老年股骨粗隆间骨折手术方式的选择

Operation Style Selection of Intertrochanteric Femoral Fractures in Elderly Patients

目的对我院骨科自1998年以来收治并得到随访的216例老年股骨粗隆间骨折手术方式的选择作一回顾性分析。方法216例老年股骨粗隆间骨折患者按Evans分型，Ⅰ型12例，Ⅱ型21例，Ⅲa型44例，Ⅲb型84例，Ⅳ型55例。加压空心钉组38例，DHS组147例，髓内钉（Gamma钉或PFN钉）组21例，骨水泥型人工假体置换组10例。216例患者均进行随访并作出不同术式的疗效分析。结果本组216例平均住院20d，住院期间无一例死亡，随访时间4～24个月，平均。1个月。患髋功能按Harris评分标准进行评价，其中优良177例，可32例，差7例，总优良率82％。结论手术应根据患者骨折类型、固定器的生物力学特点、患者的身体状况选择内固定方法。加压空心钉适用于EvansⅠ、Ⅱ型大小粗隆较完整的骨折以及全身状况较差、不能承受大的手术创伤和麻醉的高危患者；DHS和髓内钉基本适用于所有类型的骨折，但对于小粗隆等后外侧骨质严重缺损者行复位固定或植骨以增加稳定性，大粗隆外侧骨皮质粉碎者，则DHS不适合。骨水泥型人工假体置换适用于高龄、严重骨质疏松、全身情况较差、并发症多、需早期下床活动者以及内固定失败的挽救手术。

Objective Retrospectively analysis the operation style selection in 216 intertrochanteric femoral fractures in elderly patients. Methods All 216 intertrochanteric femoral fractures in elderly patients were divided according Evans classification system：type Ⅰ 12 patients ,type Ⅱ 21 ,type Ⅲ a 44,type Ⅱ b 84,type Ⅳ 55. Dynamic cannulated screw group 38 patients ,DHS（dynamic hip screw） group 147 ,intramedullary nail（Gamma nail or PFN nail） group 21, bone cemended prosthetic replacement group 10. ALL 216 patients were followed up and analyzed the curative effect of different operation style. Results The average time in hospital are 20 days ,no expiration during hospital stay. All patients were followed up from 4 months to 24 months with 11 months on the average. Evaluate the joint function of hip by Harris scoring system. ,excellent and good was 177,fair 32 and poor 5,total excellent and good rates were 82 %. Conclusion The implant selection should consider the classification of fracture,implant biomechanical feacher and patients＇ physiclal status. Dynamic cannulated screw refer to Evans classification type Ⅰ , Ⅱ such as good integrity of greater and lesser trochanter and high risk patients whose bad physiclal status can＇t tolerate the surgical trauma or anesthetic. DHS and intramedullary nail refer to all classification of fracture,except the lesser trochanter and lateral cortex severely cortical defect to improve stability by reduction or bone graft and lateral greater trochanter cortical bone comminution. Bone cemended prosthetic replacement refer to elder patients with severe osteoporosis ,bad physiclal status ,severe complication need early ambulation and failure of fixation.