难复位性股骨颈骨折的概念提出与治疗

Classification and treatment of irreducible femoral neck fractures

目的提出难复位性股骨颈骨折的概念，并探讨其分型与治疗方法。方法对2006年1月至2008年12月收治的519例移位型股骨颈骨折患者进行前瞻性研究，男241例，女278例；年龄21～66岁，平均54．9岁；左侧295例，右侧224例。所有患者首先尝试牵引闭合复位，若经3次整复骨折不能达到理想复位效果，则认为属于难复位l生股骨颈骨折，改用股骨头干三维互动复位技术复位，并采用3枚空心钉固定。分析难复位性股骨颈骨折的特点并对其进行分型，评价股骨头干三维互动复位技术的临床疗效。结果共有31例（6．0％）难复位性股骨颈骨折，男20例，女11例；年龄21～58岁，平均39．6岁；均为GardenⅣ型骨折。均采用股骨头干三维互动复位技术复位成功，28例骨折复位质量达Garden指数Ⅰ级，3例达Garden指数Ⅱ级。根据X线片及CT影像学特点，难复位性股骨颈骨折可分为3型：Ⅰ型5例（16．1％）：骨折线为斜形，近端骨折片呈“鹰嘴”状嵌插入骨折远端；Ⅱ型17例（54．8％）：骨折线不规则，骨折远端外旋并嵌插入近端；Ⅲ型9例（29．0％）：骨折端完全移位，股骨头和股骨干之间有分离，股骨头成漂浮状态，旋转移位较大。29例患者术后获2～4年（平均3．3年）随访，骨折均获骨性愈合，愈合时间为16～24周（平均20．1周）。3例发生股骨头坏死，其中Ⅱ型1例，Ⅲ型2例。结论难复位性股骨颈骨折可分为3型，采用股骨头干三维互动复位技术复位、3枚空心钉固定可获得较好的临床疗效。

Objective To explore the classification and treatment methods of femoral neck fractures which are difficult to reduce. Methods The present study enrolled 519 patients with displaced femoral neck fractures who had been treated from January 2006 to December 2008 in our institute. They were 241 men and 278 women, with a mean age of 54.9 years（from 21 to 66 years）. The left hip joint was involved in 295 cases and the right in 224 cases. If a fracture failed to obtain satisfactory reposition after we tried closed reduction for 3 times, it was defined as an irreducible femoral neck fracture which was next reduced by our self-designed technique called ＂3-D interreaction reduction＂ before it was fixed by 3 cannulated screws. The irreducible femoral neck fractures were characterized and the clinical efficacy of ＂3-D interreaction reduction＂ was evaluated. Results In this group, 31 cases of irreducible femoral neck fracture were defined and successfully reduced by the ＂3-D interreaction reduction＂ technique. Of them, 28 cases obtained reduction of Garden Grade Ⅰ and 3 cases of Garden Grade Ⅱ. The irreducible femoral neck fractures were classified into 3 types according to their radiological features. In type Ⅰ （5 cases, 16. 1% ）, the fracture line was oblique and an olecranon-shaped proximal fragment intruded into the distant fracture end. In type Ⅱ （17 cases, 54.8% ）, the fracture line was irregular and the outward-rotated distant fracture end intruded into the proximal fracture end. In type Ⅲ （9 cases, 29.0% ）, the fracture ends were completely displaced and the floating femoral head was disconnected with the shaft. Of the patients with irreducible femoral neck fracture, 29 were followed up for 2 to 4 years （average, 3.3 years）. Bone union was achieved in all the 29 cases after an average of 20. 1 weeks （from 16 to 24 weeks）. Of them, 3 cases developed necrosis of femoral head, one of type Ⅱ and 2 of type m by our classification. Conclusions Irreducible femoral neck fractures can be classified into 3 types. ＂3-D interreaction reduction＂ and fixation with 3 cannulated screws can be a fine strategy to treat them.