钳夹辅助复位治疗高位股骨转子下骨折手术技术

Clamp-Assisted Reduction of High Subtrochanteric Fractures of the Femur Surgical Technique

背景：股骨转子下骨折的治疗具有复杂性。由于该部位具有较大的（肌肉）牵拉应力而使得近端骨折块较易移位以致于使骨折端的精确复位及内固定物放置困难。本研究的目的是评价一组高位股骨转子下骨折患者采取钳夹辅助复位及髓内钉内固定对于骨折愈合率及骨折复位质量的影响。方法：自2003年12月到2007年1月，来自于两个一级创伤中心共55例移位型高位股骨转子下骨折患者，其中2例死亡，9例失访。剩余44例患者均得到随访至术后6个月或至骨性愈合；男27例，女17例，平均年龄55岁。均采用扩髓型顺行静态锁定髓内钉内固定系统，同时通过外侧小切口使用钳夹辅助复位，其中9例患者加用线缆环扎骨折端。术后常规X线检查，评价骨折复位质量及骨折愈合情况。结果：随访44例患者中，43例患者达到骨性愈合，骨折复位后冠状面及矢状面成角均不大于5°。38例（86％）达到解剖复位，6例患者骨折端发生轻微的内翻畸形（2°-5°），所有的患者均无并发症发生。结论：使用钳夹辅助复位髓内钉固定适时加用线缆环扎骨折端治疗股骨转子下骨折可达到满意的骨折复位和较高的术后骨折愈合率。手术成功要点是操作细微，尽量减少对软组织的剥离。可信水平：治疗性研究Ⅳ级。关于证据等级的完整描述详见投稿须知。

BACKGROUND： Subtrochanteric fractures can be a treatment challenge. The substantial forces that this region experiences and the fact that the proximal fragment is frequently displaced make accurate reduction and internal fixation difficult. The purpose of this study was to evaluate a series of patients who had undergone clamp-assisted reduction and intramedullary nail fixation to determine the impact of this technique on fracture union rates and reduction quality. METHODS： Between December 2003 and January 2007, fifty-five consecutive patients with a displaced high subtrochantericfemoral fracture were treated with clamp-assisted reduction and intramedullary nail fixation at two level-I trauma centers. Twopatients died, and nine were lost to follow-up. The remaining forty-four patients were followed until union or a minimum of six months. There were twenty-seven male and seventeen female patients with a mean age of fifty-five years. All were treated with an antegrade statically locked nail implanted with a reaming technique as well as the assistance of a reduction clamp placed through a small lateral incision. Nine patients were treated with a single supplemental cerclage cable. Radiographs were evaluated for the quality of the reduction and fracture union. RESULTS： Forty-three of the forty-four fractures united. All reductions were within 5° of the anatomic position in both the frontal and the sagittal plane. Thirty-eight （86%） of the forty-four reductions were anatomic. Six fractures had a minor varus deformity of the proximal fragment （between 2° and 5°）. There were no complications. DISCUSSION： Surgical treatment of subtrochanteric femoral fractures with clamp-assisted reduction and intramedullal7 nail fixation techniques with judicious use of a cerclage cable can result in excellent reductions and a high union rate. Careful attention to detail is important to perform these maneuvers with minimal additional soft-tissue disruption. LEVEL OF EVIDENCE： Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.