髓内和髓外联合内固定治疗股骨粗隆间伴外侧壁骨折的疗效分析
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摘要
目的探讨股骨近端防旋髓内钉结合髓外张力带技术治疗股骨粗隆间伴外侧壁骨折的疗效。方法回顾性分析2012年2月至2018年8广西桂林市兴安界首中西医结合医院骨科应用股骨近端防旋髓内钉结合张力带技术治疗股骨粗隆间伴外侧壁骨折的患者60例,按Evans-Jensen分型:ⅡA型18例,ⅡB型19例,Ⅲ型23例。手术均采用后外侧入路,利用股骨近端防旋髓内钉使骨折复位固定,并采用张力带法对大粗隆后外侧骨块进行复位固定,记录手术时间、术中出血量、住院时间及并发症等情况,并在术后1个月、3个月、6个月、12个月及末次随访时拍摄髋关节正侧位X线片分析颈干角、股骨颈长度及骨折愈合情况,同时用髋关节Harris评分评估治疗效果。结果全部病例术后平均随访15. 7个月,手术时间(88. 4±12. 3) min,术中出血量(207. 8±40. 8) ml,住院时间(10. 5±2. 2) d。术后3个月X线片上大粗隆骨折均获骨性愈合。术后半年Harris髋关节评分为(82. 44±9. 86)分,末次随访维持在(90. 17±5. 34)分,术后半年颈干角为(122. 1±9. 3)°,末次随访维持在(121. 7±9. 4)°,术后半年股骨颈长度为(104. 6±5. 9) mm,末次随访维持在(105. 4±6. 3) mm,无一例患者出现髓内钉及克氏针松动、断裂,骨不连等并发症。1例患者因高龄、基础疾病较多,术后出现肺栓塞死亡。1例患者浅表伤口感染,经积极抗炎换药等处理好转,患者家属均表示满意。结论髓内钉联合张力带系统治疗股骨粗隆间后外侧壁骨折患者具有髓内及髓外固定的优势,骨折愈合率高,是一种微创、安全、有效的治疗方法。
Objective To explore the clinical outcome of wire tension belt system combined with proximal femoral nail anti-rotation( PFNA) in treatment of femoral intertrochanteric fracture associated with retrolateral trochanteric wall injury. Methods The clinical data of 60 patients( 29 males and 31 females) suffering with femoral intertrochanteric fracture associated with retrolateral trochanteric wall injury in the Department of Orthopaedics,Xing'an Jieshou Hospital of Integrated Traditional Chinese and Western Medicine during February 2012 to August 2018 were retrospectively analyzed,they were treated by PFNA with Kirschner-Wires and tension band. Among them,their average age was( 69. 6 ±3. 2) years old( range from 60 to 85 years old). According to the classification of Evans-Jensen,there were 18 cases with type ⅡA,19 cases with type ⅡB,and 23 cases with type Ⅲ. All surgeries were performed through posterolateral approach. With PFNA compression,reduction and fixation of these intertrochanteric fractures. Anatomical reduction and fixation were carried out in patients with comminuted fracture of the greater trochanter by using Kirschner wires and tension band. Operating time,amount of blood loss,duration of hospital stay,postoperative complications were recorded. The neck shaft angle,femoral neck length and fracture union were measured respectively on X-ray films in 1 st month,3 rd month,6 th month and 12 th month postoperatively and last follow-up period in 2018,while the hip function was evaluated according to the Harris scores.Results These patients were followed up for an average period of 15. 7 months,the average operating time was( 88. 4 ± 12. 3) min,the average blood loss was( 207. 8 ± 40. 8) ml,and the duration of hospital stay was( 10. 5 ± 2. 2) d. The X-ray films showed bone healing in patients with fractures of greater trochanter in 3 months after operation. The mean Harris hip scores were( 82. 44 ± 9. 86) points in 6 th month after the operation,and maintained( 90. 17 ± 5. 34) points in the last follow-up period. The mean neck shaft angle was( 122. 1 ± 9. 3) degrees in 6 th month after the operation,and maintained( 121. 7 ± 9. 4) degrees in the last follow-up period. The mean femoral neck length was( 104. 6 ± 5. 9) mm at 6 th month after the operation,and maintained( 105. 4 ± 6. 3) mm in the last follow-up period. No statistical significance was observed in terms of neck shaft between each time point postoperatively( P > 0. 05). Statistical significance was found with respect to 3 rd month compared with the 6 th month,12 th month data after the operation( P < 0. 05),whereas no statistical significance between last follow-up period and the12 th month after the operation( P > 0. 05). None of these patients showed dislocation,implant loosening,or nonunion of the fractures throughout the follow-up period. An elderly patient combined with various basic diseases died of pulmonary embolism after the operation. Superficial wound infection occurred in 1 case and cured by changing the dressing regularly. All patients felt satisfied. Conclusion Intramedullary nail fixation and tension band system for treatment of femoral intertrochanteric fractures associated with retrolateral trochanteric wall injury can provide the advantage of intramedullary and extramedullary fixation and obtain high fracture union rate,and achieve an excellent clinical outcome.
Objective To explore the clinical outcome of wire tension belt system combined with proximal femoral nail anti-rotation( PFNA) in treatment of femoral intertrochanteric fracture associated with retrolateral trochanteric wall injury. Methods The clinical data of 60 patients( 29 males and 31 females) suffering with femoral intertrochanteric fracture associated with retrolateral trochanteric wall injury in the Department of Orthopaedics,Xing'an Jieshou Hospital of Integrated Traditional Chinese and Western Medicine during February 2012 to August 2018 were retrospectively analyzed,they were treated by PFNA with Kirschner-Wires and tension band. Among them,their average age was( 69. 6 ±3. 2) years old( range from 60 to 85 years old). According to the classification of Evans-Jensen,there were 18 cases with type ⅡA,19 cases with type ⅡB,and 23 cases with type Ⅲ. All surgeries were performed through posterolateral approach. With PFNA compression,reduction and fixation of these intertrochanteric fractures. Anatomical reduction and fixation were carried out in patients with comminuted fracture of the greater trochanter by using Kirschner wires and tension band. Operating time,amount of blood loss,duration of hospital stay,postoperative complications were recorded. The neck shaft angle,femoral neck length and fracture union were measured respectively on X-ray films in 1 st month,3 rd month,6 th month and 12 th month postoperatively and last follow-up period in 2018,while the hip function was evaluated according to the Harris scores.Results These patients were followed up for an average period of 15. 7 months,the average operating time was( 88. 4 ± 12. 3) min,the average blood loss was( 207. 8 ± 40. 8) ml,and the duration of hospital stay was( 10. 5 ± 2. 2) d. The X-ray films showed bone healing in patients with fractures of greater trochanter in 3 months after operation. The mean Harris hip scores were( 82. 44 ± 9. 86) points in 6 th month after the operation,and maintained( 90. 17 ± 5. 34) points in the last follow-up period. The mean neck shaft angle was( 122. 1 ± 9. 3) degrees in 6 th month after the operation,and maintained( 121. 7 ± 9. 4) degrees in the last follow-up period. The mean femoral neck length was( 104. 6 ± 5. 9) mm at 6 th month after the operation,and maintained( 105. 4 ± 6. 3) mm in the last follow-up period. No statistical significance was observed in terms of neck shaft between each time point postoperatively( P > 0. 05). Statistical significance was found with respect to 3 rd month compared with the 6 th month,12 th month data after the operation( P < 0. 05),whereas no statistical significance between last follow-up period and the12 th month after the operation( P > 0. 05). None of these patients showed dislocation,implant loosening,or nonunion of the fractures throughout the follow-up period. An elderly patient combined with various basic diseases died of pulmonary embolism after the operation. Superficial wound infection occurred in 1 case and cured by changing the dressing regularly. All patients felt satisfied. Conclusion Intramedullary nail fixation and tension band system for treatment of femoral intertrochanteric fractures associated with retrolateral trochanteric wall injury can provide the advantage of intramedullary and extramedullary fixation and obtain high fracture union rate,and achieve an excellent clinical outcome.
引文
[1]Radaideh AM,Qudah HA,Audat ZA,et al.Functional and Radiological Results of Proximal Femoral Nail Antirotation(PFNA)Osteosynthesis in the Treatment of Unstable Pertrochanteric Fractures[J].J Clin Med,2018,7(4).pii:E78.
[2]Zhang Y,Dong Q,Sun X,et al.External fixation versus dynamic hip screw in treatment of elderly intertrochanteric hip fractures:A systematic review and meta-analysis[J].J Orthop Sci,2016,21(6):841-846.
[3]Pradeep AR,KiranKumar A,Dheenadhayalan J,et al.Intraoperative lateral wall fractures during Dynamic Hip Screw fixation for intertrochanteric fractures-Incidence,causative factors and clinical outcome[J].Injury,2018,49(2):334-338.
[4]Caviglia HA,Osorio PQ,Comando D.Classification and diagnosis of intracapsular fractures of the proximal femur[J].Clin Orthop Relat Res,2002,(399):17-27.
[5]史振才,李子荣,介国斌,等.全髋关节置换术的软组织平衡[J].中国矫形外科杂志,2005,13(4):306-309.
[6]Tian W,De Jong G,Munin MC,et al.Patterns of rehabilitation after hip arthroplasty and the association with outcomes:an episode of care view[J].Am J Phys Med Rehabil,2010,89(11):905-918.
[7]杨明,王海龙,覃鼎文,等.老年全髋置换者臀大肌及臀中肌的肌力训练[J].中国组织工程研究与临床康复,2011,15(17):3202-3205.
[8]曾令源.股骨近端防旋髓内钉在老年股骨粗隆间骨折治疗中的应用[J].临床和实验医学杂志,2012,11(7):514-516.
[9]Boopalan PR,Oh JK,Kim TY,et al.Incidence and radiologic outcome of intraoperative lateral wall fractures in OTA 31A1 and A2 fractures treated with cephalomedullary nailing[J].J Orthop Trauma,2012,26(11):638-642.
[10]Kregor PJ,Obremskey WT,Kreder HJ,et al.Unstable pertrochanteric femoral fractures[J].J Orthop Trauma,2014,28 Suppl 8:S25-28.
[11]罗从风,朱越,王磊,等.459例动力髋螺钉治疗股骨粗隆周围骨折结果分析[J].中华创伤骨科杂志,2002,4(3):188-191.
[12]Ziran BH,Darowish M,Klatt BA,et al.Intramedullary nailing in open tibia fractures:a comparison of two techniques[J].Int Orthop,2004,28(4):235-238.
[13]Bryan Yijia Tan,Adrian Cheng Kiang Lau,Ernest Beng Kee Kwek.Morphology and fixation pitfalls of a highly unstable intertrochanteric fracture variant[J].J Orthop Surg(Hong Kong),2015,23(2):142-145.
[14]Hélin M,Pelissier A,Boyer P,et al.Does the PFNATMnail limit impaction in unstable intertrochanteric femoral fracture?A 115 case-control series[J].Orthop Traumatol Surg Res,2015,101(1):45-49.
[15]Wei XM,Sun ZZ,Song XJ.Case-control study on percutaneous compressing plating and proximal femoral nail antirotation in treating in tertrochanteric fracture with risk external wall[J].Zhongguo Gu Shang,2013,26(12):981-984.
[16]Giancola R,Antonini G,Delle Rose G,et al.Percutaneous compression plating versus gamma nail for the treatment of pertrochanteric hip fractures[J].Strategies Trauma Limb Reconstr,2008,3(1):9-14.
[17]Bourne RB,Rorabeck CH.Soft tissue balancing:the hip[J].J Arthroplasty,2002,17(4 Suppl 1):17-22.
[2]Zhang Y,Dong Q,Sun X,et al.External fixation versus dynamic hip screw in treatment of elderly intertrochanteric hip fractures:A systematic review and meta-analysis[J].J Orthop Sci,2016,21(6):841-846.
[3]Pradeep AR,KiranKumar A,Dheenadhayalan J,et al.Intraoperative lateral wall fractures during Dynamic Hip Screw fixation for intertrochanteric fractures-Incidence,causative factors and clinical outcome[J].Injury,2018,49(2):334-338.
[4]Caviglia HA,Osorio PQ,Comando D.Classification and diagnosis of intracapsular fractures of the proximal femur[J].Clin Orthop Relat Res,2002,(399):17-27.
[5]史振才,李子荣,介国斌,等.全髋关节置换术的软组织平衡[J].中国矫形外科杂志,2005,13(4):306-309.
[6]Tian W,De Jong G,Munin MC,et al.Patterns of rehabilitation after hip arthroplasty and the association with outcomes:an episode of care view[J].Am J Phys Med Rehabil,2010,89(11):905-918.
[7]杨明,王海龙,覃鼎文,等.老年全髋置换者臀大肌及臀中肌的肌力训练[J].中国组织工程研究与临床康复,2011,15(17):3202-3205.
[8]曾令源.股骨近端防旋髓内钉在老年股骨粗隆间骨折治疗中的应用[J].临床和实验医学杂志,2012,11(7):514-516.
[9]Boopalan PR,Oh JK,Kim TY,et al.Incidence and radiologic outcome of intraoperative lateral wall fractures in OTA 31A1 and A2 fractures treated with cephalomedullary nailing[J].J Orthop Trauma,2012,26(11):638-642.
[10]Kregor PJ,Obremskey WT,Kreder HJ,et al.Unstable pertrochanteric femoral fractures[J].J Orthop Trauma,2014,28 Suppl 8:S25-28.
[11]罗从风,朱越,王磊,等.459例动力髋螺钉治疗股骨粗隆周围骨折结果分析[J].中华创伤骨科杂志,2002,4(3):188-191.
[12]Ziran BH,Darowish M,Klatt BA,et al.Intramedullary nailing in open tibia fractures:a comparison of two techniques[J].Int Orthop,2004,28(4):235-238.
[13]Bryan Yijia Tan,Adrian Cheng Kiang Lau,Ernest Beng Kee Kwek.Morphology and fixation pitfalls of a highly unstable intertrochanteric fracture variant[J].J Orthop Surg(Hong Kong),2015,23(2):142-145.
[14]Hélin M,Pelissier A,Boyer P,et al.Does the PFNATMnail limit impaction in unstable intertrochanteric femoral fracture?A 115 case-control series[J].Orthop Traumatol Surg Res,2015,101(1):45-49.
[15]Wei XM,Sun ZZ,Song XJ.Case-control study on percutaneous compressing plating and proximal femoral nail antirotation in treating in tertrochanteric fracture with risk external wall[J].Zhongguo Gu Shang,2013,26(12):981-984.
[16]Giancola R,Antonini G,Delle Rose G,et al.Percutaneous compression plating versus gamma nail for the treatment of pertrochanteric hip fractures[J].Strategies Trauma Limb Reconstr,2008,3(1):9-14.
[17]Bourne RB,Rorabeck CH.Soft tissue balancing:the hip[J].J Arthroplasty,2002,17(4 Suppl 1):17-22.