Objective To investigate the reasons of failure of Gamma nail treatment for intertrochanteric fractures and define operative techniques of the revision surgery. Methods From January 1999 to January 2008, 20 cases of 432 patients treated with Gamma nails for intertrochanteric fractures were revised. There were 9 males and 11 females, aged 24-87 years (median 65 years). Among them, there were 4 cases of femoral shaft fracture, 2 cases of screw penetrating the femoral head,11 cases of screw cutting out the femoral head and neck, 2 cases of internal rotation malformation, and 1 case of nfection. The operative procedures of revision were as follows: 4 cases were treated with the long Gamma nail, 4 cases by adjusting the position of Gamma nail, 11 cases with artificial femoral head replacement, and 1 case by removing Gamma nail and debriding and reimplant the Gamma nail. Results The hospital ization days were 16-28 days (21.2 days on average); the bleeding volume during operation was 150-600 mL (380 mL on average). All wounds healed by first intention. Bed rest days were 7-15 days (12.5 days on average). All the patients were followed up for 1-8 years (5 years on average). The operations were successful, the femoral intertrochanteric fracture and femoral shaft fracture reached bony union. Compl ications such as loosening, breakage of hardware and coxa adduct were not observed. No loosening and dislocation of the prosthesis occurred. Among the patients with compl ications, 9 patients were treated with a Gamma nail again. Fracture heal ing was achieved within 2 to 5 months, with an average of 3 months. According to the WANG Fang et al. criterion for hip joint function, the results were excellent in 7 cases and good in 2 cases. In 11 patients who receieved artificial femoral head replacement, the hip joint function restored to normal. Harris score was 90-93. Conclusion Various causes such as osteoporosis, ti p-apex distance ( 25 mm), femoral shaft malformation, Gamma nail shortcomings may lead to compl ications after Gamma nail treatment for intertrochanteric fractures. Good results will be achieved by different revision techniques.
【摘要】 目的 研究棘突顶端上下缘与椎弓根中心点水平面垂直距离的关系，为微创胸腰段脊柱内固定术椎弓根的体表定位提供实验依据。 方法 20具完整脊柱骨标本，测量标本两侧胸11~腰2椎弓根中心点与棘突旁开距离（CO）、棘突上、下缘至椎弓根中心点水平面垂直距离（AC、BC），以棘突顶端的上、下缘为参照点确定椎弓根的最佳体表投影点。选取20例无神经症状的单节段椎体骨折男性患者；年龄23~54岁，平均37.6岁。损伤部位:胸11、胸12、腰1、腰2骨折椎体各5例。以棘突顶端上缘点为确定椎弓根中心的参考点，行经皮椎弓根螺钉固定，分别测定术前、术后相应椎体Cobb角。 结果 男、女性各椎体左右两侧CO、AC、BC比较差异均无统计学意义（Pgt;0.05）。男女组间相同椎体CO和BO及胸11、胸12椎体的AC比较差异均有统计学意义（Plt;0.05），腰1、腰2椎体的AC比较差异无统计学意义（Pgt;0.05）。男性或女性胸11~腰2的CO依次变大、AC和BC逐渐减小，各椎体间比较差异均有统计学意义（Plt;0.01）。临床应用显示，术前、术后相应椎体Cobb角比较，差异均有统计学意义（Plt;0.05）。 结论 棘突顶端上缘为确定椎弓根中心点的最佳参照点，微创脊柱内固定术体表定位椎弓根时应根据性别和具体骨折椎体确定进针点。【Abstract】 Objective To study the anatomic distances from the upper and lower edges of the spinous process peak to the horizontal plane of the center of pedicle of vertebral arch, to provide assistance for the percutaneous positioning of the pedicle of vertebral arch in minimally-invasive transpedicular internal fixation for the thoracic and lumbar vertebrae. Methods We studied 20 integral thoraco-lumbar vertebrae samples, and the distance between the vertical plane including the upper and lower points of the spinous process peak and the horizontal plane of the center of pedicle of vertebral arch was measured and marked as CO. We also measured the distances from the upper and lower points of the spinous process peak to the horizontal plane of the center of pedicle of vertebral arch and marked them as AC and BC respectively. The upper and lower points of the spinous process peak were designated as reference points to define the optimal body surface projective point of the pedicle of vertebral arch. Twenty male patients with single segmental fractured vertebral body and without nervous symptoms were selected. The age of the patients were ranged from 23 to 54 years old, averaging at 37.6. The fractured vertebral bodies included T11, T12, L1, and L2 with 5 cases for each of them. The percutaneous transpedicular internal fixation was carried out with the upper point of the spinous process peak as the reference point to define the body surface projective point of the pedicle of vertebral arch and the preoperative and postoperative Cobb angle of each fractured vertebral body were measured. Results There was no significant differences in CO, AC and BC on both sides between male and female (Pgt;0.05). Statistical difference existed between male and female in CO and BO of the same vertebra, and AC of T11 and T12 (Plt;0.05), while AC of L1 and L2 had no significant difference (Pgt;0.05). In both males and females, CO of the vertebrae from T11 to L2 increased, while AC and BC decreased, and there was a significant difference among different vertebrae (Plt;0.01). Clinical application showed there was a significant difference between the Cobb angle before operation and that after operation (Plt;0.05). Conclusion The upper point of the spinous process peak is the best reference point to define the center of pedicle of vertebral arch. Deciding on the needle insertion spot should be based on gender and specific vertebral body, when minimally-invasive transpedicular internal fixation is performed to define the body surface projective point of the pedicle of vertebral arch.