老年股骨转子间骨折内固定治疗方法的选择

Selection of internal fixation for intertrochanteric fractures in elderly patients

目的比较髓外固定系统、髓内固定系统及髋关节置换治疗老年股骨转子间骨折的疗效。方法对2007年1月-2011年1月收治的184例患者按照治疗方法分为DHS组（99例）、锁定钢板组（19例）、髓内固定组（25例）和关节置换组（41例）。对患者资料进行回顾性分析，其中男80例，女104例，年龄60—99岁[（72．4±3．9）岁]。骨折类型按改良Evans分型：IA型20例，IB型21例，Ⅱ型75例，Ⅲ型68例。比较四组患者术前情况、术后负重时间、骨折愈合时间、患髋功能及并发症等。结果患者术后获得7—22个月随访，平均12个月。四组患者在性别、年龄、骨折分型、内科合并症方面差异无统计学意义。术后有限负重时间关节置换组较其他三组明显缩短，差异有统计学意义。术后骨折愈合时间四组差异无统计学意义。术后发生并发症24例（13％），其中DHS组11例，锁定钢板组6例，髓内固定系统组5例，关节置换组2例。关节置换组Harris评分最高，差异有统计学意义。结论对于不稳定骨折或严重骨质疏松骨折且不能耐受关节置换术者，髓内固定为首选；对于高龄不稳定骨折、严重骨质疏松、术前可行走、能耐受手术的患者可首选人工双极股骨头置换。

Objective To compare the clinical efficacy of extramedullary fixation system, intramedullary fixation system and hip arthroplasty in treatment of intertrochanteric fractures in the elderly. Methods The retrospective study involved 184 patients treated between January 2007 and January 2011, which were assigned to dynamic hip screw （DHS） group （n = 99） , locking plate group （n = 19 ） , intramedullary fixation group （n = 25 ） and joint replacement group （n = 41 ）. There were 80 males and 104 females, at age range of 60-99 years, mean （72.4 ± 3.9） years. According to the modified Evan classification, the fractures included type I A in 20 patients, type I B in 21, type 11 in 75 and type m in 68. The preoperative conditions, postoperative welght-bearing time, fracture healing time, hip function and complications were comparatively studied among four groups. Results The patients were followed up for 7-22 months （mean 12 months）. The four groups showed no significant differences regarding the gender, age, fracture types and medical complications. The postoperative weight-bearing time of the joint replacement group was significantly shorter than that of the other three groups, with statistical significance. The fracture healing time was insignificantly different among the four groups. The postoperative complications were found in 24 patients （13%）, including 11 patients in the DHS group, six in the loc- king plate group, five in the intramedullary fixation group and two in the joint replacement group. Harris score was the highest in the joint replacement group, with statistical significance in comparison with the other three groups. Conclusions Intramedullary fixation should be the treatment of choice for the patients with unstable, or severe osteoporosis fractures and with intolerance of joint replacement. Artificial bipolar femoral head replacement is suitable for the elderly patients with unstable or severe osteoporosis fractures, capability of walk or tolerance of operation.