髓内外固定治疗老年股骨转子间骨折的临床研究

Intramedullary and extramedully fixation methods for the treatment of senile intertrochateric fracture

[目的]比较髓内固定股骨近端防旋髓内钉(PFNA)和髓外固定包括动力髋螺钉(DHS),股骨近端解剖锁定钢板3种手术方法治疗股骨转子间骨折的疗效。[方法]对2004年3月～2009年9月收治的258例分别接受DHS、PFNA、解剖锁定钢板手术治疗的老年股骨转子间骨折患者资料进行回顾性分析,其中男99例,女159例;年龄61～96岁,平均(76.4±5.4)岁。骨折AO分型:31-A1型114例,31-A2型88例,31-A3型56例。其中DHS组109例,PFNA组86例,解剖锁定钢板组63例。对3组患者的术中情况、术后功能及并发症等情况进行比较。[结果]258例患者术后获12～36个月(平均22.6)个月随访;随访期间无死亡病例。PFNA组手术切口长度较DHS组及解剖锁定钢板组短,比较差异有统计学意义(P<0.05)。DHS组、PFNA组、解剖锁定钢板组手术时间平均分别为(82.6±15.3)min、(69.4±10.4)min、(76.8±11.2)min,出血量平均分别为(314.2±68.2)ml、(162.2±46.5)ml、(210.5±80.2)ml,3组间比较差异均有统计学意义(P<0.05)。PFNA组平均住院天数、术后负重时间较DHS组及解剖锁定钢板组短,比较差异有统计学意义(P<0.05)。3种内固定术后骨折愈合时间及1年优良率比较差异无统计学意义(P>0.05)。[结论]3种手术治疗方式均有各自的优缺点,DHS适应于稳定型的骨折;PFNA适用于骨质疏松的不稳定型骨折和合并症较多的患者,其下床活动较早;对于严重骨质疏松的粉碎性骨折,可以选用解剖锁定钢板,术后要适当延迟下地负重时间。

[Objective]To compare the clinical effect of intramedullary fixation proximal femoral nail anti-rotation（PFNA） and extramedullary fixation including dynamic hip screw（DHS） and proximal femoral anatomic locking plate in the treatment of intertrochanteric fractures in the elderly patients. [Method]From March 2004 to September 2009,258 old patients with intertrochanteric fractures were treated by either DHS,or PFNA or anatomic locking plate,including 99 males and 159 females with an average age of 76.4±5.4 years（61-96）.According to AO/ASIF classification,there were 114 patients with type 31-A1 fractures,88 patients with type 31-A2 and 56 with 31-A3.Totally 109 patients were treated with DHS,86 with PFNA and 63 with anatomic locking plate.The operative procedures,therapeutic effects and complications were compared between 3 methods. [Result]The patients included in the present study were followed up for 12 to 36 months（average,22.6 months）.No deaths occurred during follow-up.PFNA group had smaller incision length than DHS and anatomic locking plate group,there were significant differences（P0.05）.The operative time of DHS,PFNA,and anatomic locking plate group were（82.6±15.3）,（69.4±10.4）,（76.8±11.2）min,the intraoperative blood loss of the three groups were（314.2±68.2）,（162.2±46.5）,（210.5±80.2）ml,there were significant differences（P0.05）.The length of hospital stay and walking time in PFNA group were shorter than in other two groups,there were significant differences（P0.05）.There were no significant difference in union time and the excellent rate one year postoperatively between the 3 groups. [Conclusion]Each of them has its own advantages,DHS is fit for stable fractures,PFNA is more appropriate for the aged and unhealthy patients with unstable fractures,and postoperative walking is earlier,anatomic locking plate can be applied to the elderly patients with severe comminuted fractures and osteoporosis.