粉碎性股骨逆转子间骨折一期重建外侧壁:如何提高修复后骨生物力学稳定性

One-stage reconstruction of the lateral wall of comminuted reverse oblique intertrochanteric fractures:how to improve the biomechanical stability of bone after repair

背景:进入21世纪以来随着对股骨近端解剖结构认识的不断提高,是否需要一期修复外侧壁成为伴外侧壁损伤的股骨转子间骨折手术需要考虑的问题。目的:围绕近年来重建粉碎性股骨逆转子间骨折(AO/OTA分型A3.3型骨折)外侧壁常用的手术方式进行综述,对比不同治疗方案的优缺点,展望外侧壁重建治疗的发展方向。方法:以"A3.3型,粉碎性,逆转子间骨折,外侧壁,内固定手术,修复重建"及"AO/OTA 31-A3.3,comminuted,reverse oblique intertrochantericfractures,lateralwall,internalfixationtechniques,repairmentandreconstruction"作为关键词,在万方、中国知网、Pub Med数据库查阅国内外相关文献,检索时间为2014至2021年,共选取69篇文献进行综述。结果与结论:(1)针对粉碎性股骨逆转子间骨折,单纯髓外固定能够重建外侧壁且防旋性能较好,但软组织剥离较多且生物力学较差;(2)髓内固定联合髓外固定,同样不可避免地对软组织及血运有所破坏,但生物力学稳定、内固定失效率低、髋关节功能明显提高;(3)其中以股骨近端防旋髓内钉联合微创经皮钢板内固定为代表的髓内+有限髓外固定,有效降低了联合固定的创伤,综合疗效最佳,也揭示了粉碎性逆转子间骨折手术方式微创化的发展前景。

BACKGROUND:Since the beginning of the 21 st century,one-stage repair of the lateral wall has become a problem to be considered in the internal fixation of femoral intertrochanteric fractures with lateral wall injury with the continuous improvement of the understanding of the anatomical structure of the proximal femur.OBJECTIVE:To review common surgical methods for reconstruction of the lateral wall of comminuted reverse oblique intertrochanteric fractures(AO/OTA classification system:type A3.3 fracture)in recent years,compare the advantages and disadvantages of different treatment options,and look forward to the development direction of reestablishment of the lateral wall.METHODS:The author searched databases including Wanfang,CNKI and Pub Med for domestic and foreign relevant articles with key words"type A3.3,comminuted,reverse oblique intertrochanteric fractures,lateral wall,internal fixation operation,repairment and reconstruction"in Chinese and English.The search time was from 2014 to 2021 and a total of 69 articles were selected for review.RESULTS AND CONCLUSION:(1)For comminuted reverse oblique intertrochanteric fractures,simple extramedullary fixation can reestablish the lateral wall while having a better anti-rotation performance,but brings more soft tissue exfoliations and poorer biomechanical performance.(2)Intramedullary fixation combined with extramedullary fixation inevitably destroys soft tissues and the blood supply,but it has the advantages of maintaining biomechanical stability,the low failure rate,and the significant better effect of improving the function of hip joint than that of simple extramedullary fixation.(3)Among them,the osteosynthesis that proximal femoral nail antirotation combined with minimally invasive percutaneous plate represents intramedullary combined with limited extramedullary fixation,and it effectively reduces the trauma of combined fixation and has the best comprehensive curative effect,and also reveals the prospects based on the rationale of minimal invasion.