阳性支撑对股骨粗隆间骨折内固定效果的影响

Effect of positive medial cortical support on the internal fixation for intertrochanteric fractures

目的研究阳性支撑、阴性支撑、中性支撑对股骨粗隆间骨折内固定效果的影响。方法回顾性分析2009年9月—2016年1月惠州市第六人民医院骨科应用股骨近端髓内钉(PFNA)治疗股骨粗隆间骨折80例,男性31例,女性49例;年龄54～88岁,平均71. 4岁。根据复位后髋关节正位X线片中股骨干内侧皮质与股骨颈内侧骨皮质的位置关系,分为三组,即股骨干内侧皮质位于股骨颈内侧骨皮质外侧(阳性支撑组46例)、股骨干内侧皮质位于内侧(阴性支撑组19例)、近似解剖复位(中性支撑组15例)。比较三组患者年龄、性别、骨折前基本日常生活能力、股骨近端外侧壁完整性、小转子完整性、术后及时尖顶距(TAD)以及术后3个月后TAD、颈干角、股骨颈长度的变化情况。结果三组患者在年龄、性别、骨折前基本日常生活能力、股骨近端外侧壁完整性、小转子完整性、术后及时TAD等方面差异无统计学意义(P>0. 05)。术后3个月影像学随访,阳性支撑组的TAD、颈干角改变较小(平均1. 24mm和2. 87°),而阴性支撑组变化较大(平均5. 55mm和6. 21°),中性支撑组变化最小(平均1. 04mm和2. 81°),阴性支撑组TAD、颈干角改变与阳性支撑组、中性支撑组的差异均具有统计学意义(P <0. 05),阳性支撑组与中性支撑组差异无统计学意义。股骨颈长度变化的平均值在阳性支撑组、阴性支撑组、中性支撑组中分别为4. 89mm、5. 03mm、2. 86mm,中性支撑组股骨颈长度变化与阳性支撑组、阴性支撑组的差异均有统计学意义(P <0. 05),阳性支撑组与阴性支撑组的差异无统计学意义(P>0. 05)。三组患者术后6个月均恢复基本日常生活能力。结论股骨粗隆间骨折行PFNA内固定术在复位时,应尽量解剖复位(中性支撑),若达不到解剖复位,允许骨折远端向外轻度移位,使股骨内侧皮质位于股骨颈内侧骨皮质的外侧(阳性支撑),如此能为骨折端提供有效的力学稳定,从而利于骨折愈合。

Objective To study the relationship of the medial cortex between the femoral shaft and femoral neck,and its effect on the results of internal fixation of femoral intertrochanteric fracture. Methods A total of 80 cases of intertrochanteric fractures were treated with proximal femoral nail （PFNA） from Sep. 2009 to Jan. 2016. Of them 31 cases were males and 49 were females,aged between 54 and 88 years（average 71.4 years）. They were divided into three groups according to the relationship of the medial cortex between the femoral shaft and the medial femoral neck after the operative reduction,including positive medial cortical support group （the femoral medial cortex was located in the lateral,61 cases）,negative medial cortical support group （femoral medial cortex was located in the medial,19 cases）,and neutral medial cortical support group （anatomical reduction,15 cases）. The age,gender,basic activities of daily living （ADL） before the fracture,the integrity of lateral wall of proximal femur,lesser trochanter integrity,postoperative tip-apex distance （TAD） at the time point of postoperation of the three groups were compared.The variations of tip-apex distance,neck-shaft angle and femoral neck length after three months of operation were also compared statistically. Results There was no statistical difference among the three groups in the patient age,gender,basic ADL before the fracture,the integrity of lateral femoral wall,lesser trochanter integrity,postoperative tip-apex distance （TAD） at the time point of postoperation （ P 〉0.05）. After 3 months of follow-up by imaging,the neck shaft angle and tip-apex distance of the positive group changed less （average 1.24mm and 2.87°）,while the negative group changed most （average 5.55mm and 6.21°） and the neutral group changed least （1.04mm and 2.81°）.The differences between the negative group and the other two groups were all statistically significant （ P 〈0.05）. There was no statistical difference between positive group and negative group in the change of TAD and the neck shaft angle. The length change of femoral necks in these groups on average was 4.89mm,5.03mm,2.86mm in positive,negative and neutral group,respectively. Neutral group had a statistically significant difference with the other groups（ P 〈0.05）.There was no statistical difference between positive group and negative group（ P 〉0.05）. The basic activities of daily living were all recovered in the patients of these groups after 6 months of operation. Conclusion Anatomical reduction is important for intertrochanteric fracture during PFNA fixation（neutral medial cortical support）. It is preferable that the femoral medial cortex is located in the lateral slightly （positive medial cortical support）,if impossible to reduce anatomically. This form of reduction could provide biomechanical stability and help fracture healing.