有限切开和经皮辅助复位髓内钉治疗股骨转子下骨折的比较研究

Limited incision vs. percutaneous assistance for reduction of subtrochanteric fractures treated with intramedullary nail

[目的]比较研究髓内钉治疗闭合复位失败的股骨转子下骨折时，经皮辅助（percutancous assistance，PA）和有限切开（limitedinc ision，LI）两种不同复位方法手术过程及术后恢复情况的差异。[方法]2008年1月～2012年6月间，分别采用PA和LI法复位治疗闭合复位失败的46例股骨转子下骨折，以重建髓内钉进行固定。PA组经皮以Schanz钉或者斯氏针等工具控制骨折近段，内收、内旋、后伸纠正骨折移位并维持。LI组经大转子下方3～5cm皮肤切口钝性分离股外侧肌至骨折，C型臂X线机透视下经切口以复位钳等工具纠正骨块移位和分离，部分患者以钢丝环扎维持复位。比较两组患者在手术过程（手术时间、术中出血、透视次数）和术后恢复（内外、前后成角畸形，旋转畸形、骨折愈合时间、下肢缩短及Sanders创伤性髋关节等级评分）情况。[结果]患者获得12～21个月（平均16．4个月）随访，均无血管神经损伤、伤口感染坏死，无内固定物松动、断裂及骨折不愈合等并发症。两组患者在术中出血、术后旋转和缩短畸形、骨折临床愈合时间、功能评分方面差异无统计学意义；LI组在手术时间、术中透视、骨折内外翻畸形方面优于PA组，差异有统计学意义。[结论]通过有限切开复位、髓内钉治疗股骨转子下骨折，有利于术中判断和维持复位，方便插入髓内钉，减少内外翻畸形，可以和经皮复位一样获得良好的治疗效果。术中需要谨慎操作，减少对骨折愈合的影响。

[ Objective] To compare the method of limited incision with percutaneous assistance for reduction in surgery and postoperative recovery in subtrochanteric fractures treated with intramedullary nail. [ Method] From January 2008 to June 2012, we used two different methods of reduction （limited incision and percutanious assistance） to treat 46 cases of subtrochanteric fracture with intramedullary nail when manual reduction failed intraoperatively. In PA group,we used Schanz nail or Steinmann＇s pin to control proximal fracture, then corrected displacement by adduction, internal rotation, extension. In LI group, we inserted clamp or other tools to assist reduction under C-arm while a limited incision of 3 - 5 cm in lateral skin and blunt dissection of the vastuslateralis muscle was made. The two groups were compared with intraoperative indicators （ operation time,intraoperative blood loss, the number of fluoroscopy） and postoperative recovery （ angular malunion, rotational deformity, fracture healing time, lower limb shortening and the Sanders traumatic functional score）. [ Result] Patients had 12 to 21 months （ mean 16.4 months） follow-up without vascular nerve injury, wound infection and necrosis, no internal fixator loosening, breakage and non-union were found. There were no difference in intraoperative bleeding, rotational deformity, lower limb shortening, fracture healing time, and function score between the two groups. LI group was better than PA group in operation time, intraoperative fluoroscopy, angular malunion, and the difference was statistically significant. [ Conclusion ] Limited incision reduction with intramedullary nail in treating of subtrochanteric fractures will conduct intraoperative judgment and maintain the reduction, can easily insert intramed- ullary nail,reduce angular deformity,and can get the same therapeutic effect as percutaneous assistance. It requires attention to reduce the impact on fracture healing in LI group.