PFNA治疗股骨转子间伴或不伴外侧壁骨折的疗效分析

Radiographic and functional results of the intertrochanteric fractures with or without lateral femoral wall fractures using proximal femoral nail antirotation （PFNA）

目的探讨PFNA治疗股骨转子间伴或不伴外侧壁骨折的临床疗效。方法回顾性分析2008年5月至2011年6月应用PFNA治疗102例股骨转子间骨折资料。术前根据CT三维重建图像所示外侧壁情况分为2组：外侧壁骨折组（A组，41例，其中AO／OTA31-A2型5例，31-A3型36例），外侧壁未骨折组（B组，61例，均为AO／OTA31-A2型）。比较两组患者的手术时间、术中出血量、住院天数，根据术后2周的X线片及CT三维重建图像比较外侧壁爆裂情况。采用老年髋部骨折功能恢复量表（functional recovery scale，FRS）对术后疗效进行评估。结果A组手术时间为（56±8）min、术中出血量为（238±21）ml、住院天数为（17±3）d，均高于B组的（45±6）min、（175±11）m1、（15±3）d，两者比较差异均有统计学意义。术后X线片示A组8例（19．5％，8／41）、B组3例（4．9％，3／61）发生外侧壁爆裂；而术后CT三维重建示A组36例（87．8％，36／41）、B组45例（73．8％，45／61）发生外侧壁爆裂。82例患者获得随访，随访时间6-35个月，平均19．5个月。随访时间在1年以上有56例，FRS评分：A组为（64．2±4．8）分，B组为（76．5±7．9）分。结论PFNA治疗不稳定型股骨转子间骨折时，容易造成股骨转子外侧壁骨折或加重外侧壁损伤，影响患者髋部功能恢复。CT三维重建技术可有效评估该类医原性创伤。

Objective To evaluate the clinical effect of the intertrochanteric fractures with or without lateral femoral wall fractures using proximal femoral nail antirotation （PFNA）. Methods From May 2008 to June 2011, 102 patients with intertrochanteric fractures were treated with PFNA. In accordance with the preoperative three dimensional CT reconstruction（3D CT） images, the group A included 41 cases with lateral femoral wall fractures, and the other 61 cases with an intact lateral wall were in group B. According to the AO/OTA classification, there were 5 cases in 31-A2, 36 in 31-A3 in group A, and 61 in 31-A2 in group B. The operative time, operative blood loss, average length of stay, postoperative X-ray images, and 3D CT images were collected for each patient. Time of partial weight-bearing, full weight-bearing and fracture healing were also recorded. Clinical evaluation was made using the functional recovery scale （FRS） of hip fractures. Results The mean operation time was 56±8 min in group A vs 45±6 min in group B; the mean blood loss was 238±21 ml vs 175±11 ml; the average length of stay was 17±3 days vs 15±3 days. On the postoperative radiography, the blowout of lateral trochanteric wall only occurred in 8 （19.5%, 8/41） cases in group A and 3 （4.9%, 3/61） in group B. According to the postoperative 3D CT, the similar findings were seen in 36 （87.8%, 36/41） cases in group A and 45 （73.8%, 45/61） in group B. Eighty-two cases were followed up for 6 to 35 months （mean, 19.5 months）. The mean FRS score was 64.2±4.8 points in group A and 76.5±7.9 points in group B. Conclusion When treating unstable intertrochanteric fractures, iatrogenic fractures in lateral trochanteric wall could be easily caused with using PFNA. 3D CT could effectively evaluate iatrogenic trauma in the intertrochanteric fractures.