)通过力学分析,新型大粗隆固定装置能承受正常人活动过程中大粗隆所受的负荷,确保大粗隆获得可靠固定。更多还原

【Abstract】 ObjectiveTo analyze the functional outcomes of intertrochanteric hip fractures retrospectively, explore the displacement of the greater trochanter after surgery on the prognosis of the fractures, design a new method for fixation of the greater trochanter and analyze its biomechanical efficacy.Methods(1) Follow up 636 patients of intertrochanteric fractures admitted to PLA General Hospital from 1993 to 2008, statistically analysis the information before、during and after surgery of the patient, compare the Harris Hip Score of all the patients grouped by the kind of treatment, and analyze the relationship between the displacement of the greater trochanter after sugery and the functional outcomes of intertrochanteric hip fracture.(2) Design a new method for fixation of the greater trochanter, which has two hooks in its proximal, while has two screw holes in its distant.(3) Five fresh-frozen human cadaveric proxiamal femora were used in biomechanical analysis.A cyclic shear load was applied, and displacement of the trochanter was measured with increasing load. Meanwhile, force required to displace to 1cm,2cm was recorded.Results(1) Among the 636 patients,145 patientswere lost during the follow up,28 patients committed to conservative treatment for disagreement to the surgry,111 patients died during the follow-up period.In all 225 patients, compare the difference between 109 cases of Jesen-Evans typeⅢand type V and 116 cases of Jesen-Evans typeⅠ、typeⅡ、typeⅣVand type R, The result shows that the Harris Hip Score is 87.628±8.509,84.971±7.742 respectively, which exists statistical significance of the Harris Hip Score (p=0.0153).Compare the different displacement of the greater trochanter at<1cm (34cases)、1-2cm(62cases) and>2cm(13cases) of the 109 cases of Jesen-Evans typeⅢand type V. the Harris Hip Score is 89.50±8.510,80.692±7.983,85.573±7.651 respectively, which exists statistical significance of the Harris Hip ScoreAmong 109 cases of Jesen-Evans typeⅢand type V, consist of 30cases of Hemiarthroplasty and 79 cases of intramedullary fixation.Compare the difference of the age and efficacy of therapy.The group of Hemiarthroplasty is older than the other, but has no statistical significance (78.6±5.2岁,71.4±18.5岁p=0.357),while the group of Hemiarthroplasty attain better results than the other and has statistical significance(81.6±12.9,70.4±18.5, p=0.012).(2) Five fresh-frozen human cadaveric proxiamal femora were applied cyclic shear load.Force required to displace to 1cm is 1600N, force required to displace to 2cm is 2400N.When analyzing displacement of the greater trochanter at different loads, the trochanter diaplaced an average of 2mm with the initial load of 700N and continue to displace with each increase in load in a linar fashion. The trochanter diaplaced an average of 5mm with load of 1400N, an average of 15mm with load of 2100N and an average of more than 20mm with load of 2800N.Conclusions:(1) The displacement of the greater trochanter after surgery could decrease the function of gluteus medius significantly, thus for the fracture of dissociated greater trochanter, it is essential to have the greater trochanter repositioned and fixed properly.(2) The newly designed method for fixation of the greater trochanter can not only provide a solide fixation of the greater trochanteric fragment against shear load,but also offer a perpendicular pressure to accelerater the procedure of healing.(3) Through biomechanical analysis, we can conclude that this fixation method can stand the load to the greater trochanter during daily life, without the failure of the fixation.更多还原