小切口股骨近端防旋髓内钉治疗老年股骨粗隆间骨折

Small Incision Proximal Femoral Nail Antirotation for Femoral Intertrochanteric Fractures in Elderly Patients

目的探讨股骨近端防旋髓内钉（proximal femoral nail antirotation,PFNA）小切口治疗老年股骨粗隆间骨折的疗效。方法 2011年1月～2014年8月使用骨科牵引床,闭合复位165例股骨粗隆间骨折,在大粗隆近端做长约3 cm小切口,于大粗隆内侧壁开孔扩髓后插入PFNA主钉,调整主钉深度及螺旋刀头孔的前倾角,安装螺旋刀头及远端锁钉,固定骨折。结果手术时间为25～45 min,平均38 min;术中出血量50～150 ml,平均80 ml;术后61例接受输血,输红细胞1.5～5U,平均2.8 U。165例随访8～24个月,平均10个月,骨折愈合时间3～6个月,平均4个月;术后颈干角丢失：Evans分类Ⅰ型1度0例,Ⅰ型2度0例,Ⅰ型3度3例,Ⅰ型4度11例,Ⅱ型2例。1例术后2个月时出现主钉断裂,重新更换PFNA及骨折处植骨后5个月因心脏病死亡;1例术后9个月骨折不愈合,到其他医院治疗。均未发生下肢深静脉血栓,股骨头未发生螺旋刀头切出。165例术后6个月患肢Harris髋关节评分：优107例,良53例,差5例,优良率97.0%（160/165）。结论采用PFNA小切口治疗老年股骨粗隆间骨折,具有固定可靠及恢复快的特点,适合所有类型的股骨粗隆间骨折,但需要注意术后隐性失血的问题。

Objective To evaluate the effect of small incision proximal femoral nail antirotation（ PFNA） for the treatment of femoral intertrochanteric fractures in elderly patients. Methods From January 2011 to August 2014, 165 patients with intertrochanteric fractures were treated with PFNA under closed reduction by using orthopedic traction table. A mini-incision of about 3cm in length at the level of proximal greater trochanter was made before the nail was inserted into the medullary canal of the proximal femur after reaming,and then the nail depth and the anteversion of the helical blade were adjusted. The fracture was fixed with assembling the helical blade and distal locking screw. Results The mean operation time was 38 min（ range,25- 45 min） and the mean intraoperative blood loss was 80 ml（ range,50- 150 ml） ml. Postoperatively,61 cases accepted blood transfusion with a mean of 2. 8 units of red blood cells（ range,1. 5- 5 units）. All the patients were followed up for an average of 10 months（ range,8- 24months）. The average bone union time was 4 months（ range,3- 6 months）. The postoperative collodiaphyseal angle loss was 0 case for the Evans type Ⅰdegree 1,0 case for type Ⅰ degree 2,3 cases for type Ⅰdegree 3,11 cases for type Ⅰ degree 4,and 2 cases for Evans type Ⅱ. There was one case of reoperation because of nail break,which underwent a new PFNA insertion and allograft bone implantation. However,the patient finally died of heart disease 5 months after the secondary operation. There was one case of nonunion at 9 months postoperation,and the patient was discharged to another hospital. No deep vernous embolism was detected and no helical blade cut-out of femoral head was founded. Of all the 165 cases,according to the Harris criteria,clinical results at 6 months postoperation were excellent in 107 cases,good in 53 and poor in 5,the excellent or good rate being 97. 0%（ 160 /165）.Conclusions PFNA with small incision is an excellent choice for intertrochanteric fractures in elderly patients. It provides stable fixation and guick recovery,which is suitable for all types of intertrochanteric fractures. However,the hidden blood loss after operation should be noticed.