三种手术方式治疗老年移位型股骨颈骨折疗效比较

COMPARISON OF EFFECTIVENESS OF THREE OPERATIONS IN TREATMENT OF DISPLACED FEMORAL NECK FRACTURES IN THE ELDERLY PATIENTS

目的比较加压螺钉内固定术、人工股骨头置换术和人工全髋关节置换术治疗65～80岁移位型股骨颈骨折患者临床疗效,为临床选择治疗方法提供依据。方法 2005年5月-2008年4月,收治108例老年移位型股骨颈骨折患者。其中31例行加压螺钉内固定术(螺钉组),男8例,女23例;年龄65～80岁,平均73岁。摔伤25例,车祸伤6例。骨折分型:GardenⅢ型17例,Ⅳ型14例。受伤至手术时间8h～13d,平均4.2d。37例行人工股骨头置换术(股骨头置换组),男10例,女27例;年龄65～80岁,平均74岁。摔伤29例,车祸伤8例。骨折分型:GardenⅢ型21例,Ⅳ型16例。受伤至手术时间1～14d,平均4.4d。40例行人工全髋关节置换术(全髋关节置换组),男11例,女29例;年龄66～80岁,平均73岁。摔伤32例,车祸伤8例。骨折分型:GardenⅢ型23例,Ⅳ型17例。受伤至手术时间2～14d,平均5.6d。各组一般资料比较,差异均无统计学意义(P>0.05),具有可比性。结果螺钉组手术时间、术中出血量优于两置换组(P<0.05),两置换组间比较差异亦有统计学意义(P<0.05)。3组患者术后均获随访,随访时间1年4个月～2年3个月,平均1年8个月。螺钉组早期并发症发生率为19.4%(6/31),股骨头置换组为8.1%(3/37),全髋关节置换组为7.5%(3/40);晚期并发症发生率分别为29.0%(9/31)、13.5%(5/37)、7.5%(3/40);再手术率分别为29.0%(9/31)、10.8%(4/37)、5.0%(2/40)。螺钉组术后早、晚期并发症发生率及再手术率明显高于两置换组,差异均有统计学意义(P<0.05);两置换组间比较,差异均无统计学意义(P>0.05)。术后1年螺钉组、股骨头置换组、全髋关节置换组死亡率分别为16.1%(5/31)、13.5%(5/37)、15.0%(6/40),组间比较差异均无统计学意义(P>0.05)。术后1年各组存活患者髋关节功能行Harris评分,螺钉组优良率为65.4%(17/26),股骨头置换组为81.3%(26/32),全髋关节置换组为85.3%(29/34);各组间优良率比较,差异均有统计学意义(P<0.05)。结论对于65～80岁、预计生存期较长且对活动能力要求较高的老年移位型股骨颈骨折患者,相对于加压螺钉内固定及人工股骨头置换术,人工全髋关节置换术是较好选择。

Objective To compare the effectiveness of internal fixation, hemiarthroplasty, and total hip arthroplasty in the treatment of displaced femoral neck fractures in elderly patients so as to provide the evidence for the selection of therapeutic methods. Methods Between May 2005 and April 2008, 108 elderly patients with displaced femoral neck fractures were treated by internal fixation with compression screw （IF group, n=31）, hemiarthroplasty （HA group, n=37）, and total hip arthroplasty （THA group, n=40）. In IF group, there were 8 males and 23 females with an average age of 73 years （range, 65-80 years）; fractures were caused by tumbling （25 cases） and traffic accident （6 cases）, including 17 cases of Garden type III and 14 cases of Garden type IV; and the time from injury to operation ranged from 8 hours to 13 days with an average of 4.2 days. In HA group, there were 10 males and 27 females with an average age of 74 years （range, 65-80 years）; fractures were caused by tumbling （29 cases） and traffic accident （8 cases）, including 21 cases of Garden type III and 16 cases of Garden type IV; and the time from injury to operation ranged from 1 to 14 days with an average of 4.4 days. In THA group, there were 11 males and 29 females with an average age of 73 years （range, 66-80 years）; fractures were caused by tumbling （32 cases） and traffic accident （8 cases）, including 23 cases of Garden type III and 17 cases of Garden type IV; and the time from injury to operation ranged from 2 to 14 days with an average of 5.6 days. There was no significant difference in general data among 3 groups （P 0.05）. Results There were significant differences in operation time and blood loss among 3 groups （P 0.05）, and IF group was less than other 2 groups. All patients were followed up 1 year and 4 months to 2 years and 3 months with an average of 1 year and 8 months. In IF group, HA group, and THA group, the rates of early postoperative complications were 19.4% （6/31）, 8.1% （3/37）, and 7.5% （3/40）, respectively; the rates of late postoperative complications were 29.0% （9/31）, 13.5% （5/37）, and 7.5% （3/40）, respectively; and the reoperation rates were 29.0% （9/31）, 10.8% （4/37）, and 5.0% （2/40）, respectively. The rates of the early postoperative complication, late postoperative complication, and reoperation rate were significantly higher in IF group than in HA group and THA group （P 0.05）, but there was no significant difference between HA group and THA group （P 0.05）. The mortality rates were 16.1% （5/31）, 13.5% （5/37）, and 15.0% （6/40） in IF group, HA group, and THA group, respectively; showing no significant difference （P 0.05）. According to Harris hip score, the excellent and good rates were 65.4% （17/26）, 81.3% （26/32）, and 85.3% （29/34） in IF group, HA group, and THA group, respectively; showing significant differences among 3 groups （P 0.05）. Conclusion According to patient’s age, life expectancy, and general conditions, THA is a reasonable choice for the patients aged 65-80 years with displaced femoral neck fracture.