With the development of society our population is gradually entering an aging society, the incidence of femoral neck fractures in the elderly is increasing year by year, especially the comorbidities and complications of fractures in the elderly, and there is a high risk of high difficulty for surgical treatment. From 1995 to 2004, 126 cases were treated with minimally invasive surgery using manipulative closed reduction multi-pin crossover internal fixation with satisfactory results, which are summarized as follows.
1.Treatment method
(1) Preoperative preparation and anesthesia selection
According to the fracture end misalignment, shortening and displacement, the skin set traction was performed, and various biochemical items and cardiac function tests were performed to comprehensively analyze the cardiopulmonary function and systemic condition, and medication was given to correct the treatment according to the abnormality. Anesthesia is selected as continuous epidural or in general analgesia plus local infiltration anesthesia. The preoperative preparation is usually completed within 3~7 days.
(2) Preoperative repositioning
After successful anesthesia, the patient is placed supine on the operating table, and the fracture end is misaligned by C-arm X-ray machine, and closed repositioning is given in the traction state.
(3) Surgical method
The first needle was drilled with an electric drill and entered at a low angle as close as possible to the femoral spine in the direction of the stress-resistant trabeculae of the femoral neck to 1~3.5m below the cartilage of the femoral head, and the second one entered at an angle of 20~30 below the femoral neck in the tension-resistant zone of the femoral spine distribution, and the angle of the needle was controlled to be at an angle with the femoral stem. between 20~30 or even smaller.
The third needle with the first two needles into the angle of triangular distribution, in the distal and proximal ends of the fracture to form a multi-angle crossed triangle, the tail of the needle bending clamp break left into the subcutaneous layer. After the operation, the affected limb was kept in an abduction-neutral position wearing a dingzi shoe, and the analgesic pump was applied for about three days. After 24 hours, the patient was allowed to sit in a semi-sitting position, paying attention to the functional exercise of the joint without cross-leggedness, side-lying and weight-bearing, and local topical application of tendon and bone healing ointment ① to promote the early healing of the fracture.
2.Treatment results
(1) Assessment criteria
According to the industry standard of Chinese medicine, cure: satisfactory alignment, no local pain, no limp, normal hip extension, more than 90 degrees of hip flexion, and disappearance of fracture line on X-ray; improvement: good alignment, mild pain, limp, semi-squatting, and self-care, and disappearance of fracture line on X-ray; not cured: the injured limb could not walk, the fracture did not heal or the femoral head was necrotic. The group cured 96 cases, accounting for 76%, improved 16 cases, accounting for 12.7%, and not cured 14 cases, accounting for 11.1%.
(2) Follow-up results
The average follow-up was 3.5 years (1~5 years), 112 cases of fracture healing, 6 cases of femoral head necrosis, and 8 cases of non-healing, including 6 cases of Garden type IV. There was no early death and wound infection.
3. Discussion
(1) Selection of treatment methods
At present, the choice of treatment for femoral neck fracture in the elderly is mainly based on the patient’s age, disease duration, physical condition, type of fracture and clinical experience of the physician. There are major complications such as non-healing fracture and femoral head necrosis regardless of surgical or conservative treatment. Due to the poor ability of elderly patients to tolerate surgery, there is a high surgical risk for the long and traumatic surgery using artificial femoral head replacement.
Minimally invasive multi-needle cross fixation surgery is painless percutaneous internal fixation under anesthesia, easy to operate, completed in about 10 minutes, minimally invasive fixation is reliable, early postoperative non-weight-bearing joint functional exercise can be performed to prevent complications, and the cost is lower.
(2) Optimal mechanical layout of three kerf pins
In femoral neck fracture using three pins cross fixation, with the characteristics of multi-party fixation combined into geometric forms are isosceles triangle, sector, equilateral triangle and inverted triangle, the force on the femoral neck section is a compound of pressure, bending and shear, so for internal fixation equipment requires good anti-rotation and shear resistance; the direction, site and number of internal fixation have obvious influence on the strength of fixation, low angle into the needle and above Femoral stem into 20~30° is conducive to the pressure between the broken ends is conducive to shear resistance.
The pressure trabeculae and tension trabeculae in the parallel femoral neck area of the Kirschner pin meet the biomechanical requirements. It is proved by CT scan that the area with the greatest bone density during fracture fixation is the same as the femoral distance into the pin area, and the main stress area is in the same direction, so that the tension trabeculae carrying certain weight-bearing effects can bear the tension, and the three pins are crossed and fixed into a triangular three-dimensional to achieve a dynamic and static pressure effect, which minimizes the stress masking effect, and its pin is fine with little trauma, and the triangular crossed tensile strength is large, and the torsional strength is also It is the most solid fixation.
(3) Femoral head necrosis and fracture healing
The factors affecting fracture healing and femoral head necrosis include age, fracture type, compression defect and dislocation, fracture repositioning, operation time and operation technique. Most of them are directly related to the early and timely repositioning of the fracture and the reliable fixation. 150 cases in China have been reported by Bangfu and found no difference in the healing rate of those operated within two weeks, while the non-healing rate of those operated after two weeks increased.
Age is also a factor affecting healing. Foreign literature Brawn reported that the non-healing rate was 41% in female patients over 75 years old, and Beijing Jishuitan Hospital reported that the non-healing rate of fractures after 70 years old could be as high as 42.5%. The main causative factors of non-healing femoral head necrosis are rough technique, repeated repositioning, poor alignment of the fracture end, unreliable rotational fixation of the femoral head end, and collapse.
(4) Promote fracture healing with tendon and bone healing spirit
Fracture healing is an extremely complicated repair process, and Chinese medicine has a long history of treating fractures with remarkable efficacy. Chinese medicine can promote the deposition of calcium salts in the bone matrix at the fracture site, promote the secretion of growth hormone and control the effect of bone growth factor. The active ingredients of Tendon Healing Ointment are extracted by modern pharmaceutical process, and the absorption through skin is confirmed by clinical and animal pharmacodynamics, and it is observed that there is a significant difference between topical application of Tendon Healing Ointment at the same age, same site and same type of fracture in early stage and not using it for 5~12 days. After statistical treatment P<0.01, it is proved that Chinese medicine has the effect of promoting hematoma mechanization calcification, early internal and external bone scab formation with blood circulation and blood stasis, moving qi and relieving pain, joining bones and tendons, and promoting fracture healing.
We believe through clinical observation that the key to improving the overall treatment efficacy and preventing complications lies in early treatment and choosing the correct treatment plan. Minimally invasive multi-pin cross fixation for the treatment of high-grade femoral neck fractures is generally implemented within three to seven days of surgical treatment, reducing patient pain under anesthesia, and the key to obtaining good repositioning by skillful manipulation under X-ray television, and good repositioning is in turn the key to improving the fracture healing rate.
The method has a high fracture reduction rate, and the operation does not enter the joint, which is less traumatic, less bleeding, less trauma to the intramedullary vessels, less pain and faster recovery. The multi-pin crossover is in line with the biomechanical fixation principle, and the fixation is stable and reliable. Therefore, it is very conducive to the recovery of hip joint function, short bed rest time, and improves the overall efficacy of treating senior femoral neck fracture. Pre-operatively, a thorough treatment plan was formulated together with internal medicine and anesthesiology physicians, and the perioperative treatment was done well.
Postoperative analgesic pump is applied for about 3 days to relieve pain and intermittent oxygenation to improve the oxygen supply to the heart and brain, effectively preventing the occurrence of angina pectoris, myocardial infarction, and the risk of cardiovascular and cerebrovascular accidents. Promote fracture healing and prevent osteoporosis through traditional Chinese medicine and diet to reduce the occurrence of complications and improve the health and quality of life of the elderly.