股骨近端防旋髓内钉、锁定加压钢板、动力髋螺钉、Gamma钉4种内固定方式治疗老年股骨转子间骨折
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摘要
背景:股骨转子间骨折不同手术方式引起的并发症类型及恢复情况各不相同,临床常用的内固定方法缺少系统全面的总结。目的:探讨股骨近端防旋髓内钉、股骨近端锁定加压钢板、动力髋螺钉和Gamma钉治疗老年股骨转子间骨折的效果。方法:回顾性分析2014年3月至2017年3月中山市中医院收治的178例老年股骨转子间骨折患者,按内固定方式分为股骨近端防旋髓内钉组(n=41)、股骨近端锁定加压钢板组(n=44)、动力髋螺钉组(n=48)和Gamma钉组(n=45)。收集整理每组患者临床资料,记录术中及术后情况,观察髋关节功能恢复及术后并发症发生情况,并对术后疗效优良率进行比较。结果与结论:(1)股骨近端防旋髓内钉组手术时间明显短于其他3组(F=87.741,P=0.000),切口长度明显小于其他3组(F=650.796,P=0.000),术中出血量与输血量均明显少于其他3组(F=1890.363,P=0.000;F=452.550,P=0.000),骨折愈合时间早于其他3组(F=24.731,P=0.000);(2)股骨近端防旋髓内钉组的并发症发生率明显低于股骨近端锁定加压钢板组(χ~2=4.571,P=0.033)、动力髋螺钉组(χ~2=3.928,P=0.047)和Gamma钉组(χ~2=4.398,P=0.036);(3)术后3个月,股骨近端防旋髓内钉组Harris评分高于其他3组(F=24.842,P=0.000),疗效优良率高于其他3组(χ~2=12.363,P=0.006);(4)结果表明,4种内固定方式治疗老年股骨转子间骨折的临床疗效均较满意,其中股骨近端防旋髓内钉具有手术时间短、术中出血量少、愈合快的优点,且术后髋关节功能恢复方面优于股骨近端锁定加压钢板、动力髋螺钉、Gamma钉等内固定方式。
BACKGROUND: The types of complications and recovery of different surgical procedures for intertrochanteric fractures vary. The clinically commonly used internal fixation method lacks a comprehensive summary. OBJECTIVE: To investigate the effects of proximal femoral nail antirotation, proximal femoral locking compression plate, dynamic hip screw and Gamma nail in the treatment of elderly intertrochanteric fractures. METHODS: A retrospective analysis of 178 elderly patients with intertrochanteric fractures admitted at Zhongshan Hospital of Traditional Chinese Medicine from March 2014 to March 2017 was performed. The patients were divided into proximal femoral nail group(n=41), proximal femoral locking compression plate group(n=44), dynamic hip screw group(n=48) and Gamma nail group(n=45) according to the internal fixation. The clinical data of patients were collected and arranged, the intraoperative and postoperative conditions were recorded. The recovery of hip joint function, and the occurrence of postoperative complications were observed. The excellent and good rate of postoperative curative effect was compared. RESULTS AND CONCLUSION:(1) The operation time, incision length, intraoperative blood loss and transfusion in the proximal femoral nail group were significantly lower than those in the other three groups(F=87.741, P=0.000; F=650.796, P=0.000; F=1 890.363, P=0.000; F=452.550, P=0.000). The fracture healing time in the proximal femoral nail group was earlier than that in the other three groups(F=24.731, P=0.000).(2) The incidence of complications in the proximal femoral nail group was significantly lower than that in the proximal femoral locking compression plate group(χ~2=4.571, P=0.033), dynamic hip screw group(χ~2=3.928, P=0.047), and Gamma nail group(χ~2=4.398, P=0.036).(3) The Harris hip scores in the proximal femoral nail group were higher than those in the other three groups(F=24.842, P=0.000), and the excellent and good rate was higher than that in the other three groups(χ~2=12.363, P=0.006).(4) In summary, the clinical effects of four internal fixation methods for elderly patients with intertrochanteric fractures are satisfactory. Among them, proximal femoral nail has the advantages of shorter operation time, less intraoperative blood loss, and quicker healing. The postoperative hip joint function recovery is better after using proximal femoral nail antirotation than proximal femoral locking compression plate, dynamic hip screw, and Gamma nail.
BACKGROUND: The types of complications and recovery of different surgical procedures for intertrochanteric fractures vary. The clinically commonly used internal fixation method lacks a comprehensive summary. OBJECTIVE: To investigate the effects of proximal femoral nail antirotation, proximal femoral locking compression plate, dynamic hip screw and Gamma nail in the treatment of elderly intertrochanteric fractures. METHODS: A retrospective analysis of 178 elderly patients with intertrochanteric fractures admitted at Zhongshan Hospital of Traditional Chinese Medicine from March 2014 to March 2017 was performed. The patients were divided into proximal femoral nail group(n=41), proximal femoral locking compression plate group(n=44), dynamic hip screw group(n=48) and Gamma nail group(n=45) according to the internal fixation. The clinical data of patients were collected and arranged, the intraoperative and postoperative conditions were recorded. The recovery of hip joint function, and the occurrence of postoperative complications were observed. The excellent and good rate of postoperative curative effect was compared. RESULTS AND CONCLUSION:(1) The operation time, incision length, intraoperative blood loss and transfusion in the proximal femoral nail group were significantly lower than those in the other three groups(F=87.741, P=0.000; F=650.796, P=0.000; F=1 890.363, P=0.000; F=452.550, P=0.000). The fracture healing time in the proximal femoral nail group was earlier than that in the other three groups(F=24.731, P=0.000).(2) The incidence of complications in the proximal femoral nail group was significantly lower than that in the proximal femoral locking compression plate group(χ~2=4.571, P=0.033), dynamic hip screw group(χ~2=3.928, P=0.047), and Gamma nail group(χ~2=4.398, P=0.036).(3) The Harris hip scores in the proximal femoral nail group were higher than those in the other three groups(F=24.842, P=0.000), and the excellent and good rate was higher than that in the other three groups(χ~2=12.363, P=0.006).(4) In summary, the clinical effects of four internal fixation methods for elderly patients with intertrochanteric fractures are satisfactory. Among them, proximal femoral nail has the advantages of shorter operation time, less intraoperative blood loss, and quicker healing. The postoperative hip joint function recovery is better after using proximal femoral nail antirotation than proximal femoral locking compression plate, dynamic hip screw, and Gamma nail.
引文
[1]周跃江,包洪卫,王海红,等.小切口股骨近端防旋髓内钉治疗老年股骨粗隆间骨折[J].中国微创外科杂志,2016,16(4):344-346.
[2]张伟强,祁宝昌,邓鹏飞,等.老年股骨粗隆间骨折治疗的临床进展[J].中国老年学杂志,2015,35(1):266-268.
[3]G?rmeli G,Korkmaz MF,G?rmeli CA,et al.Comparison of femur intertrochanteric fracture fixation with hemiarthroplasty and proximal femoral nail systems.Ulus Travma Acil Cerrahi Derg.2015;21(6):503-508.
[4]Tan BY,Lau AC,Kwek EB.Morphology and fixation pitfalls of a highly unstable intertrochanteric fracture variant.J Orthop Surg(Hong Kong).2015;23(2):142-145.
[5]赵新勇,张玉宏,杜跃华.两种内固定方式治疗老年股骨粗隆间骨折临床疗效观察[J].实用骨科杂志,2016,22(1):64-66.
[6]魏九定,付廷军,成中阳,等.动力髋螺钉置入固定股骨转子间骨折:失效原因分析[J].中国组织工程研究,2015,19(13):2096-2102.
[7]曹溢,巩文庆,程晓东.Gamma钉治疗股骨粗隆间骨折疗效及失效原因分析[J].安徽医学,2015,36(10):1226-1228.
[8]Xu R,Ru J,Ji F,et al.Comparison of efficacy,complications and TGF-β2 expression between DHS and PFNA in elderly patients with osteoporotic femoral intertrochanteric fracture.Exp Ther Med.2018;16(1):394-399.
[9]杨大伟,宋雪,罗宗键.内固定治疗老年股骨粗隆间骨折回顾性分析[J].吉林中医药,2017,37(8):809-810.
[10]袁明武,张晓冬.Gamma3髓内钉治疗改良Evans分型Ⅱ-Ⅲ型老年股骨转子间骨折[J].中华创伤骨科杂志,2012,14(4):364-366.
[11]刘凡凡,刘朝阳,张杰斌,等.PFNA与LCP治疗老年不稳定股骨粗隆间骨折的疗效比较[J].实用骨科杂志,2016,22(2):164-167.
[12]张涛,杨扉扉,张松,等.两种手术方式治疗外侧壁危险型股骨粗隆间骨折的疗效比较[J].中国矫形外科杂志,2017,25(2):174-177.
[13]蔡景奎.闭合复位Gamma3钉与PFNA内固定治疗股骨粗隆间骨折的疗效对比研究[J].湖南师范大学学报(医学版),2018,15(2):69-72.
[14]徐风瑞,何明武,姚忠军,等.PFNA内固定与人工股骨头置换术治疗高龄骨质疏松性股骨粗隆间骨折的比较[J].中国骨与关节损伤杂志,2016,31(2):130-133.
[15]Li H,Zhang W,Yan J,et al.Greater trochanter of the femur(GTF)vs.proximal femoral nail anti-rotation(PFNA)for unstable intertrochanteric femoral fracture.Eur Rev Med Pharmacol Sci.2018;22(1 Suppl):8-14.
[16]Seyhan M,Turkmen I,Unay K,et al.Do PFNA devices and Intertan nails both have the same effects in the treatment of trochanteric fractures?A prospective clinical study.J Orthop Sci.2015;20(6):1053-1061.
[17]蒋协远,王大伟.骨科临床疗效评价标准[M].北京:人民卫生出版社,2005.
[18]于洋,王振虎,赵力,等.人工关节置换术对老年股骨粗隆间骨折患者Harris评分和预后的影响[J].现代生物医学进展,2017,17(35):6905-6908,6920.
[19]陈宇翔,唐佩福.股骨粗隆间骨折内固定手术治疗的研究进展[J].解放军医学院学报,2017,38(2):171-174,178.
[20]李璐兵,韩然,王成伟,等.老年骨质疏松合并股骨粗隆间骨折采用关节置换法治疗疗效及对骨密度的影响分析[J].河北医学,2016,22(9):1495-1497.
[21]梁培雄,杨洋,刘忠.股骨近端髓钉与锁定加压钢板治疗股骨反转子间骨折36例分析[J].中国医师杂志,2016,18(5):769-771.
[22]高晓宇,新苏雅拉图,刘峰.PFNA与PF-LCP治疗股骨粗隆间骨折临床应用及疗效分析[J].中国继续医学教育,2016,8(29):124-125.
[23]Ibrahim S,Meleppuram JJ.A retrospective analysis of surgically-treated complex proximal femur fractures with proximal femoral locking compression plate.Rev Bras Ortop.2017;52(6):644-650.
[24]Imerci A,Aydogan NH,Erciyes OS.Letter to the editor concerning"A biomechanical study comparing proximal femur nail and proximal femur locking compression plate in fixation of reverse oblique proximal femur fractures".Injury.2018;49(3):734-735.
[25]朱书涛,刘洋,张明辉,等.股骨粗隆间骨折DHS内固定术后骨折不愈合的危险因素[J].中国矫形外科杂志,2016,24(12):1076-1079.
[26]Gashi YN,Elhadi AS,Elbushra IM.Outcome of primary cemented bipolar hemiarthroplasty compared with dynamic hip screw in elderly patients with unstable intertrochanteric fracture.Malays Orthop J.2018;12(1):36-41.
[27]Siavashi B,Aalirezaei A,Moosavi M,et al.A comparative study between multiple cannulated screws and dynamic hip screw for fixation of femoral neck fracture in adults.Int Orthop.2015;39(10):2069-2071.
[28]程建,雷会宁,冯仕明,等.PFNA与DHS治疗不稳定型股骨粗隆间骨折的Meta分析[J].重庆医学,2016,45(21):2956-2961.
[29]曹鎏,王玉召,陈高峰,等.PFNA与DHS治疗超高龄股骨粗隆间骨折患者的疗效对照研究[J].西北国防医学杂志,2017,38(4):241-243.
[30]Chang CW,Chen YN,Li CT,et al.Role of the compression screw in the dynamic hip-screw system:A finite-element study.Med Eng Physm.2015;37(12):1174-1179.
[31]胡云根,韩雷,方伟利,等.解剖型锁定钢板及Gamma钉治疗伴有外侧壁骨折股骨转子间骨折的病例对照研究[J].中国骨伤,2016,29(6):496-501.
[32]王飞,茆文龙,李力毅,等.髓内、外内固定方式治疗高龄股骨粗隆间骨折患者失血量及相关因素分析[J].中国骨与关节损伤杂志,2016,31(10):1023-1026.
[33]Ma JX,Kuang MJ,Fan ZR,et al.Comparison of clinical outcomes with InterTan vs Gamma nail or PFNA in the treatment of intertrochanteric fractures:A meta-analysis.Sci Rep.2017;7(1):15962.
[34]Arirachakaran A,Amphansap T,Thanindratarn P,et al.Comparative outcome of PFNA,Gamma nails,PCCP,Medoff plate,LISS and dynamic hip screws for fixation in elderly trochanteric fractures:a systematic review and network meta-analysis of randomized controlled trials.Eur J Orthop Surg Traumatol.2017;27(7):937-952.
[35]Umer M,Rashid H,Shah I,et al.Use of femoral nail with spiral blade in subtrochanteric fractures.Acta Orthop Traumatol Turc.2014;48(1):32-36.
[36]曹兴兵,孙继芾,许腊梅,等.PFNA治疗股骨粗隆间骨折内固定失败的多因素分析[J].中国骨与关节损伤杂志,2016,31(10):1034-1038.
[37]Sharma A,Sethi A,Sharma S.Treatment of stable intertrochanteric fractures of the femur with proximal femoral nail versus dynamic hip screw:a comparative study.Rev Bras Ortop.2017;53(4):477-481.
[38]郭涛,张亚奎,张星火,等.股骨近端防旋髓内钉与股骨近端解剖型锁定钢板治疗股骨粗隆间骨折的生物力学研究[J].河北医学,2016,22(1):10-13.
[39]Zang W,Liu PF,Han XF.A comparative study of proximal femoral locking compress plate,proximal femoral nail antirotation and dynamic hip screw in intertrochanteric fractures.Eur Rev Med Pharmacol Sci.2018;22(1 Suppl):119-123.
[2]张伟强,祁宝昌,邓鹏飞,等.老年股骨粗隆间骨折治疗的临床进展[J].中国老年学杂志,2015,35(1):266-268.
[3]G?rmeli G,Korkmaz MF,G?rmeli CA,et al.Comparison of femur intertrochanteric fracture fixation with hemiarthroplasty and proximal femoral nail systems.Ulus Travma Acil Cerrahi Derg.2015;21(6):503-508.
[4]Tan BY,Lau AC,Kwek EB.Morphology and fixation pitfalls of a highly unstable intertrochanteric fracture variant.J Orthop Surg(Hong Kong).2015;23(2):142-145.
[5]赵新勇,张玉宏,杜跃华.两种内固定方式治疗老年股骨粗隆间骨折临床疗效观察[J].实用骨科杂志,2016,22(1):64-66.
[6]魏九定,付廷军,成中阳,等.动力髋螺钉置入固定股骨转子间骨折:失效原因分析[J].中国组织工程研究,2015,19(13):2096-2102.
[7]曹溢,巩文庆,程晓东.Gamma钉治疗股骨粗隆间骨折疗效及失效原因分析[J].安徽医学,2015,36(10):1226-1228.
[8]Xu R,Ru J,Ji F,et al.Comparison of efficacy,complications and TGF-β2 expression between DHS and PFNA in elderly patients with osteoporotic femoral intertrochanteric fracture.Exp Ther Med.2018;16(1):394-399.
[9]杨大伟,宋雪,罗宗键.内固定治疗老年股骨粗隆间骨折回顾性分析[J].吉林中医药,2017,37(8):809-810.
[10]袁明武,张晓冬.Gamma3髓内钉治疗改良Evans分型Ⅱ-Ⅲ型老年股骨转子间骨折[J].中华创伤骨科杂志,2012,14(4):364-366.
[11]刘凡凡,刘朝阳,张杰斌,等.PFNA与LCP治疗老年不稳定股骨粗隆间骨折的疗效比较[J].实用骨科杂志,2016,22(2):164-167.
[12]张涛,杨扉扉,张松,等.两种手术方式治疗外侧壁危险型股骨粗隆间骨折的疗效比较[J].中国矫形外科杂志,2017,25(2):174-177.
[13]蔡景奎.闭合复位Gamma3钉与PFNA内固定治疗股骨粗隆间骨折的疗效对比研究[J].湖南师范大学学报(医学版),2018,15(2):69-72.
[14]徐风瑞,何明武,姚忠军,等.PFNA内固定与人工股骨头置换术治疗高龄骨质疏松性股骨粗隆间骨折的比较[J].中国骨与关节损伤杂志,2016,31(2):130-133.
[15]Li H,Zhang W,Yan J,et al.Greater trochanter of the femur(GTF)vs.proximal femoral nail anti-rotation(PFNA)for unstable intertrochanteric femoral fracture.Eur Rev Med Pharmacol Sci.2018;22(1 Suppl):8-14.
[16]Seyhan M,Turkmen I,Unay K,et al.Do PFNA devices and Intertan nails both have the same effects in the treatment of trochanteric fractures?A prospective clinical study.J Orthop Sci.2015;20(6):1053-1061.
[17]蒋协远,王大伟.骨科临床疗效评价标准[M].北京:人民卫生出版社,2005.
[18]于洋,王振虎,赵力,等.人工关节置换术对老年股骨粗隆间骨折患者Harris评分和预后的影响[J].现代生物医学进展,2017,17(35):6905-6908,6920.
[19]陈宇翔,唐佩福.股骨粗隆间骨折内固定手术治疗的研究进展[J].解放军医学院学报,2017,38(2):171-174,178.
[20]李璐兵,韩然,王成伟,等.老年骨质疏松合并股骨粗隆间骨折采用关节置换法治疗疗效及对骨密度的影响分析[J].河北医学,2016,22(9):1495-1497.
[21]梁培雄,杨洋,刘忠.股骨近端髓钉与锁定加压钢板治疗股骨反转子间骨折36例分析[J].中国医师杂志,2016,18(5):769-771.
[22]高晓宇,新苏雅拉图,刘峰.PFNA与PF-LCP治疗股骨粗隆间骨折临床应用及疗效分析[J].中国继续医学教育,2016,8(29):124-125.
[23]Ibrahim S,Meleppuram JJ.A retrospective analysis of surgically-treated complex proximal femur fractures with proximal femoral locking compression plate.Rev Bras Ortop.2017;52(6):644-650.
[24]Imerci A,Aydogan NH,Erciyes OS.Letter to the editor concerning"A biomechanical study comparing proximal femur nail and proximal femur locking compression plate in fixation of reverse oblique proximal femur fractures".Injury.2018;49(3):734-735.
[25]朱书涛,刘洋,张明辉,等.股骨粗隆间骨折DHS内固定术后骨折不愈合的危险因素[J].中国矫形外科杂志,2016,24(12):1076-1079.
[26]Gashi YN,Elhadi AS,Elbushra IM.Outcome of primary cemented bipolar hemiarthroplasty compared with dynamic hip screw in elderly patients with unstable intertrochanteric fracture.Malays Orthop J.2018;12(1):36-41.
[27]Siavashi B,Aalirezaei A,Moosavi M,et al.A comparative study between multiple cannulated screws and dynamic hip screw for fixation of femoral neck fracture in adults.Int Orthop.2015;39(10):2069-2071.
[28]程建,雷会宁,冯仕明,等.PFNA与DHS治疗不稳定型股骨粗隆间骨折的Meta分析[J].重庆医学,2016,45(21):2956-2961.
[29]曹鎏,王玉召,陈高峰,等.PFNA与DHS治疗超高龄股骨粗隆间骨折患者的疗效对照研究[J].西北国防医学杂志,2017,38(4):241-243.
[30]Chang CW,Chen YN,Li CT,et al.Role of the compression screw in the dynamic hip-screw system:A finite-element study.Med Eng Physm.2015;37(12):1174-1179.
[31]胡云根,韩雷,方伟利,等.解剖型锁定钢板及Gamma钉治疗伴有外侧壁骨折股骨转子间骨折的病例对照研究[J].中国骨伤,2016,29(6):496-501.
[32]王飞,茆文龙,李力毅,等.髓内、外内固定方式治疗高龄股骨粗隆间骨折患者失血量及相关因素分析[J].中国骨与关节损伤杂志,2016,31(10):1023-1026.
[33]Ma JX,Kuang MJ,Fan ZR,et al.Comparison of clinical outcomes with InterTan vs Gamma nail or PFNA in the treatment of intertrochanteric fractures:A meta-analysis.Sci Rep.2017;7(1):15962.
[34]Arirachakaran A,Amphansap T,Thanindratarn P,et al.Comparative outcome of PFNA,Gamma nails,PCCP,Medoff plate,LISS and dynamic hip screws for fixation in elderly trochanteric fractures:a systematic review and network meta-analysis of randomized controlled trials.Eur J Orthop Surg Traumatol.2017;27(7):937-952.
[35]Umer M,Rashid H,Shah I,et al.Use of femoral nail with spiral blade in subtrochanteric fractures.Acta Orthop Traumatol Turc.2014;48(1):32-36.
[36]曹兴兵,孙继芾,许腊梅,等.PFNA治疗股骨粗隆间骨折内固定失败的多因素分析[J].中国骨与关节损伤杂志,2016,31(10):1034-1038.
[37]Sharma A,Sethi A,Sharma S.Treatment of stable intertrochanteric fractures of the femur with proximal femoral nail versus dynamic hip screw:a comparative study.Rev Bras Ortop.2017;53(4):477-481.
[38]郭涛,张亚奎,张星火,等.股骨近端防旋髓内钉与股骨近端解剖型锁定钢板治疗股骨粗隆间骨折的生物力学研究[J].河北医学,2016,22(1):10-13.
[39]Zang W,Liu PF,Han XF.A comparative study of proximal femoral locking compress plate,proximal femoral nail antirotation and dynamic hip screw in intertrochanteric fractures.Eur Rev Med Pharmacol Sci.2018;22(1 Suppl):119-123.