不稳定股骨转子间骨折前内侧皮质支撑复位的影像学研究
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摘要
[目的]不稳定股骨转子间骨折(31A2型)均伴有分离的后内侧小转子骨块,获得前内侧皮质复位是重建骨折稳定性的关键。本研究比较前内侧皮质对位关系的术中透视影像与术后三维CT(3D-CT)立体影像,探讨二者的一致性和变化因素。[方法]回顾性分析2016年1月~2017年10月,本院采用头髓钉治疗A2型不稳定股骨转子间骨折患者,收集具有完整术中透视和术后3D-CT影像资料的病例共63例,男22例,女41例,平均年龄(82.34±6.85)岁。术中侧位透视将前侧皮质对位关系分为3种:正性支撑、中性支撑和负性支撑。正性支撑指头颈骨块前侧皮质位于骨干前侧皮质的前方(髓腔外),中性支撑指头颈骨块前侧皮质与骨干前侧皮质获得平滑的完全对位;负性支撑指头颈骨块前侧皮质位于骨干前侧皮质的后方(髓腔内,即前侧皮质无支撑)。术后3D-CT旋转立体观察,能反映真正的皮质对位情况,将头颈骨块与骨干前内侧角皮质的关系分为有接触有抵住和无接触未抵住两种类型。将术中透视影像与术后CT影像进行对比,计算各种皮质对位类型的例数、百分比及术后改变。[结果]术中侧位透视皮质对位为负性者23例,术后3D-CT观察仅5例(21.74%)获得真正的前内侧皮质支撑。术中侧位透视为中性或正性者40例,术后3D-CT观察32例(80.00%)获得前内侧皮质支撑,两者差异有统计学意义(P<0.05)。术中侧位透视为正性者仅4例,术后3D-CT观察全部获得前内侧皮质支撑(100.00%)。[结论]术中侧位透视前侧皮质对位关系为正性或中性者,术后头颈骨块容易获得稳定的前内侧角皮质接触支撑,而负性对位关系则意味着头颈骨块容易失去前内侧皮质的接触。
[Objective] To compare the consistency and variation factors between intra-operative fluoroscopy and post-operative 3D-CT reconstruction for the relationship of anteromedial cortical support reduction in femoral cephalomedullary nail for unstable pertrochanteric fractures. [Methods] A retrospective study was conducted on 63 patients treated with short femoral cephalomedullary nails for pertrochanteric fractures between January 2016 and October 2017. Of them, 22 males and 41 females aged(82.34±6.85) years on average. All patients had full sets of intra-operative fluoroscopy and post-operative 3D-CT images. The relation of proximal and distal fragments on the lateral view of intraoperative fluoroscopy was categorized into 3 types: the positive, neutral and negative support. The positive support meant that the anterior cortex of the head-neck fragment located anteromedially outside the medullary cavity of the femoral shaft, the neutral support denoted that the anterior cortices well aligned, while the negative support referred to that the cortex of the head-neck fragment positioned posteromedially inside the medullary cavity of the femoral shaft. In addition, the cortical contact and non-cortical contact of the fracture ends were identified on the postoperative 3D-CT images. The numbers of various types of cortical alignment and changes in cortical support and reduction quality were calculated and compared between intraoperative fluoroscopy and postoperative 3D-CT images. [Results] Only 5 patients(21.74%) of 23 patients who had negative support on lateral view by intraoperative fluoroscopy, obtained anteromedial cortical contact on the postoperative3 D-CT images. By contrast, among 40 patients had neutral or positive support on lateral view of fluoroscopy intraoperatively, 32 patients(80.00%) achieved anteromedial cortical contact on postoperative 3D-CT. There was a statistically significant difference revealed by Chi-square test between the two group(P<0.05). Although only 4 patients got positive support on lateral fluoroscopy intraoperatively, all of them(100.00%) obtained anteromedial cortical contact on postoperative 3D-CT images. [Conclusions] Obtaining a positive or neutral cortex position in intraoperative fluoroscopy usually means a true cortex support in postoperative 3D-CT, while a negative cortical position usually means lost cortical support.
[Objective] To compare the consistency and variation factors between intra-operative fluoroscopy and post-operative 3D-CT reconstruction for the relationship of anteromedial cortical support reduction in femoral cephalomedullary nail for unstable pertrochanteric fractures. [Methods] A retrospective study was conducted on 63 patients treated with short femoral cephalomedullary nails for pertrochanteric fractures between January 2016 and October 2017. Of them, 22 males and 41 females aged(82.34±6.85) years on average. All patients had full sets of intra-operative fluoroscopy and post-operative 3D-CT images. The relation of proximal and distal fragments on the lateral view of intraoperative fluoroscopy was categorized into 3 types: the positive, neutral and negative support. The positive support meant that the anterior cortex of the head-neck fragment located anteromedially outside the medullary cavity of the femoral shaft, the neutral support denoted that the anterior cortices well aligned, while the negative support referred to that the cortex of the head-neck fragment positioned posteromedially inside the medullary cavity of the femoral shaft. In addition, the cortical contact and non-cortical contact of the fracture ends were identified on the postoperative 3D-CT images. The numbers of various types of cortical alignment and changes in cortical support and reduction quality were calculated and compared between intraoperative fluoroscopy and postoperative 3D-CT images. [Results] Only 5 patients(21.74%) of 23 patients who had negative support on lateral view by intraoperative fluoroscopy, obtained anteromedial cortical contact on the postoperative3 D-CT images. By contrast, among 40 patients had neutral or positive support on lateral view of fluoroscopy intraoperatively, 32 patients(80.00%) achieved anteromedial cortical contact on postoperative 3D-CT. There was a statistically significant difference revealed by Chi-square test between the two group(P<0.05). Although only 4 patients got positive support on lateral fluoroscopy intraoperatively, all of them(100.00%) obtained anteromedial cortical contact on postoperative 3D-CT images. [Conclusions] Obtaining a positive or neutral cortex position in intraoperative fluoroscopy usually means a true cortex support in postoperative 3D-CT, while a negative cortical position usually means lost cortical support.
引文
[1]姬晨妮,陈伟,朱燕宾,等.京津唐地区1583例老年股骨转子间骨折流行病学特征分析[J/CD].中华老年骨科与康复电子杂志,2015,1(1):45-49.
[2]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.
[3]Chang SM,Zhang YQ,Ma Z,et al.Fracture reduction with positive medial cortical support:a key element in stability reconstruction for the unstable pertrochanteric hip fractures[J].Arch Orthop Trauma Surg,2015,135(6):811-818.
[4]Murena L,Moretti A,Meo F,et al.Predictors of cut-out after cephalomedullary nail fixation of pertrochanteric fractures:a retrospective study of 813 patients[J].Arch Orthop Trauma Surg,2018,138(3):351-359.
[5]Li J,Zhang L,Zhang H,et al.Effect of reduction quality on postoperative outcomes in 31-A2 intertrochanteric fractures following intramedullary fixation:a retrospective study based on computerised tomography findings[J/CD].Int Orthop,2018 Aug 16.doi:10.1007/s00264-018-4098-1.[Epub ahead of print]
[6]Nie B,Chen X,Li J,et al.The medial femoral wall can play a more important role in unstable intertrochanteric fractures compared with lateral femoral wall:a biomechanical study[J].J Orthop Surg Res,2017,12(1):197.
[7]Park YC,Yoon SP,Yang KH.The effects of extramedullary reduction in unstable intertrochanteric fracture:a biomechanical study using cadaver bone[J].J Kor Fract Soc,2018,31(3):79-86.
[8]Chang SM,Zhang YQ,Du SC,et al.Anteromedial cortical support reduction in unstable pertrochanteric fractures:a comparison of intra-operative fluoroscopy and post-operative 3D CT reconstruction[J].Int Orthop,2018,42(1):183-189.
[9]张世民,李海丰,俞光荣.老年髋部骨折的临床治疗流程[J].中国矫形外科杂志,2005,13(18):1365-1368.
[10]张世民,祝晓忠,黄轶刚,等.外侧壁危险型股骨粗隆间骨折DHS与PFNA治疗的回顾性对比研究[J].中国矫形外科杂志,2010,18(22):1868-1872.
[11]Tsukada S,Wakui M,Yoshizawa H,et al.Three-dimensional computed tomographic analysis for comminution of pertrochanteric femoral fracture:comminuted anterior cortex as a predictor of cutting out[J].Open Orthop J,2016,10(1):62-70.
[12]Sharma G,Gn KK,Khatri K,et al.Morphology of the posteromedial fragment in pertrochanteric fractures:a three-dimensional computed tomography analysis[J].Injury,2017,48(2):419-431.
[13]Ehrnthaller C,Olivier AC,Gebhard F,et al.The role of lesser trochanter fragment in unstable pertrochanteric A2 proximal femur fractures-is refixation of the lesser trochanter worth the effort[J].Clin Biomech(Bristol,Avon),2017,42(1):31-37.
[14]Kim GM,Nam KW,Seo KB,et al.Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable intertrochanteric fractures:a modified candy-package wiring technique[J].Injury,2017,48(2):406-413.
[15]Lee SR,Kim ST,Yoon MG,et al.The stability score of the intramedullary nailed intertrochanteric fractures:stability of nailed fracture and postoperative patient mobilization[J].Clin Orthop Surg,2013,5(1):10-18.
[16]Baumgaertner MR,Curtin SL,Lindskog DM,et al.The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip[J].J Bone Joint Surg Am,1995,77(7):1058-1064.
[17]Fogagnolo F,Kfuri M Jr,Paccola CA.Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail[J].Arch Orthop Trauma Surg,2004,124(1):31-37.
[18]Butler BA,Selley RS,Summers HD,et al.Preventing wedge deformities when treating intertrochanteric femur fractures with intramedullary devices:a technical tip[J].J Orthop Trauma,2018,32(3):112-116.
[19]Tsukada S,Okumura G,Matsueda M.Postoperative stability on lateral radiographs in the surgical treatment of pertrochanteric hip fractures[J].Arch Orthop Trauma Surg,2012,132(6):839-846.
[20]Kozono N,Ikemura S,Yamashita A,et al.Direct reduction may need to be considered to avoid postoperative subtype P in patients with an unstable trochanteric fracture:a retrospective study using a multivariate analysis[J].Arch Orthop Trauma Surg,2014,134(12):1649-1654.
[21]Ito J,Takakubo Y,Sasaki K,et al.Prevention of excessive postoperative sliding of the short femoral nail in femoral trochanteric fractures[J].Arch Orthop Trauma Surg,2015,135(5):651-657.
[22]Kim TY,Lee YB,Chang JD,et al.Torsional malalignment,how much significant in the trochanteric fractures[J].Injury,2015,46(11):2196-2200.
[2]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.
[3]Chang SM,Zhang YQ,Ma Z,et al.Fracture reduction with positive medial cortical support:a key element in stability reconstruction for the unstable pertrochanteric hip fractures[J].Arch Orthop Trauma Surg,2015,135(6):811-818.
[4]Murena L,Moretti A,Meo F,et al.Predictors of cut-out after cephalomedullary nail fixation of pertrochanteric fractures:a retrospective study of 813 patients[J].Arch Orthop Trauma Surg,2018,138(3):351-359.
[5]Li J,Zhang L,Zhang H,et al.Effect of reduction quality on postoperative outcomes in 31-A2 intertrochanteric fractures following intramedullary fixation:a retrospective study based on computerised tomography findings[J/CD].Int Orthop,2018 Aug 16.doi:10.1007/s00264-018-4098-1.[Epub ahead of print]
[6]Nie B,Chen X,Li J,et al.The medial femoral wall can play a more important role in unstable intertrochanteric fractures compared with lateral femoral wall:a biomechanical study[J].J Orthop Surg Res,2017,12(1):197.
[7]Park YC,Yoon SP,Yang KH.The effects of extramedullary reduction in unstable intertrochanteric fracture:a biomechanical study using cadaver bone[J].J Kor Fract Soc,2018,31(3):79-86.
[8]Chang SM,Zhang YQ,Du SC,et al.Anteromedial cortical support reduction in unstable pertrochanteric fractures:a comparison of intra-operative fluoroscopy and post-operative 3D CT reconstruction[J].Int Orthop,2018,42(1):183-189.
[9]张世民,李海丰,俞光荣.老年髋部骨折的临床治疗流程[J].中国矫形外科杂志,2005,13(18):1365-1368.
[10]张世民,祝晓忠,黄轶刚,等.外侧壁危险型股骨粗隆间骨折DHS与PFNA治疗的回顾性对比研究[J].中国矫形外科杂志,2010,18(22):1868-1872.
[11]Tsukada S,Wakui M,Yoshizawa H,et al.Three-dimensional computed tomographic analysis for comminution of pertrochanteric femoral fracture:comminuted anterior cortex as a predictor of cutting out[J].Open Orthop J,2016,10(1):62-70.
[12]Sharma G,Gn KK,Khatri K,et al.Morphology of the posteromedial fragment in pertrochanteric fractures:a three-dimensional computed tomography analysis[J].Injury,2017,48(2):419-431.
[13]Ehrnthaller C,Olivier AC,Gebhard F,et al.The role of lesser trochanter fragment in unstable pertrochanteric A2 proximal femur fractures-is refixation of the lesser trochanter worth the effort[J].Clin Biomech(Bristol,Avon),2017,42(1):31-37.
[14]Kim GM,Nam KW,Seo KB,et al.Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable intertrochanteric fractures:a modified candy-package wiring technique[J].Injury,2017,48(2):406-413.
[15]Lee SR,Kim ST,Yoon MG,et al.The stability score of the intramedullary nailed intertrochanteric fractures:stability of nailed fracture and postoperative patient mobilization[J].Clin Orthop Surg,2013,5(1):10-18.
[16]Baumgaertner MR,Curtin SL,Lindskog DM,et al.The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip[J].J Bone Joint Surg Am,1995,77(7):1058-1064.
[17]Fogagnolo F,Kfuri M Jr,Paccola CA.Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail[J].Arch Orthop Trauma Surg,2004,124(1):31-37.
[18]Butler BA,Selley RS,Summers HD,et al.Preventing wedge deformities when treating intertrochanteric femur fractures with intramedullary devices:a technical tip[J].J Orthop Trauma,2018,32(3):112-116.
[19]Tsukada S,Okumura G,Matsueda M.Postoperative stability on lateral radiographs in the surgical treatment of pertrochanteric hip fractures[J].Arch Orthop Trauma Surg,2012,132(6):839-846.
[20]Kozono N,Ikemura S,Yamashita A,et al.Direct reduction may need to be considered to avoid postoperative subtype P in patients with an unstable trochanteric fracture:a retrospective study using a multivariate analysis[J].Arch Orthop Trauma Surg,2014,134(12):1649-1654.
[21]Ito J,Takakubo Y,Sasaki K,et al.Prevention of excessive postoperative sliding of the short femoral nail in femoral trochanteric fractures[J].Arch Orthop Trauma Surg,2015,135(5):651-657.
[22]Kim TY,Lee YB,Chang JD,et al.Torsional malalignment,how much significant in the trochanteric fractures[J].Injury,2015,46(11):2196-2200.