股骨颈骨折空心钉固定闭合复位治疗策略

STRATEGIES OF CLOSED REDUCTION IN TREATMENT OF FEMORAL NECK FRACTURE USING CANNULATED SCREW FIXATION

目的探讨股骨颈骨折空心钉固定治疗过程中术中复位策略及复位优良率与术后疗效的关系。方法回顾分析2005年8月-2015年3月收治的符合选择标准的174例股骨颈骨折患者临床资料。男78例,女96例;年龄23～75岁,平均53.8岁。致伤原因：摔伤85例,交通事故伤61例,高处坠落伤28例。按照Garden分型：Ⅰ型35例,Ⅱ型56例,Ⅲ型47例,Ⅳ型36例。受伤至手术时间1～7 d,平均2.74 d。遵循复位策略进行复位并采用闭合3枚空心加压螺钉方式固定。术后摄股骨颈正侧位X线片,遵循复位策略制定股骨颈骨折复位效果评价标准;采用Harris评分标准进行疗效评价。结果 174例患者均获随访,随访时间12～42个月,平均36.5个月。152例患者骨折愈合,愈合时间为6～12个月,平均9个月。9例骨折不愈合及3例内固定失效者（术后2～8个月）行人工半髋关节置换术;6例于术后15～26个月,平均18.5个月取出内固定物后6～12个月出现股骨头坏死,行全髋关节置换术;4例骨折不愈合行带血管蒂髂骨瓣移植术。均未出现内固定物切出等严重并发症。末次随访时,GardenⅠ～Ⅳ型复位标准优良率分别为94.29%、91.07%、87.23%、75.00%,综合优良率为87.36%;Harris评分优良率分别为97.14%、78.57%、68.09%和50.00%,综合优良率为73.56%。结论空心钉内固定治疗股骨颈骨折除应具有合理的植钉技术外,遵循正确良好的复位策略并进行复位效果评估可取得较好疗效,骨折复杂程度与复位优良率成反比,复杂骨折应尽量取得较高的复位优良率以达到后期良好预后。

Objective To study intraoperative reduction strategy in treatment of femoral neck fracture using cannulated screw fixation and the relationship between excellent and good rate of reduction and postoperative effectiveness. Methods A retrospective analysis was made on the clinical data of 174 cases of femoral neck fracture treated between August 2005 and March 2015. There were 78 males and 96 females with an average age of 53.8 years（range, 23-75 years）. The injury causes were falling in 85 cases, traffic accident in 61 cases, and falling from height in 28 cases. According to Garden typing, there were 35 cases of type I, 56 cases of type II, 47 cases of type III, and 36 cases of type IV. The time from injury to operation was 1-7 days（mean, 2.74 days）. Based on reduction strategy, closed 3 hollow compression screws were used; evaluating standards for fracture reduction effect were also established. Harris score was used for effectiveness evaluation. Results All the cases received follow-up of 12-42 months（mean, 36.5 months）. Bone healing was obtained in 152 cases at 6-12 months（mean, 9 months）. Non-union and internal fixation failure occurred in 9 and 3 patients respectively, who underwent hemiarthroplasty; femoral head necrosis occurred in 6 patients after removing internal fixator at 15-26 months（mean, 18.5 months） after operation, who underwent total hip arthroplasty; 4 patients with non-union received vascular pedicle iliac flap transplantation. No other serious complications were observed. At last follow-up, the excellent and good rate of reduction was 94.29% for Garden type I, 91.07% for type II, 87.23% for type III, and 75.00% for type IV, with a total excellent and good rate of 87.36%; the excellent and good rate of Harris score was 97.14% for Garden type I, 78.57% for type II, 68.09% for type III, and 50.00% for type IV, with a total excellent and good rate of 73.56%. Conclusion To obtain high Harris score in fixation of femoral neck fractures by using hollow screws, surgeons not only need reasonable technology, but also follow correct and good reduction strategy and assessment, fracture complexity is inversely proportional to excellent and good rate of reduction. Higher excellent and good reduction rate of complexity fracture should be obtained as much as possible in order to achieve good prognosis.