经皮加压钢板治疗移位型股骨颈骨折的前瞻性随机对照研究

PROSPECTIVE RANDOMIZED CONTROLLED STUDY ON TREATMENT OF DISPLACED FEMORAL NECK FRACTURES WITH PERCUTANEOUS COMPRESSION PLATE

目的采用前瞻性随机对照研究比较经皮加压钢板（percutaneous compression plate,PCCP）与空心加压螺钉固定治疗移位型股骨颈骨折的疗效。方法 2010年1月-2014年6月,收治符合选择标准的70例移位型股骨颈骨折患者,随机分为两组（n=35）;骨折闭合复位后,A组采用PCCP固定,B组采用空心加压螺钉固定。两组患者性别、年龄、致伤原因、侧别、骨折分型、受伤至手术时间、合并症构成、术前Harris评分以及疼痛视觉模拟评分（VAS）等一般资料比较,差异均无统计学意义（P〉0.05）。记录两组患者手术时间、术中出血量、骨折愈合时间、复位质量以及术后实际下地康复时间、完全负重时间;术后12个月行Harris评分和VAS评分,评价术后疗效。结果术后两组切口均Ⅰ期愈合,无感染等并发症发生。70例患者均获随访,随访时间13~34个月,平均23.7个月。两组患者手术时间、术中出血量、骨折愈合时间比较,差异有统计学意义（P〈0.05）;骨折复位质量比较,差异无统计学意义（P〉0.05）。术后A组2例发生股骨头缺血性坏死（骨折复位质量均为Ⅳ级）,无骨不连和退钉发生;B组4例发生股骨头缺血性坏死、1例发生骨不连（骨折复位质量Ⅰ级2例,Ⅱ、Ⅲ、Ⅳ级各1例）,3例退钉;两组术后股骨头缺血性坏死及骨不连并发症发生率比较,差异有统计学意义（χ~2=—3.997,P=0.046）;且发生股骨头缺血性坏死和骨不连患者的骨折复位质量比较,差异有统计学意义（χ~2=1.991,P=0.047）。A组患者术后实际下地康复时间和完全负重时间均早于B组,差异有统计学意义（P〈0.05）;术后12个月,A组Harris评分和VAS评分均优于B组,比较差异有统计学意义（P〈0.05）。结论与空心加压螺钉相比,PCCP治疗移位型股骨颈骨折具有更好的静态稳定性和骨折端动态滑动加压作用,术后允许早期康复锻炼和负重,骨不连及股骨头缺血性坏死发生率明显降低,但骨折复位质量较差和粉碎骨折患者仍可能发生股骨头缺血性坏死并发症。

Objective To compare the effectiveness of percutaneous compression plate（PCCP） and hollow compression screw in the treatment of displaced femoral neck fractures. Methods Between January 2010 and June 2014, 70 patients with displaced femoral neck fractures were randomly divided into 2 groups. After reduction, fracture was fixed with PCCP in 35 cases（group A） and with hollow compression screw in 35 cases（group B）. There was no significant difference in the gender, age, cause, side and type of fractures, time from injury to operation, associated disease, pre-operative Harris score and visual analogue scale（VAS） score between 2 groups（P〈0. 05）. The operation time, intra-operative blood loss, fracture healing time, fracture reduction quality, time of rehabilitation and weightloading; complication, post-operative Harris score and post-operative VAS score were compared between 2 groups. Results The incisions healed by first intention. All patients were followed up 13- 34 months（mean, 23. 7 months）. There were significant differences in operation time, intra-operative blood loss, and fracture healing time between 2 groups（P〈0. 05）. There was no significant in the fracture reduction quality between 2 groups（P〈0. 05）. Avascular necrosis of the femoral head occurred in 2 cases of group A after operation（fracture reduction quality： grade IV）; and avascular necrosis of the femoral head occurred in 4 cases of group B after operation（fracture reduction quality： grade I in 2 cases, grade II in 1 case, grade III in 1 case, and grade IV in 1 case）, nonunion in 1 case, and screw loosening in 3 cases; and there was significant difference in the incidence of bone nonunion and avascular necrosis of the femoral head between 2 groups（χ2= — 3. 997, P= 0. 046）. Difference was significant in fracture reduction quality in the patients with avascular necrosis of the femoral head and nonunion between 2 groups（χ2= 1. 991, P= 0. 047）. The time of rehabilitation and weight-loading of group A was significantly earlier than that of group B（P〈0. 05）; the Harris and VAS scores of group A were significantly better than those of group B at 12 months after operation（P〈0. 05）. Conclusion PCCP for treatment of displaced femoral neck fractures has better static stability and better sliding dynamic pressure effect than hollow compression screw, and it can provide earlier rehabilitation and weight-loading postoperatively and obviously decrease the incidence of bone nonunion and avascular necrosis of the femoral head, but avascular necrosis of the femoral head still occur in patients with poor reduction or comminuted fracture.