防旋股骨近端髓内钉治疗股骨逆转子间骨折

TREATMENT OF REVERSE OBLIQUE FRACTURES OF INTERTROCHANTERIC REGION OF FEMUR WITH PROXIMAL FEMORAL NAIL ANTIROTATION

目的探讨防旋股骨近端髓内钉(proximal femoral nail antirotation,PFNA)治疗股骨逆转子间骨折的手术方法,并评估其疗效。方法2007年1月-2008年2月,采用闭合复位PFNA内固定治疗30例股骨逆转子间骨折。其中男14例,女16例;年龄40～88岁,平均68.6岁。患者均为闭合骨折。骨折根椐AO分型:31-A3.1型6例,31-A3.2型7例,31-A3.3型17例。受伤至手术时间2～14d,平均5.3d。31-A3.1型及31-A3.2型骨折均以标准型PFNA固定,31-A3.3型骨折中9例以标准型PFNA固定,8例以加长型PFNA固定。患者均在术后1、2、3、6、12、18个月定期复查X线片并行功能检查,临床评价采用Sanders等评分标准。结果术中发生医源性股骨干骨折1例,因骨折稳定性较好未作特殊处理。1例术后5d发生切口浅表感染,经换药及应用抗生素后愈合;余切口均Ⅰ期愈合。30例均获随访,随访时间12～19个月,平均14.1个月。骨折均于术后12～30周愈合,平均16.2周。5例髋部疼痛,2例大腿外侧疼痛,经对症处理后疼痛缓解。1例合并同侧胫骨平台骨折的患者膝关节屈曲功能受限,1例合并同侧髋臼及骨盆骨折的患者髋关节功能受限,经功能锻炼后好转。无内固定断裂、螺旋刀片拔出或穿破股骨头关节面等并发症发生。根据Sanders等评分标准评定,获优22例,良6例,差2例,优良率93.3%。结论闭合复位PFNA内固定是一种治疗股骨逆转子间骨折的有效方法,具有骨折愈合率高、软组织损伤小、可早期功能锻炼、并发症少等优点。

Objective To investigate the operative method and to evaluate the clinical outcome of proximal femoral nail antirotation （PFNA） in treating reverse oblique fractures of intertrochanteric region of the femur. Methods From January 2007 to February 2008, 30 cases of reverse oblique fractures of intertrochanteric region of the femur were treated by dosed reduction and fixation with PFNA, including 14 males and 16 females and aging 40-88 years old with an average of 68.6 years old. All patients had closed fractures. According to AO classification, there were 6 cases of 31-A3.1 type, 7 cases of 31-A3.2 type and 17 cases of 31-A3.3 types. The time from injury to operation was 2-14 days （with an average of 5.3 days）. All 31-A3.1 and 31-A3.2 type farctures and 9 cases of AO 31-A3.3 type fractures were fixed with the standard PFNA, and 8 cases of 31-A3.3 type fractures with the PFNA-long. The clinical and radiological examinations were done at 1, 2, 3, 6, 12, and 18 months after operation. The clinical outcomes were evaluated according to the Sanders scoring. Results Iatrogenic fracture of femoral shaft occurred in 1 case; no additional procedures were applied as fracture kept favorable stability. Superficial infection occurred in 1 case at 5 days after operation, wound healed after dressing change and intravenous antibiotic therapy. Other wounds healed by first intention. All cases were followed up for 12-19 months （mean 14.1 months）. All fractures healed uneventfully after 12-30 weeks （mean 16.2 weeks）. Five patients complained of hi p pain, 2 patients had lateral leg pain, and the pain was eliminated after symptomatic treatment. One case complicated by ipsilateral fracture of the tibial plateau had functional disturbance of knee, and one case complicated by ipsilateral fracture of the acetabulum and pelvis had functional disturbance of hip, and the function was improved after functional exercise. No complications such as cut-out or breakage of the implants occurred. According to Sanders criteria, the clinical results were excellent in 22 cases, good in 6 cases, and poor in 2 cases. The excellent and good rate was 93.3%. Conclusion PFNA is an effective treatment method for reverse oblique fractures of intertrochanteric region of the femur, with a high rate of bone union, minor soft tissue damage, early functional exercise and acceptable complication related to implant.