老年股骨粗隆间骨折三种手术方法疗效比较

EVALUATION ON CURATIVE EFFECT OF THREE OPERATIVE METHODS IN TREATMENT OF SENILE INTERTROCHANTERIC FRACTURE

目的比较老年股骨粗隆间骨折人工股骨头置换与内固定的临床疗效。方法2004年7月-2007年2月,收治73例老年股骨粗隆间骨折患者。33例采用双极人工股骨头(artificial bipolar femoral head,ABFH)置换治疗(ABFH置换组):男19例,女14例;年龄(72.5±3.8)岁。摔伤19例,交通伤7例,坠落伤4例,其他伤3例。Evans分型:Ⅰ型6例,Ⅱ型9例,Ⅲ型11例,Ⅳ型7例。术前Harris评分(16.8±4.8)分。病程(21.2±7.8)h。18例采用动力髋螺钉(dynamic hip screw,DHS)固定(DHS固定组):男10例,女8例;年龄(69.5±3.2)岁。摔伤11例,交通伤5例,坠落伤1例,其他伤1例。Evans分型:Ⅰ型6例,Ⅱ型3例,Ⅲ型5例,Ⅳ型4例。术前Harris评分(18.6±5.5)分。病程(19.8±6.5)h。22例采用防旋股骨近端髓内钉(proximal femoral nail anti-rotation,PFNA)固定(PFNA固定组):男13例,女9例;年龄(70.3±3.5)岁。摔伤11例,交通伤6例,坠落伤3例,其他伤2例。Evans分型:Ⅰ型5例,Ⅱ型6例,Ⅲ型6例,Ⅳ型5例。术前Harris评分(20.4±6.6)分。病程(20.0±5.8)h。3组组间一般资料比较,差异均无统计学意义(P>0.05)。结果术后ABFH置换组切口均Ⅰ期愈合,1例术后3d出现深静脉血栓。DHS固定组切口16例Ⅰ期愈合,2例Ⅱ期愈合;2例出现髋内翻。PFNA固定组切口均Ⅰ期愈合,1例头颈位置欠佳。3组手术时间、术中失血、下床时间及住院时间比较,差异均有统计学意义(P<0.05)。患者术后均获随访,其中ABFH置换组随访(30.5±6.5)个月,骨折愈合时间(7.5±2.5)个月;DHS固定组随访(27.6±6.2)个月,骨折愈合时间为(8.4±2.2)个月;PFNA固定组随访(24.8±5.4)个月,骨折愈合时间为(7.2±2.4)个月。3组骨折愈合时间、术前与术后各时间点Harris评分及术后各时间点3组间Harris评分比较,差异均有统计学意义(P<0.05)。结论3种手术治疗方式均有一定优势,但人工股骨头置换具有操作简便、手术时间短、术中失血少、可早期下床活动等优点,更适用于老年股骨粗隆间骨折的治疗。

Objective To analyze the clinical application and e ect of three operation methods in treatment of senile intertrochanteric fracture.Methods From July 2004 to February 2007, 73 patients with intertrochanteric fracture were treated.Of 73 patients, 33 patients were treated by arti cial bipolar femoral head（ABFH group）, 18 patients by dynamic hip screw（DHS group） and 22 by proximal femoral nail anti-rotation（PFNA group）.In ABFH group, there were 19 males and 14 females with age of（72.5 ± 3.8） years.The injury was by tumbling in 19 cases, by accident tra c in 7 cases, falling from height in 4 cases and others in 3 cases, including 6 cases of type I, 9 cases of type II, 11 cases of type Ⅲ and 7 cases of type IV according to Evans classi cation.The Harris hip score was 16.8 ± 4.8, and the disease course was（21.2 ± 7.8） hours.In DHS group, there were 10 males and 8 females with age of（69.5 ± 3.2） years.The injury was by tumbling in 11 cases, by accident tra c in 5 cases, falling from height in 1 case and other in 1 case, including 6 cases of type I, 3 cases of type II, 5 cases of type Ⅲ and 4 cases of type IV according to Evans classi cation.The Harris hip score of was 18.6 ± 5.5, and the disease course was（19.8 ± 6.5） hours.In PFNA group, there were 13 males and 9 females with age of（70.3 ± 3.5） years.The injury was by tumbling in 11 cases, by accident tra c in 6 cases, falling from height in 3 cases and others in 2 cases, including 5 cases of type I, 6 cases of type II, 6 cases of type Ⅲ and 5 cases of type IV according to Evans classi cation.The Harris hip score was 20.4 ± 6.6, and the disease course was（20.0 ± 5.8） hours.All fractures were fresh.There were no signi cant di erence in general data between three groups（P 〉 0.05）.Results In ABFH group, all incisions healed by rst intention, but deep vein thrombosis occurred in 1 case on the postoperative third day.In DHS group, incisions healed by rst intention in 16 cases and by second intention in 2 cases, coxa adducta occurred in 2 cases after operation.In PFNA group, all incisions healed by rst intention.Cacothesis in pate occurred in 1 case after operation.There were signi cant di erences in operation time, blood loss, and out-of-bed time（P 〈 0.05）.Thepatients were followed up（30.5 ± 6.5） months in ABFH group,（27.6 ± 6.2） months in DHS group, and（24.8 ± 5.4） months in PFNA group.The union time of fracture was（7.5 ± 2.5） months in ABFH group,（8.4 ± 2.2） months in DHS group and（7.2 ± 2.4） months in PFNA group.There were signi cant di erences in Harris score between before operation and after operation and between di erent time after operation in three groups（P 〈 0.05）.Conculsion The three operative methods have some their superiority, but the replacement of arti cial bipolar femoral head is more suitable for the senile unstable intertrochanteric fracture because of simply procedure, short operation time, less blood loss and early ambulation.