三种植入物治疗老年脑梗死偏瘫侧股骨转子间骨折的比较
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摘要
背景:股骨近端防旋髓内钉与锁定加压钢板均为临床治疗老年股骨转子间骨折的常用方法,同时也有部分学者认为骨水泥型人工股骨头置换治疗老年转子间骨折亦可取得较好疗效,但针对老年脑梗死偏瘫侧股骨转子间骨折患者的手术治疗方案,目前仍存在较多争议。目的:比较骨水泥型人工股骨头置换、股骨近端防旋髓内钉和锁定加压钢板植入治疗老年脑梗偏瘫侧股骨转子间骨折的临床疗效。方法:纳入2010年6月至2017年1月承德医学院附属医院和河北医科大学第三医院收治的96例老年脑梗死偏瘫侧股骨转子间骨折患者,男38例,女58例,年龄≥65岁,其中29例选择骨水泥型人工股骨头置换治疗(置换组),32例选择股骨近端防旋髓内钉内固定治疗(防旋髓内钉组),35例选择股骨近端锁定加压钢板内固定治疗(锁定加压钢板组)。对比3组手术时间、术中出血量、手术前后血红蛋白差值、术后卧床时间、术后并发症发生率及术后半年、1年的髋关节Harris评分。结果与结论:①防旋髓内钉组手术时间短于置换组、锁定加压钢板组(P <0.05);置换组术中出血量多于防旋髓内钉组、锁定加压钢板组(P <0.05);锁定加压钢板组术后卧床时间长于置换组、锁定加压钢板组(P <0.05),手术前后血红蛋白差值低于置换组、锁定加压钢板组(P <0.05);②3组术后并发症发生率比较差异无显著性意义(P> 0.05);③置换组术后半年的Harris评分高于防旋髓内钉组、锁定加压钢板组(P <0.05),置换组、防旋髓内钉组术后1年的Harris评分高于锁定加压钢板组(P <0.05);④结果说明,与锁定加压钢板相比,骨水泥型人工股骨头置换和股骨近端防旋髓内钉治疗老年脑梗偏瘫侧股骨转子间骨折的术后卧床时间短、术后髋关节功能恢复更好,均可做为优先选择;但关节置换因术中出血多,手术风险相对增大,所以临床工作中需对每例患者进行个体化评估和治疗。
BACKGROUND: Proximal femoral nail anti-rotation and the locking compression plate are common methods for treating intertrochanteric fractures in the elderly. At the same time, some scholars believe that the cemented hemiarthroplasty can achieve good curative effect.However, there are still many controversies in the surgical treatment of intertrochanteric fractures of cerebral infarction hemiplegia side in the elderly.OBJECTIVE: To compare the clinical efficacy of cemented hemiarthroplasty, proximal femoral nail anti-rotation and locking compression plate for senile intertrochanteric fractures of cerebral infarction hemiplegia side.METHODS: Ninety-six patients with senile intertrochanteric fractures of cerebral infarction hemiplegia side at Affiliated Hospital of Chengde Medical University and the Third Hospital of Hebei Medical University from June 2010 to January 2017 were enrolled. There were 38 males and 58 females, aged ≥ 65 years, 29 patients were treated with cemented hemiarthroplasty, 32 patients were treated with proximal femoral nail anti-rotation, and 35 patients were treated with proximal femoral locking compression plate. The operation time, intraoperative blood loss,hemoglobin difference before and after surgery, postoperative bed rest time, postoperative complication rate and hip Harris scores at 6 and 12 months postoperatively were compared among groups.RESULTS AND CONCLUSION:(1) The operation time in the anti-rotation intramedullary nail group was shorter than that in the cemented hemiarthroplasty and locking compression plate groups(P < 0.05). The intraoperative blood loss in the cemented hemiarthroplasty group was more than that in the anti-rotation intramedullary nail and the locking compression plate groups(P < 0.05). The anti-rotation intramedullary nail group had longer bed rest time than the cemented hemiarthroplasty and the locking compression plate groups(P < 0.05), and the difference of hemoglobin before and after surgery was lower than that in the cemented hemiarthroplasty and locking compression plate groups(P < 0.05).(2) There was no difference in the incidence of complications among groups(P > 0.05).(3) The Harris score at 6 months postoperatively in the cemented hemiarthroplasty group was higher than that in the anti-rotation intramedullary nail and the locking compression plate group(P <0.05). The Harris score at 12 months postoperatively in the cemented hemiarthroplasty and the anti-rotation intramedullary nail groups was higher than that in the locked compression plate group(P < 0.05).(4) These results suggest that compared with the locking compression plate,the cemented hemiarthroplasty and anti-rotation intramedullary nail for treating senile intertrochanteric fractures of cerebral infarction hemiplegia side, can shorten postoperative bed rest time, and good postoperative hip function recovery, can be used as a priority.Arthroplasty due to intraoperative bleeding, surgical risk is relatively increased, so individualized assessment and treatment are required.
BACKGROUND: Proximal femoral nail anti-rotation and the locking compression plate are common methods for treating intertrochanteric fractures in the elderly. At the same time, some scholars believe that the cemented hemiarthroplasty can achieve good curative effect.However, there are still many controversies in the surgical treatment of intertrochanteric fractures of cerebral infarction hemiplegia side in the elderly.OBJECTIVE: To compare the clinical efficacy of cemented hemiarthroplasty, proximal femoral nail anti-rotation and locking compression plate for senile intertrochanteric fractures of cerebral infarction hemiplegia side.METHODS: Ninety-six patients with senile intertrochanteric fractures of cerebral infarction hemiplegia side at Affiliated Hospital of Chengde Medical University and the Third Hospital of Hebei Medical University from June 2010 to January 2017 were enrolled. There were 38 males and 58 females, aged ≥ 65 years, 29 patients were treated with cemented hemiarthroplasty, 32 patients were treated with proximal femoral nail anti-rotation, and 35 patients were treated with proximal femoral locking compression plate. The operation time, intraoperative blood loss,hemoglobin difference before and after surgery, postoperative bed rest time, postoperative complication rate and hip Harris scores at 6 and 12 months postoperatively were compared among groups.RESULTS AND CONCLUSION:(1) The operation time in the anti-rotation intramedullary nail group was shorter than that in the cemented hemiarthroplasty and locking compression plate groups(P < 0.05). The intraoperative blood loss in the cemented hemiarthroplasty group was more than that in the anti-rotation intramedullary nail and the locking compression plate groups(P < 0.05). The anti-rotation intramedullary nail group had longer bed rest time than the cemented hemiarthroplasty and the locking compression plate groups(P < 0.05), and the difference of hemoglobin before and after surgery was lower than that in the cemented hemiarthroplasty and locking compression plate groups(P < 0.05).(2) There was no difference in the incidence of complications among groups(P > 0.05).(3) The Harris score at 6 months postoperatively in the cemented hemiarthroplasty group was higher than that in the anti-rotation intramedullary nail and the locking compression plate group(P <0.05). The Harris score at 12 months postoperatively in the cemented hemiarthroplasty and the anti-rotation intramedullary nail groups was higher than that in the locked compression plate group(P < 0.05).(4) These results suggest that compared with the locking compression plate,the cemented hemiarthroplasty and anti-rotation intramedullary nail for treating senile intertrochanteric fractures of cerebral infarction hemiplegia side, can shorten postoperative bed rest time, and good postoperative hip function recovery, can be used as a priority.Arthroplasty due to intraoperative bleeding, surgical risk is relatively increased, so individualized assessment and treatment are required.
引文
[1]Tucker A,Donnelly KJ,Rowan C,et al.Is the best plate a nail?A review of3230 unstable intertrochanteric fractures of the proximal femur.J Orthop Trauma.2018;32(2):53-60.
[2]Hiragami K,Ishii J.Embedding the lateral end of the lag screw within the lateral wall in the repair of reverse obliquity intertrochanteric femur fracture.J Int Med Res.2018;46(3):1103-1108.
[3]Yoo JI,Ha YC,Lim JY,et al.Early Rehabilitation in Elderly after Arthroplasty versus Internal Fixation for Unstable Intertrochanteric Fractures of Femur:Systematic Review and Meta-Analysis.J Korean Med Sci.2017;32(5):858-867.
[4]王凌斌,朴民声,陆龙卫,等.手术时机对70岁以上股骨转子间骨折预后的影响[J].中国矫形外科杂志,2018,26(8):712-715.
[5]Parker MJ,Cawley S.Sliding hip screw versus the Targon PFT nail for trochanteric hip fractures:a randomised trial of 400 patients.Bone Joint J.2017;99-B(9):1210-1215.
[6]Zhang H,Zeng X,Zhang N,et al.INTERTAN nail versus proximal femoral nail antirotation-Asia for intertrochanteric femur fractures in elderly patients with primary osteoporosis.J Int Med Res.2017;45(4):1297-1309.
[7]Shah MD,Kapoor CS,Soni RJ,et al.Evaluation of outcome of proximal femur locking compression plate(PFLCP)in unstable proximal femur fractures.J Clin Orthop Trauma.2017;8(4):308-312.
[8]唐佩福.股骨转子间骨折的治疗进展与策略[J].中华创伤骨科杂志,2017,19(2):93-94.
[9]Karapinar L,Kumbaraci M,Kaya A,et al.Proximal femoral nail anti-rotation(PFNA)to treat peritrochanteric fractures in elderly patients.Eur J Orthop Surg Traumatol.2012;22(3):237-243.
[10]Viste A,Perry KI,Taunton MJ,et al.Proximal femoral replacement in contemporary revision total hip arthroplasty for severe femoral bone loss:a review of outcomes.Bone Joint J.2017;99-B(3):325-329.
[11]Kovalak E,Ermutlu C,Atay T,et al.Management of unstable pertrochanteric fractures with proximal femoral locking compression plates and affect of neck-shaft angle on functional outcomes.J Clin Orthop Trauma.2017;8(3):209-214.
[12]胡文雄,蒋家正,韩宏德,等.股骨近端防旋髓内钉和解剖型锁定钢板治疗不稳定型股骨粗隆间骨折的临床疗效比较[J].中国老年学杂志,2016,36(4):903-904.
[13]Wong JS,Brooks D,Inness EL,et al.The Impact of Falls on Motor and Cognitive Recovery after Discharge from In-Patient Stroke Rehabilitation.J Stroke Cerebrovasc Dis.2016;25(7):1613-1621.
[14]Haddaway MJ,Bainbridge NJ,Powell DE,et al.Bone Resorption in Stroke and Institutionalized Subjects.Calcif Tissue Int.2009;84(2):118-125.
[15]江海良,郭开今,王翔,等.生物型与骨水泥型假体半髋置换治疗老年不稳定性股骨转子间骨折的比较[J].中国组织工程研究,2017,21(23):3622-3627.
[16]吴强,王欣,杨旭,等.股骨转子间骨折围手术期隐性失血的性别差异研究[J].中华骨科杂志,2017,37(1):31-35.
[17]危杰,王军,高明,等.老年髋部骨折围手术期失血量的分析[J].中华创伤骨科杂志,2015,17(2):104-107.
[18]Lorich DG,Geller DS,Nielson JH.Osteoporotic pertrochanteric hip fractures:management and current controversies.Instr Course Lect.2004;53(2):441-454.
[19]Esen E,Dur H,Atao?lu MB,et al.Evaluation of proximal femoral nail-antirotation and cemented,bipolar hemiarthroplasty with calcar replacement in treatment of intertrochanteric femoral fractures in terms of mortality and morbidity ratios.Eklem Hastalik Cerrahisi.2017;28(1):35-40.
[20]Reindl R,Harvey EJ,Berry GK,et al.Intramedullary Versus Extramedullary Fixation for Unstable Intertrochanteric Fractures:A Prospective Randomized Control ed Trial.J Bone Joint Surg Am.2015;97(23):1905-1912.
[21]Kleweno C,Morgan J,Redshaw J,et al.Short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years.J Orthop Trauma.2014;28(7):391-397.
[22]杨力,孙奇,易立明,等.人工股骨头置换与髓内固定治疗脑卒中后老年股骨转子间骨折的疗效比较[J].中华创伤骨科杂志,2013,15(5):397-401.
[2]Hiragami K,Ishii J.Embedding the lateral end of the lag screw within the lateral wall in the repair of reverse obliquity intertrochanteric femur fracture.J Int Med Res.2018;46(3):1103-1108.
[3]Yoo JI,Ha YC,Lim JY,et al.Early Rehabilitation in Elderly after Arthroplasty versus Internal Fixation for Unstable Intertrochanteric Fractures of Femur:Systematic Review and Meta-Analysis.J Korean Med Sci.2017;32(5):858-867.
[4]王凌斌,朴民声,陆龙卫,等.手术时机对70岁以上股骨转子间骨折预后的影响[J].中国矫形外科杂志,2018,26(8):712-715.
[5]Parker MJ,Cawley S.Sliding hip screw versus the Targon PFT nail for trochanteric hip fractures:a randomised trial of 400 patients.Bone Joint J.2017;99-B(9):1210-1215.
[6]Zhang H,Zeng X,Zhang N,et al.INTERTAN nail versus proximal femoral nail antirotation-Asia for intertrochanteric femur fractures in elderly patients with primary osteoporosis.J Int Med Res.2017;45(4):1297-1309.
[7]Shah MD,Kapoor CS,Soni RJ,et al.Evaluation of outcome of proximal femur locking compression plate(PFLCP)in unstable proximal femur fractures.J Clin Orthop Trauma.2017;8(4):308-312.
[8]唐佩福.股骨转子间骨折的治疗进展与策略[J].中华创伤骨科杂志,2017,19(2):93-94.
[9]Karapinar L,Kumbaraci M,Kaya A,et al.Proximal femoral nail anti-rotation(PFNA)to treat peritrochanteric fractures in elderly patients.Eur J Orthop Surg Traumatol.2012;22(3):237-243.
[10]Viste A,Perry KI,Taunton MJ,et al.Proximal femoral replacement in contemporary revision total hip arthroplasty for severe femoral bone loss:a review of outcomes.Bone Joint J.2017;99-B(3):325-329.
[11]Kovalak E,Ermutlu C,Atay T,et al.Management of unstable pertrochanteric fractures with proximal femoral locking compression plates and affect of neck-shaft angle on functional outcomes.J Clin Orthop Trauma.2017;8(3):209-214.
[12]胡文雄,蒋家正,韩宏德,等.股骨近端防旋髓内钉和解剖型锁定钢板治疗不稳定型股骨粗隆间骨折的临床疗效比较[J].中国老年学杂志,2016,36(4):903-904.
[13]Wong JS,Brooks D,Inness EL,et al.The Impact of Falls on Motor and Cognitive Recovery after Discharge from In-Patient Stroke Rehabilitation.J Stroke Cerebrovasc Dis.2016;25(7):1613-1621.
[14]Haddaway MJ,Bainbridge NJ,Powell DE,et al.Bone Resorption in Stroke and Institutionalized Subjects.Calcif Tissue Int.2009;84(2):118-125.
[15]江海良,郭开今,王翔,等.生物型与骨水泥型假体半髋置换治疗老年不稳定性股骨转子间骨折的比较[J].中国组织工程研究,2017,21(23):3622-3627.
[16]吴强,王欣,杨旭,等.股骨转子间骨折围手术期隐性失血的性别差异研究[J].中华骨科杂志,2017,37(1):31-35.
[17]危杰,王军,高明,等.老年髋部骨折围手术期失血量的分析[J].中华创伤骨科杂志,2015,17(2):104-107.
[18]Lorich DG,Geller DS,Nielson JH.Osteoporotic pertrochanteric hip fractures:management and current controversies.Instr Course Lect.2004;53(2):441-454.
[19]Esen E,Dur H,Atao?lu MB,et al.Evaluation of proximal femoral nail-antirotation and cemented,bipolar hemiarthroplasty with calcar replacement in treatment of intertrochanteric femoral fractures in terms of mortality and morbidity ratios.Eklem Hastalik Cerrahisi.2017;28(1):35-40.
[20]Reindl R,Harvey EJ,Berry GK,et al.Intramedullary Versus Extramedullary Fixation for Unstable Intertrochanteric Fractures:A Prospective Randomized Control ed Trial.J Bone Joint Surg Am.2015;97(23):1905-1912.
[21]Kleweno C,Morgan J,Redshaw J,et al.Short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years.J Orthop Trauma.2014;28(7):391-397.
[22]杨力,孙奇,易立明,等.人工股骨头置换与髓内固定治疗脑卒中后老年股骨转子间骨折的疗效比较[J].中华创伤骨科杂志,2013,15(5):397-401.