内窥镜干预微创置入中空加压钉内固定治疗股骨颈骨折的探讨

The Mini-invasive Internal Fixation of Annulated Compression Screws Assisted with Microendoscope for Femoral Neck Fractures

目的探讨在内窥镜技术干预下微创置入中空加压钉内固定治疗股骨颈骨折的方法和效果。方法我院2005年1月~2012年10月引入内窥镜技术干预微创置入中空加压钉内固定治疗股骨颈骨折69例。骨折按Garden分型：Ⅱ型9例,Ⅲ型54例,Ⅳ型6例。按骨折线部位分类：头下型9例,头颈型36例,经颈型15例,基底型9例。选用椎间盘镜系统,在C臂X线机监视下牵引复位,经皮由股骨大粗隆外下向股骨头方向钻入两根导引针,沿两针之间作长约1.5 cm切口直达骨质,沿其中一根导引针置入工作通道,在内窥镜监视下清理置钉区域软组织并置入中空加压钉,同法置入第2及第3枚中空加压钉。取钉时沿原切口疤痕切开皮肤长1.5 cm直至骨质,放置工作通道,在内窥镜监视下分辨、寻找钉尾,并依次取出。结果本组69例患者均在内窥镜监视下完成手术,平均手术时间45（30~60）min;术中平均失血量10（6~20）ml;均未出现伤口感染、下肢深静脉血栓、肺栓塞或内固定物折断现象,无围术期死亡发生。本组69例均获得随访,时间10~48个月。63例内固定稳定,骨折愈合良好,平均愈合时间18（12~24）周;3例头下型骨折出现骨不愈合,其中2例行全髋关节置换术治愈,1例行股方肌蒂骨瓣移植术后骨折愈合;3例随访期间发生股骨头坏死、塌陷,均行全髋关节置换术治愈。术后Harris髋关节功能评分平均95.4（93.5~97.3）分。结论内窥镜干预下微创置钉治疗股骨颈骨折具有微创、直观、可操作性强、止血方便等优点,尤其在取钉时可高清晰辨认组织及钉尾,快速取钉。

Objective To explore the method and effect of the mini-invasive internal fixation of annulated compression screws assisted with diskoscope for femoral neck fracture （FNF）. Methods A total of 69 cases with FNF admitted from January 2005 to October 2012 were performed mini-invasive internal fixation assisted by mi- croendoscopic tubular retractor system（METR）. There were 9 cases of Garden Ⅱ, 54 cases of Garden Ⅲ and 6 cases of Garden Ⅳ according to Garden typing, and 9 cases of sub-head type, 36 cases of head-neck type, 15 cases of via-neck type and 9 cases of basal-neck type according to location of fracture line. Two percutaneous guidewires were inserted along the infer lateral of femoral trochanter to femoral head under C-am guidance after the traction and reduction of fractures. The work channel and image system were placed along one guidewire through 1.5 cm long incision to bone cortex in the line of two guidewires. The annulated compression screw was set after clearing up the soft tissue of needle region under endoscope monitoring. Radiograph was taken to confirm that screws were positioned correctly after the second and third screw was placed with the same method. When removing screws, the work channel was inserted through the former incision, and the bottom of screws was found out, the screws were removing under endoscope. Results All 69 cases were accomplished the surgical intervention under endo- scope with 30 to 60 minutes of operative duration and 6 to 20 of blood loss. There was no post-operative complica- tion such as wound infection, deep venous thrombosis of lower extremity, pulmonary embolism and internal fixator broken, and no peri-operative death occurred. All cases were followed up for 10 to 48 months. 63 cases were a- chieved stable internal fixation and fracture healing during 12 to 24 weeks, 3 cases with sub-head type appeared bone nonunion and cured by total hip replacement （THR） in 2 cases and pedicled bone graft of quadrat muscle of thigh in 1 case, and 3 cases was found femur head necrosis and collapse and cured by THR. The Harris score of hip joint function was 93.5 to 97.3 with an average of 95.4. Conclusion The mini-invasive internal fixation of annulated compression screws assisted with endoscope has advantages as mini-trauma, intuitionistic and easy oper- ating and effective hemostasis, especially in identifying tissue and bottom of screws and removing screws quickly.