全髋关节置换术治疗股骨转子间骨折内固定失败的中期疗效

Mid-term outcome of total hip arthroplasty for failed internal fixation of intertrochanteric fracture

目的探讨股骨转子间骨折内固定失败后全髋关节置换术（total hip arthroplasty，THA）治疗的中期疗效。方法回顾性分析2007年1月-2010年12月采用THA治疗股骨转子间骨折内固定失败后患者21例，其中男10例，女11例；年龄66～79岁，平均71．7岁。动力髋螺钉（dynamic hip screw，DHS）／动力髁螺钉（dynamic condyle screw，DCS）固定失败16例，髓内钉固定失败3例，空心螺钉固定失败2例。内固定术后至THA时间10—79个月，平均29个月。失败原因：螺钉松动、切割或内固定断裂致骨折移位或不愈合19例，股骨头坏死2例。所有患者均选择THA，髋臼杯采用生物型固定，股骨柄使用广泛多孔钛涂层长柄近端固定假体，其中5例AML柄，16例Solution柄。股骨大转子骨折用鲁克钢丝固定。评价术前及术后最后一次随访Harris髋关节评分；术前、术后3，6，12个月及术后最后一次随访X线片，评价骨折复位及愈合以及假体初始固定及中期生存情况。结果1例术后1．5年死于肺部感染，2例失访，18例获得随访，时间3～5年，平均3．9年。末次随访时13例恢复自由行走，4例需要手杖帮助下行走，1例需要助行器帮助下行走。未见假体松动、下沉断裂。髋关节Harris评分由术前的25．3分提高到末次随访的80．6分，其中优11例，良6例，可1例，优良率94％。结论对于股骨转子间骨折内固定失败的患者，行挽救性THA能有效改善髋关节功能，提高患者的生活质量，中期随访结果较好。

Objective To evaluate the mid-term effect of total hip arthroplasty （THA） after failed internal fixation of intertrochanteric fracture. Methods Twenty-one patients treated with THA due to failed internal fixation of intertrochanteric fracture from January 2007 to December 2010 were stud- ied retrospectively. There were 10 males and 11 females, at mean age of 71. 7 years （ range, 66- 79 years）. Sixteen patients were treated with dynamic hip screws/dynamic condyle screws （DHS/DCS）, 3 proximal femoral nails, 2 hollow screws. Mean interval from internal fixation to THA was 29 months （range, 10-79 months）. Causes for the failed internal fixation were loosening, cutting, and breakage of screws which generated fracture displacement or nonunion in 19 patients and femoral head necrosis in 2 patients. All patients received THA with uncemented acetabulum cups and proximally long-stemmed, porous-coated titanium femoral components including AML stems for 5 patients and Solution stems for 16 patients. Moreover, greater trochanteric fracture was fixed by Luke wire. Harris hip score were meas- ured before operation and at final follow-up. Radiographs were performed before operation, at 3, 6 and 12 months after operation, and at final follow-up to assess the fracture restoration, healing, prosthesis initial fixation, and mid-term survival condition. Results One patient was died due to pulmonary infection 1.5 years after operation. Two patients were lost to follow-up and 18 patients were followed up for 3- 5 years （ mean, 3.9 years）. At final follow-up, 13 patients regained the ability to walk independently,4 needed support of a cane, 1 needed assistance of a walker. There were no signs of loosening, subsidence or rupture of the prosthesis. Mean Harris hip score increased from 25.3 points preoperatively to 80. 6 points at final follow-up ; the score was excellent in 11 patients, good in 6, good in 1, with the excellent and good rate of 94%. Conclusion THA can improve hip function, patients＇ quality of life and midterm outcome in salvage of failed internal fixation of intertrochanteric fractures.