髓外固定对超高龄股骨粗隆间骨折内固定的疗效和意义

Effects and values of extramedullary fixation for femoral intertrochanteric fractures of the old superolderly patients

目的分析髓外固定[动力髋螺钉（DHs）和锁定板]对超高龄股骨粗隆间骨折的疗效，并与髓内固定（GammaⅢ）对照。方法回顾性收集、整理2007年9月-2012年9月接受手术治疗的股骨粗隆问骨折患者的资料126例。男51例，女75例；年龄85～102岁，平均年龄为（89．2±14．3）岁。按采用的内固定方式分为DHS组（32例）、锁定板组（49例）和GammaⅢ组（45例）。比较3组患者的手术时间，X线透视次数（不包括闭合复位和确认的透视），失血量（总失血量、显性失血量、隐性失血量）和输血量，术后院内并发症发生率和住院病死率，预后情况，术后1年Harris髋关节功能评分。结果GammaⅢ组的显性失血量显著少于锁定板组和DHS组（P值均〈0．05），但总失血量、隐性失血量和输血量均显著多于锁定板组和DHS组（P值均〈0．05）。锁定板组的总失血量和隐性失血量均显著多于DHS组（P值均〈0．05），但两组间显性失血量和输血量的差异均无统计学意义（P值均〉O．05）。DHS组和锁定板组的院内重要脏器并发症发生率、围术期病死率显著低于GammaⅢ组（P值均〈0．05）。GammaⅢ组开始负重的时间显著早于锁定板组和DHS组（P值均〈0．05）。3组间手术时间、X线透视次数、切口感染发生率、内固定失败发生率、开始坐轮椅的时间、骨折愈合的时间和术后1年Harris髋关节功能评分的差异均无统计学意义（P值均〉0．05）。结论对于超高龄的股骨粗隆间骨折患者，相对于髓内固定，髓外固定（DHS和锁定板）的总失血量少，有利于减少术后重要脏器并发症、死亡事件的发生。髓外固定可能是超高龄老年粗隆间骨折较为安全的内固定方式。

Objective To assess the effect of extramedullary fixation such as dynamic hip screw （DHS） and locking plate on femoral intertrochanteric fractures in the old super-olderly patients, and to make a comparison with intramedullary fixation such as Gamma Ⅲ nail. Methods A total of 126 patients with femoral intertrochanteric fractures treated surgically between September 2007 and September 2012 were enrolled in this retrospective study. There were 51 males and 75 females, with an average age of （89.2 ± 14.3） years （range, 85 to 102 years）. The patients were divided into 3 groups.. DHS group （32 cases）, locking plate group （49 cases） and GammaⅢ group （45 cases）. The indexes, including operation time, frequency of X-ray examination （except for closed reduction and confirmation）, total blood loss, obvious blood loss, hidden blood loss, poor healing and infection of incision, complications and death, failure of fixation, the start of bed-to-chair and weight-bearing, the time of bone healing and Harris scores of hip were observed and compared between groups. Results The obvious blood loss of Gamma Ⅲ group was significantly less than those of DHS group and locking plate group, while the total blood loss, hidden blood loss and blood transfusion of Gamma Ⅲ group were significantly more than those in the other two groups （all P〈0.05）. The total blood loss and hidden blood loss of locking plate group were signifi-cantly more than those of DHS group （both P〈0.05）, but there was no significant difference in obvious blood loss or blood transfusion between the two clroups （both P〉0.05）. The incidence rates of complications ofessential organs and death in GammaⅢ group were significantly higher than those in the other two groups （all P〉 0.05）. Weight-bearing of Gamma Ⅲgroup was significantly earlier than those of the other two groups （both P〈 0.05）. There were no significant difference in operation time, frequency of X ray examination, infection of incision, failure of fixation, the start of bed-to-chair, bone healing or Harris score between groups （all P〉0.05）. Conclusion Compared with intramedullary fixation, extramedullary fixation （DHS and locking plate） is more safe and effective for the femoral intertrochanteric fracture in the super-olderly patients. Extramedullary fixation has less blood loss and lower incidence of postoperative complications and death.