Clinical application of trilobal titanium plate reconstruction of the greater trochanter in artificial femoral head replacement for unstable fractures of the trochanter in the elderly
With the gradual increase of elderly patients with osteoporosis, the incidence of intertrochanteric fractures in the senior femur is on a yearly upward trend, of which 35%-40% are unstable fractures and compared with internal fixation, artificial femoral head replacement can significantly shorten the bed resting time. The incidence of complications caused by bed rest can be reduced and the pre-injury living condition can be restored more quickly. Therefore, artificial joint replacement for the treatment of comminuted intertrochanteric fractures in the elderly has been widely performed in recent years. The purpose of this study is to compare the efficacy of wire and titanium plate reconstruction of the greater trochanter in cases of artificial femoral head replacement for intertrochanteric fractures over 75 years of age admitted to our hospital from March 2009 to October 2011.
1. Clinical data
1.1 General data
From March 2009 to October 2011, there were 67 cases of high age intertrochanteric fracture with artificial joint replacement, male: 31 cases; female: 36 cases. The mean age was 78.5 years (75 – 101 years); 25 cases were Evans type III, 32 cases were type IV, and 10 cases were type V. Joint replacement group: 67 cases were replaced with cemented double-stage artificial femoral head with an extended stem. The large ramus was fixed with wire plus Kirschner’s pin tension wire band in 20 cases, simple wire binding in 13 cases, and trefoil titanium reconstruction of large ramus in 34 cases. There were 43 cases of hypertension, 49 cases of coronary heart disease, 20 cases of cerebrovascular disease, 11 cases of sequelae of cerebral infarction, 36 cases of diabetes mellitus, 12 cases of old heart infarction and arrhythmia, 13 cases of senile chronic bronchitis, and 2 cases of dementia. There were 34 cases of two or more medical disorders.
1.2 Preoperative preparation
Patients were examined comprehensively on admission: routine blood tests, biochemistry, coagulation, D-dimer, sedimentation, arterial blood gas analysis, electrocardiogram, cardiac color Doppler ultrasound, abdominal B-exam, cervical vascular color ultrasound, chest X-ray, lumbar spine frontal and lateral radiographs, bilateral lower extremity vascular ultrasound to assess whether they can tolerate surgery, and to consult with disease-related internal medicine physicians for basic internal diseases and to formulate treatment plans. The patient’s heart, lungs, kidneys, brain and other important organ functions and life ability should be judged comprehensively before surgery. Correction of anemia, water-electrolyte disorders and acid-base balance disorders; improvement of nutritional status albumin must reach normal range before surgery. The patient’s heart function and respiratory function should be improved, blood viscosity should be decreased, antibiotics should be used before surgery, and blood should be prepared. Pelvic plain film examination, lateral film of the affected hip; anesthesiologist uses general anesthesia or combined lumbar and rigid anesthesia. The patient and family should be fully communicated and exchanged before the operation, and be fully informed of the surgical risks and postoperative complications.
1.3 Surgical method
Under continuous epidural block anesthesia or general anesthesia, the patient was placed in the lateral position, and the posterior lateral incision of the hip joint was taken, the gluteus maximus muscle was bluntly separated along the direction of muscle fiber travel, the attachment point of the gluteus medius muscle at the top of the femoral trochanter was preserved as much as possible, the joint capsule was opened, the femoral neck was osteotomized under the head, the femoral head and femoral neck fragments were removed, and the fracture block of the trochanter was fixed with a Kirschner pin plus wire or wire ties; a cloverleaf titanium plate was used to fix the fracture block of the trochanter The femoral stem is fixed with a cloverleaf titanium plate, and the lateral femoral stem is fixed with a single cortical screw. The bone is reamed from small to large, taking care not to damage the bone cortex, the distal plug is installed, the medullary cavity is flushed, the affected limb is flexed at 90°, and the femoral condyles are rotated forward at 10° to 15° to determine the anterior tilt angle into which the prosthesis is installed. The bone cement was injected into the medullary cavity with the third generation bone cement technique, and the femoral prosthesis stem was inserted to reshape the femoral spine with bone cement. When the bone cement solidifies, select the femoral head with appropriate neck length, reposition the joint, rinse the incision thoroughly, place a drainage tube, and suture the joint capsule and external rotation muscle group; close the incision layer by layer.
1.4 Postoperative treatment
Postoperative antibiotics for 3-5 days to prevent infection and postoperative drainage for 24-48 hours. On the first postoperative day, 5000 IU of low molecular heparin (Kesse) was injected subcutaneously once a day for 7-10 days to prevent deep vein thrombosis; the lower extremities were abducted in neutral position and worn with anti-rotation shoes. Functional exercise of lower limb muscles. Practice walking with weight on the ground within 1 week after surgery if the physical condition allows.
1.5 Observation indexes
Operating time, intraoperative bleeding, and postoperative complication rate of both groups. The postoperative hip function was evaluated by the Harris [2] scale: total score of 100 = > 90 excellent, 80-89 good, 70-79 good, < 70 poor. The imaging examination is mainly to understand whether the artificial joint prosthesis has sinking, dislocation, wear, and whether the wire and kerf pins fixing the greater trochanter have loosened and slipped. The screw titanium plate has no signs of screw loosening, etc.
1.6 Statistical processing
SPSS 13.0 software was applied for statistical analysis. The t-test and x2 test were used. p<0.05 difference was statistically significant.
2, Results
The group was followed up for 3 months-2 years; 4 cases of artificial femoral head replacement wire and kerfing needle reconstruction group had kerfing needle slipping out and displacement, wire loosening or fracture. 1 case of crushing pneumonia and 2 cases of wire cutting loosening. There were 2 cases of deep vein thrombosis in the lower extremity. There was no internal fixation loosening in the trefoil titanium plate fixation group. Typical cases. 2 cases of lower extremity deep vein thrombosis, 1 case of cerebral infarction, and 1 case of pulmonary embolism. There were no complications such as prosthesis loosening, sinking, dislocation and peripheral fracture.
There was no statistically significant (P>0.05) comparison of the operation time and bleeding volume between the two types of gross grand construction. The incidence of complications (P<0.05) was statistically significant. There was no statistically significant difference in the Harris score between the two types of gross grand construction (P > 0.05).
Table 1.
Operative time (min) Bleeding volume (ml) Complications (%) 3 months Harris score Wire group Titanium plate group
P45±25 50±20 >0.05
230±109 210±112 >0.05
27.3 11.8 <0.05
90.3±5 189.1±3.6 >0.05
3. Discussion
3.1 Selection of intertrochanteric femoral fractures in advanced age
Indications for artificial femoral head replacement.
(1) Above 75 years old; those who can take care of themselves before the injury and with medical underlying diseases that are not suitable for long-term bed rest.
(2) Unstable comminuted intertrochanteric fracture of the femur of type Evens III, IV or V; or the presence of significant osteoporotic manifestations and the expected poor prognosis of internal fixation.
(3) Well-controlled medical underlying disease does not interfere with the surgery; able to tolerate anesthesia after assessment.
(4) Good self-control and cooperation before the injury, post-stroke, Parkinson’s disease, etc., but can take care of themselves before the injury. Lower extremity muscle strength of grade 4 or above.
(5) The expected survival period is about 1-10 years.
(6) Aged old intertrochanteric fractures that do not heal.
(7) Adequate communication with the patient and family prior to surgery and willingness to accept the procedure.
3.2 About the greater trochanteric fracture
Unstable femoral intertrochanteric fractures with large and small trochanteric comminution result in unclear bony landmarks, making it difficult to determine the anterior tilt angle of the prosthesis and the length of the limb intraoperatively. The anatomical repositioning of the greater trochanter provides a good marker for the positioning of the prosthesis stem, determines the center of rotation of the femoral head, and uses the greater trochanter as a marker to reconstruct the greater trochanter with the center of the femoral head in the same plane as the greater trochanter, restores the correct eccentric distance, and ensures limb isometric length. If the height of the prosthesis is too low, the affected limb will be shortened and the abductor muscle will be weak after surgery, and it will be easy to dislocate; if it is too high, the affected limb will be lengthened and it will be difficult to reset during surgery, which will lead to pain and acetabular wear after surgery. The greater trochanter is the abductor of the gluteus medius and the stop of the lesser muscle, and the abductor muscle group is very important for maintaining the function of the hip joint and the stability of the artificial joint prosthesis.
3.2.1 The current status of the greater trochanter construction method.
(1) Wire binding fixation. Good results have been achieved by using the double wire 8-string binding fracture block method. The fracture block in the large ramus with severe osteoporosis is only cut between the fracture blocks with wire loops sometimes and loosened, which does not serve the purpose of reliable fixation. It is difficult to restore the complete structure of the region.
(2) Yang Zhikui et al. used a modified tension band wire, and the coarctation steel pin should be drilled in before the bone cement is completely dry and solid during the operation. This method is the tension band principle of using a Kirschner needle to penetrate the bone block and then binding the wire around the Kirschner needle. However, there is a possibility of loosening and slipping of the Kirschner needle.
(3) Some scholars have used multiple memory alloy riding suture nails to firmly fix the crushed bone block before expansion of the marrow to reconstruct the complete structure of the greater trochanteric region.
(4) The larger bone masses of the greater trochanter are fixed and tied with absorbable silk or antibacterial microchord.
(5) Some scholars also use non-cemented prosthesis with external auxiliary titanium plate and memory alloy band or ring bundle fixation to make the fracture block of large and small trochanter reliably repositioned, and the fracture end is mechanically bound by the memory alloy band or ring bundle with pressure to achieve maximum stability.
(6) Other orthopedic surgeons use a large trochanteric alternative prosthesis stem; for example, Liu Jianghua et al. used a G.T.F stem with two holes in the trochanteric portion of the prosthesis for intraoperative repositioning of the large trochanteric bone block after fixation with the prosthesis stem.
3.2.2 The more common method is to use double wires to bind the fracture block in 8 characters. There is also a Kirschner pin with wire. In practice, wire cutting, slippage of the Kirschner pin into the gluteal muscle, or withdrawal into the subcutaneous, wire loosening, etc. occur. Severe osteoporosis in elderly patients causes intraosseous bone loss, which is especially evident at the site of the greater trochanter, with some severe internal emptiness and only very thin cortex remaining. The titanium plate was originally used for the distal tibial fracture, which has three wing-like extensions and multiple nail holes at the distal end of the plate, and the plate is thin and easily shaped to fit well with the morphology of the greater trochanter; the repositioning of the broken end will not be displaced by the plate; the three wings increase the width of the plate and fix the area. The three wings increase the width of the plate and the fixation area is large, and the folding line of the crown surface from the greater trochanter to the lesser trochanter is just in the middle of the plate with fixation screws on both wings to make the folding line close together. The titanium plate is placed on the lateral side of the femur, and the sliding hole on the plate can be pressurized at the broken end when fixing, which also reduces the extravasation of bone cement at the broken end. The nail plate system fixation is supportive to the bone block and restores the height between the greater trochanter; while wire binding, if the bone quality of the greater trochanter is thin in severe osteoporosis, the wire is easy to cut, and the greater trochanter may tear off after pressure is applied, and the Kirschner pin placement can support it, but the Kirschner pin loosens and withdraws the pin during use. In this group, there were 4 cases of loose and slipped Kirschner’s needle, 2 cases were removed surgically into the gluteus maximus muscle, and 2 cases were removed by skin incision after receding under the skin of the ramus.
The results of our study, two types of fixation at the greater trochanter; the Kirschner pin wire loosened and fell out, and there was no internal fixation loosening and no fixation failure at the greater trochanter after the comparison of titanium plate fixation. In terms of complication rate comparison, titanium plate fixation stood out as superior. However, except for the complications of loosening of internal fixation wire and kerfing needle, there was no difference in the incidence of hip surgery complications such as deep vein thrombosis, pulmonary infection, and decubitus ulcer between the two groups. There was no difference between the two fixation methods in terms of operation time, bleeding volume, and the immediate postoperative recovery of the reverse release surface.
3.2.3 Use with cemented lengthening shank
Our experience is that the thick ridge screw, penetrating the medial bone; femoral side screw single cortical fixation, the screw just break through the inner wall, does not affect the prosthetic stem placement, the exposed nail tip has the opportunity to contact with the bone cement, cement infusion into the medullary cavity inserted into the prosthesis pressure of the bone cement pressure on the bone wall of the medullary cavity, bone cement and the exposed part of the screw in the medullary cavity “welded The cement is “welded” to the exposed part of the screw in the medullary cavity to enhance the screw holding force. In the ramus, the screws are fixed slightly longer than the medial bone of the ramus, and the bone cement is extruded into the ramus after the insertion of the prosthesis stem to wrap these screws, and the screws are firmly bonded in the bone cement after the bone cement has solidified, avoiding the occurrence of retracted nails. At the same time, the titanium plate is placed at the fracture end for support, which also enhances the proximal femur fracture fixation strength. The bending resistance and rotation and shear resistance exceeded that of the steel wire kerf pins.
3.3 Femoral spur reconstruction
If the small trochanteric bone block is large, together with the posterior medial bone block, in order to preserve more bone volume proximally, it is fixed intraoperatively with screws, or ringed with wire. It is difficult to preserve the femoral spur comminution after osteotomy, or it has been comminuted itself, and it is difficult to reconstruct the bone-femoral bone moment, and the femoral bone moment is reshaped with bone cement during surgery. In some patients with more intact femoral neck base and femoral spur fractures, the remaining part of the femoral neck is preserved as much as possible after oblique osteotomy under the femoral head in order to fix the preserved femoral spur with a prosthesis by intramedullary fixation.
Joint replacement for unstable intertrochanteric fractures in elderly patients has been widely carried out, but there are various ways to build the greater trochanter, and choosing the trefoil titanium plate system to fix the greater trochanter is an effective and worthy of promotion.
Support Us
If the above content has been helpful to you, please click the share button to share the article or website. This is the greatest support for us.
Discussion
Share your experience, or seek help from fellow patients.
