股骨颈骨折愈合后内固定取出致股骨头坏死的原因及防治策略

Analysis of causes the extraction of internal fixation after the healing of femoral neck fracture leads to femoral head necrosis and prevention strategies

目的探讨股骨颈骨折愈合后行内固定取出导致股骨头坏死的原因。方法对我院因股骨颈骨折术后愈合而行内固定取出手术的43例患者进行随访，比较患者的性别、年龄、内固定取出时机、内固定取出术中钉道是否植骨及内固定取出后负重方式等因素与股骨头坏死发生率的关系。结果经过平均2．5年随访，共有15例发生股骨头坏死，年龄40～59岁、60～83岁者股骨头坏死发生率分别为12．5％（2／16）、48．1％（13／27），差异有统计学意义（x2=5．620，P〈0．05）；〈2年与≥2年行内固定取出者股骨头坏死发生率分别为52．2％（12／23）、15．0％（3／20），差异有统计学意义（x2=6．508，P〈0．05）；常规内固定取出术中不植骨且术后拄拐保护性负重4～8周（平均6周）然后再完全负重者与内固定取出术中钉道植骨且术后拄双拐完全不负重12周然后再逐渐增加至完全负重者股骨头坏死发生率分别为52．6％（10／19）、20．8％（5／24），差异有统计学意义（x2=4．720，P〈0．05）。结论对于年龄较大的患者，股骨颈骨折愈合后内固定取出可能增加股骨头坏死的风险，建议应尽量保留内固定物；股骨颈骨折愈合后内固定取出时机应在2年以上为宜；内固定取出术中钉道植骨且术后拄双拐完全不负重12周、然后再逐渐增加至完全负重的方案能明显降低股骨颈骨折愈合后内固定取出所致的股骨头坏死发生率。

Objective To investigate the reasons of the extraction of internal fixation after the healing of femoral neck fracture leading to femoral head necrosis. Methods A total of 43 patients with the healing of femoral neck fracture who were extracted the internal fixation in Third People＇s Hospital of Mianyang were followed up. The incidence of femoral head necrosis with the factors such as the patient＇s age,gender,the timing to extract the internal fixation, bone graft in the channel of screws or not and the way to bear the weight after the extraction of internal fixation were compared. Results After an average of 2. 5 years of follow-up, there were 15 cases of femoral head necrosis, the incidence of femoral head necrosis of the age of 40-59 years old and 60 to 83 years old was 12. 5% （ 2/16）, 48. 1% （ 13/27 ） respectively, the difference was significant （ x2 = 5. 6205, P 〈0. 05）. The incidence of femoral head necrosis of〈2 years of follow-up and ≥2 years of follow-up was 52. 2% （12/23）, 15.0%（3/20） respectively, the difference was significant （X2= 6. 508, P〈0. 05）. The incidence of femoral head necrosis of the patients who had no bone graft in the channel of screws and were protected to bear the weight in 4-8 weeks （ an average of 6 weeks） after the extraction of internal fixation and then fully weight- bearing was 52. 6% （ 10/19）, and of the patients who had bone graft in the channel of screws and didn＇t to bear the weight in 12 weeks after the extraction of internal fixation and then gradually increased to full weight-bearing was 20. 8%（5/24） ,the difference was significant（ X2 =4. 720,P〈0. 05）. Conclusion For the elder patients, the extraction of internal fixation may increase the risk of the femoral head necrosis, they are recommended to preserve the internal fixation. The timing to extract the internal fixation should be above 2 years;the solution that bone graft in the channel of screws and don＇t to bear the weight in 12 weeks after the extraction of internal fixation and then gradually increased to full weight-bearing, can obviously reduce the incidence of femoral head necrosis.