Power hip screw;Anti-rotation proximal femoral intramedullary nail;Intertrochanteric fracture
With the continuous and rapid economic and social development, the average life expectancy of the nation is increasing and the aging process of the population is accelerating. The number of traffic accidents is increasing due to the significant increase in the number of motor vehicles, and the incidence of intertrochanteric fractures caused by external forces is increasing. In order to enable patients to get out of bed as soon as possible after surgery, reduce complications caused by long-term bed rest, restore limb function as soon as possible, and improve the quality of life, surgery should be performed as soon as possible if the patient’s general condition can tolerate the surgery, and the Dynamic hip screw (DHS) and Proximal femoral nail antirotation (PFNA) are now the first choice. The first choice for intertrochanteric fracture surgery. In this study, we compare the clinical efficacy of two different treatment methods and their complication prevention and control, which are reported as follows.
1. Data and methods
1.1 General information
From February 2009 to April 2012, 92 patients, 40 male and 52 female, aged 18-98 years, with an average age of 71.5 years, were selected to receive intertrochanteric fracture of the femur in our hospital. The patients were randomly divided into two groups with full consideration of the patient’s condition and the physician’s surgical habits. 52 patients in the DHS group: 25 males and 27 females, aged 49-98 years, average 68.7 years, 20 patients with hypertension, 12 patients with diabetes mellitus, and 7 patients with stroke. In the PFNA group, there were 40 patients: 20 males, 20 females, aged 18-95 years, average 74.3 years, 15 cases with hypertension, 13 cases with diabetes mellitus, 8 cases with stroke, Evans Jensen typing: 13 cases of type I-II, 13 cases of type III, and 14 cases of type IV-V. There was no statistically significant difference between the two groups in terms of gender, age, co-morbidities, and Evans typing ( > 0.05).
1.2 Surgical methods
1.2.1 DHS group: After perfecting the preoperative examination and the onset of general anesthesia, the patients were placed flat on the traction bed, and the fracture ends were repositioned by traction of the lower limbs under C-arm fluoroscopy, and the puncture path was positioned with a guide needle on the body surface. Taking the greater trochanter as the apex, a longitudinal incision was made lateral to the femur, and the proximal end of the femur and the trochanter were exposed layer by layer. The guide needle is drilled with a femoral locator below the greater trochanter, and the height, depth and anterior inclination of the guide needle are adjusted according to intraoperative fluoroscopy. A DHS drill is used to drill and tap along the guide pin, screw in the DHS sleeve nail, install the DHS steel plate, drill and screw in the screw, install the tail cap and fix it, and then the fracture end is well aligned on C-arm fluoroscopy, the wound is irrigated and drained, and sutured layer by layer.
1.2.2 PFNA group: After completing the preoperative examination and the onset of general anesthesia, the patient was placed supine on the traction table, and closed traction repositioning was performed under C-arm guidance. A longitudinal incision was made proximally starting from the apex of the greater trochanter, and a guide pin was inserted with the apex of the greater trochanter, and the position of the guide pin was confirmed under fluoroscopy. The femoral neck screw sight was installed, and the subtrochanteric bone was incised layer by layer in the direction of the sight, and the sight was inserted and one guide pin was inserted, and the position was confirmed by frontal and lateral fluoroscopy. The distal femoral screw sight was installed, and the femoral bone was incised in the direction of the sight layer by layer to reach the femoral bone, and the sight was inserted and drilled for detection, and the femoral neck trilobular screw was inserted to lock it, and the position was confirmed by fluoroscopy. Remove the sight and confirm the fracture repositioning and screw position by fluoroscopy. The wound is irrigated and sutured layer by layer. Those who are difficult to achieve satisfactory repositioning by manual repositioning can be incised and repositioned, and those who are not easily displaced by separation of the small ramus can be tied with wire.
1.3 Observation indexes
The observation indexes included incision length, operation time, intraoperative bleeding, complications, and average postoperative hospitalization days.
1.4 Statistical processing
SPSS 13.0 was used for statistical analysis. The data of measurement data were expressed as mean ± standard deviation (x ± s), and the two-sample mean t-test was applied for statistical analysis. The comparison of means between two groups was performed using the t-test, and the comparison of rates between groups was performed using the 2-test, with P < 0.05 as the basic detection index for statistically significant differences.
2. Results
2.1 Comparison of surgical treatment results between the two groups
In the DHS group, the average incision length was 12.48 cm, the average operating time was 121.92 min, the average intraoperative bleeding was 146.15 ml, and there were 16 cases of postoperative complications such as pneumonia, deep vein thrombosis, gastritis, and subcutaneous hematoma, with an average hospital stay of 19.13 d. In the PFNA group, the average incision length was 7.40 cm, the average operating time was The average incision length, operating time, intraoperative bleeding and hospital days were < 0.05, which was statistically significant, and the PFNA group was superior to the DHS group. The occurrence of complications required the use of the 2 test, < 0.05, and the difference was statistically significant, and the PFNA group was superior to the DHS group.
2.2 Comparison of postoperative hip function assessment
The postoperative hip function was evaluated according to the Harris WH scoring system, and the excellent rate was 51.9% in the DHS group and 92.5% in the PFNA group, and the excellent rate in the PFNA group was significantly higher than that in the DHS group ( 2 = 17.58, < 0.05). The patients in both groups were followed up after surgery for 9-30 m, with a mean of 15 m. The excellent rate of long-term follow-up improvement of hip function was 100% in the PFNA group and 63.5% in the DHS group. The difference was tested to be statistically significant ( 2=10.61, < 0.05).
3. Discussion
With the progress of society, the incidence of fractures caused by external injuries such as car accidents and osteoporosis in the elderly has increased, among which the incidence of intertrochanteric fractures of the femur is higher. Conservative treatment requires patients to stay in bed and brake for a long time, which is prone to complications such as decubitus ulcers, crushing pneumonia, and deep vein thrombosis, causing or aggravating other systemic diseases and even endangering life. Therefore, if there is no contraindication to surgery, a systematic evaluation of the physical condition and fracture type should be performed to select the most suitable surgical method and timing, and actively adopt surgical treatment. The former is represented by power hip screw (DHS) fixation, and the latter is represented by proximal femoral nail (PFNA) fixation, which is suitable for most intertrochanteric fractures (Evans I-IV) and has a high success rate in treating stable intertrochanteric fractures. PFNA is widely used for all types of intertrochanteric fractures.
The DHS can apply pressure and slide, and through the sliding tension screw to produce static pressure on the fracture end, so that the distal and proximal ends of the fracture are close to each other and have stress stimulation, which can accelerate fracture healing; when weight-bearing, the sleeve type connection can withstand greater bending capacity, provide power compression, and enhance stability; the DHS nail body part has a slide groove and the pin on the wall of the sleeve can effectively counteract the hip The DHS nail body has a sliding groove and a pin on the wall of the sleeve to effectively counteract the inversion shear force of the hip, ensure the stability of the fracture end and reduce the incidence of hip inversion deformity. However, because it is located on the lateral side of the femur, the surgical operation is traumatic, the operation time is long, the anti-rotation ability is relatively poor, and it is not easy to fix firmly after loosening, which often leads to fixation failure for A2.3 and A3 fractures. In addition, the procedure of screwing the main nail in DHS depends on the surgeon’s experience, which may affect the accuracy of the procedure and may affect the functional recovery of the affected limb.
The PFNA is a modification of the PFN system, which has the same biomechanical characteristics as the original PFN and inherits its advantages, and an innovative design for easier and more effective fixation, with a 6° outward curve at the tip of the main nail, which allows for smooth insertion of the main nail and minimizes marrow expansion, which reduces damage to the marrow cavity and facilitates fracture healing. The spiral blade locking technique replaces the traditional 2-screw fixation, and the wide contact area between the rotating wing and the bone improves the overall stability of the fixation by generating stronger support, especially for unstable, comminuted, and elderly intertrochanteric fractures with a high degree of osteoporosis.PFNA is designed according to the physiological load line and can take most of the medial load of the proximal femur, reducing the compressive stress in the femoral talus to almost zero.
PFNA is a reliable internal fixation modality for the treatment of intertrochanteric fractures. In addition, the use of femoral screw aimer makes the screw positioning more precise, shortens the operation time during the operation, and the needle is inserted by the greater trochanter, which reduces the damage to the hip abductor group, reduces the patient’s surgical trauma and shortens the hospital stay, all of which are beneficial to the patient’s postoperative limb function recovery. Through this clinical study, the author believes that PFNA fixation for intertrochanteric fractures is a recommended surgical method for the treatment of intertrochanteric fractures with less injury and less postoperative blood leakage, which is more conducive to the overall recovery of patients, especially for elderly people with underlying cardiopulmonary diseases or those who cannot tolerate excessive surgical trauma.