股骨转子间骨折是一种常见的骨折,手术内固定治疗已成为共识,可以降低长期卧床后的并发症。目前应用的内固定系统虽已逐步完善改进,但仍有很多失败的报道。本文总结分析了股骨近端的形态结构和力学特性,认为股骨近端的特殊形态由张力性骨小梁与压力性骨小梁共同维持,当股骨转子间发生骨折后,压力性骨小梁与张力性骨小梁的作用均消失,无法维持股骨近端正常的形态结构。目前的内固定方式是以恢复股骨近端内侧的支撑结构为主,即重塑了压力性骨小梁的作用,而忽略了张力性骨小梁的作用,过度地依赖内侧结构支撑,是一种并不完善的内固定方式。据此认为,更理想的内固定应该能重建张力性骨小梁与压力性骨小梁的双重作用,使张力-压力达到平衡重建,协同发挥作用,才能更好地维持骨折端的稳定性和股骨近端的形态。本文提出的股骨转子间骨折治疗中应该遵循“张力-压力平衡重建”的内固定理论,可为股骨近端骨折内固定设计提供新的指导方向,解决现有内固定器械的不足之处。
Intertrochanteric fractures are very common, and internal fixation has become a consensus, which can reduce bedridden complications. Although the current internal fixation system has been gradually improved, there are still many reports of failure. Considering the structure and biomechanical characteristics of the proximal femur, the special structure of the proximal femur is maintained by tension trabecula and compression trabecula together. The effects of compression and tension trabecula disappear when intertrochanteric fractures occur, and the normal morphology of the proximal femur couldn’t be maintained. Current internal fixation can reconstruct the support structure of the proximal femur, which restores the function of compression trabecula, but neglects the function of tension trabecula. Overly relying on internal structure support is not a perfect internal fixation. Therefore, a better internal fixation should be able to reconstruct both tension and compression trabecula, ensuring tension-compression balance and joint function, maintaining the stability of the affected side and the morphology of the proximal femur. We proposed for the first time the internal fixation theory of "tension-pressure balanceable reconstruction" for the treatment of intertrochanteric fractures, aiming to provide a new direction of the internal fixation design for proximal femoral fractures and address the shortcomings of current internal fixation devices.
[1] Adeyemi A, Delhougne G.Incidence and economic burden of intertrochanteric fracture: a medicare claims database analysis[J]. JBJS Open Access, 2019,4(1): e0045.
[2] Chang SM, Hou ZY, Hu SJ, et al.Intertrochanteric femur fracture treatment in Asia: what we know and what the world can learn[J]. Orthop Clin N Am, 2020,51(2): 189-205.
[3] Fischer H, Maleitzke T, Eder C, et al.Management of proximal femur fractures in the elderly: current concepts and treatment options[J]. Eur J Med Res, 2021, 26(1): 86.
[4] Mattisson L, Bojan A, Enocson A.Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register[J]. BMC Musculoskelet Disord, 2018, 19(1): 369.
[5] Fan JX, Xu XY, Zhou F, et al.Risk factors for implant failure of intertrochanteric fractures with lateral femoral wall fracture after intramedullary nail fixation[J]. Injury, 2021,52(11):3397-3403.
[6] Zhang W, Antony Xavier RP, Decruz J, et al.Risk factors for mechanical failure of intertrochanteric fractures after fixation with proximal femoral nail antirotation (PFNA II): a study in a Southeast Asian population[J]. Arch Orthop Trauma Surg, 2021,141(4): 569-575.
[7] Zhong G, Teng L, Li H, et al.Surgical treatment of internal fixation failure of femoral peritrochanteric fracture[J]. Orthop Surg, 2021, 13(6): 1739-1747.
[8] 祝晓忠,梅炯,倪明,等. 股骨近端骨小梁结构的大体解剖和影像重建分析[J]. 中国修复重建外科杂志,2019,33(10):1254-1259.
[9] Tobin WJ. The internal architecture of the femur and its clinical significance; the upper end[J]. J Bone Joint Surg (Am), 1955, 37-A(1): 57-72
[10] 马信龙, 李海涛, 马剑雄, 等. 股骨近端主张力骨小梁生物力学特性[J]. 国际生物医学工程杂志, 2011, 34(5): 270-274.
[11] Johannesdottir F, Poole K, Reeve J, et al.Distribution of cortical bone in the femoral neck and hip fracture: a prospective casecontrol analysis of 143 incident hip fractures; the AGESREYKJAVIK Study[J]. Bone, 2011, 48(6): 1268-1276.
[12] Gotfried Y.The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures[J]. Clin Orthop Relat Res,2004,(425):82-86.
[13] Jensen JS.Classification of trochanteric fractures[J].Acta Orthop Scand, 1980, 51(5): 803-810.
[14] Chen SY, Tuladhar R, Chang SM.Fracture reduction quality is more important than implant choice for stability reconstruction in two-part intertrochanteric femur fractures[J]. J Orthop Trauma, 2020, 34(6): e227-228.
[15] Evans EM.The treatment of trochanteric fractures of the femure[J].J Bone Joint Surg Br, 1949,31(2):190-203.
[16] 王欣,张英琪,张世民,等. 股骨转子间骨折前内侧角骨皮质形态的影像学研究[J]. 中国修复重建外科杂志,2019, 33(10):1260-1264.
[17] Gotfried Y. The Gotfried (Nonanatomic, Closed) reduction of unstable subcapital femoral fractures[J]. Tech in Ortho, 2014, 29(4):259-261.
[18] 张世民,张英琪,李清,等. 内侧皮质正性支撑复位对老年股骨粗隆间骨折内固定效果的影响[J]. 中国矫形外科杂志, 2014,22(14):1256-1261.
[19] Dendorfer S, Maier HJ, Taylor D, et al.Anisotropy of the fatigue behaviour of cancellous bone[J]. Biomech, 2008,41(3): 636-641.
[20] 朱燕宾,丁凯,李泳龙,等. 三角支撑固定系统固定股骨转子间骨折的生物力学有限元分析[J]. 中华骨科杂志,2021,41(18):1361-1366.
[21] 张殿英, 郁凯, 杨剑, 等. "杠杆-支点平衡"理论——对股骨转子间骨折治疗的新认识[J]. 中华创伤杂志, 2020, 36(7): 647-651.
[22] 朱燕宾,陈伟,叶丹丹,等. 股骨近端N三角理论及股骨近端仿生髓内钉(PFNB)的设计理念[J]. 中华老年骨科与康复电子杂志,2021,7(5):257-259.
