金属植入物髓内外固定修复老年股骨转子间骨折:围术期隐性失血量比较

Metal implant intramedullary and extramedullary fixation in repair of intertrochanteric fractures in the elderly: comparison of perioperative hidden blood loss

背景:股骨转子间骨折是指发生于髋关节囊线以外至小转子下方区域内的骨折,好发于老年患者,目前对于股骨转子间骨折的主要治疗方式,包括髓内固定和髓外固定。目的:比较老年股骨转子间骨折患者髓内外固定的隐性失血量,并探讨围手术期失血量的相关影响因素。方法:回顾性分析65岁以上资料齐全的298例股骨转子间骨折患者,男138例,女160例,其中采用髓内固定者153例(股骨近端防旋髓内钉81例,Gamma钉72例),髓外动力髋螺钉固定者145例。根据Gross方程计算髋部骨折患者围手术期固定前隐性失血量、固定后隐性失血量、总隐性失血量、总失血量和总隐性失血量占比,比较股骨转子间骨折髓内固定和髓外固定围手术期失血量情况,并分析性别、手术时间、受伤与手术时间间隔、合并糖尿病和高血压内科疾病等因素对以上指标的影响。结果与结论:Gamma钉组和股骨近端防旋髓内钉组的固定后隐性失血量、总隐性失血量、总隐性失血量占比均显著大于动力髋螺钉组(P<0.05);Gamma钉组和股骨近端防旋髓内钉组的显性失血量显著小于动力髋螺钉组(P<0.05);3组固定前隐性失血量、总失血量差异无显著性意义。受伤与手术的时间间隔<48 h组固定前隐性失血量明显低于>48 h组,且差异有显著性意义(P<0.05);糖尿病组固定后隐性失血量和总隐性失血量均明显高于非糖尿病组,且差异均有显著性意义(P<0.05);高血压组固定后隐性失血量和总隐性失血量均明显高于非高血压组,且差异均有显著性意义(P<0.05)。提示固定方式、受伤与手术的时间间隔、高血压和糖尿病是老年股骨转子间骨折患者围手术期隐性失血量的主要影响因素;对合并高血压和糖尿病的老年股骨转子间骨折患者要高度重视其围手术期隐性失血。

BACKGROUND： Intertrochanteric fracture refers to the fracture occurred outside hip capsule line to the region below the lesser trochanter, frequently in elder patients. At present, the main therapeutic manner of intertrochanteric fractures includes intramedullary fixation and extramedullary fixation. OBJECTIVE： To compare hidden blood loss in patients with elderly intertrochanteric fractures after intramedullary and extramedullary fixation, and to explore the related influential factors for perioperative blood loss. METHODS： We retrospectively analyzed 298 patients aged 〉 65 years with intertrochanteric fractures, including 138 males and 160 females. 153 cases underwent intramedullary fixation （81 cases of proximal femoral nail anti-rotation, and 72 cases of Gamma nail）. 145 cases received extramedullary fixation. According to Gross equation, perioperative pre-fixation hidden blood loss, post-fixation hidden blood loss, total hidden blood loss, total blood loss and total hidden blood loss proportion were calculated in patients with hip fracture. Perioperative blood loss was compared after intramedullary fixation and extramedullary fixation for intertrochanteric fractures. The effects of gender, operation time, injuries, surgical interval, diabetes and hypertension on above indexes were analyzed. RESULTS AND CONCLUSION： Post-fixation hidden blood loss, total hidden blood loss and total hidden blood loss proportion were significantly higher in the Gamma nail group and proximal femoral nail anti-rotation group than those in the dynamic hip screw group （P 〈 0.05）. Dominant blood loss was significantly less in the Gamma nail group and proximal femoral nail anti-rotation group than those in the dynamic hip screw group （P 〈 0.05）. No significant difference in hidden blood loss and total blood loss was detected before fixation in the three groups. Pre-fixation hidden blood loss was significantly lower in the group whose time from injury to surgery was 〈 48 hours compared with 〉 48 hours group （P 〈 0.05）. Post-fixation hidden blood loss and total hidden blood loss were significantly greater in the diabetes group than those in the non-diabetes group （P 〈 0.05）. Post-fixation hidden blood loss and total hidden blood loss were significantly higher in the hypertension group than those in the non-hypertension group （P 〈 0.05）. These data indicated that fixation mode, the time between injury and surgery, hypertension and diabetes are major influential factors for perioperative hidden blood loss in patients with elderly intertrochanteric fractures. We should pay attention to perioperative hidden blood loss in elderly intertrochanteric fracture patients combined with hypertension and diabetes.