加长型股骨近端防旋髓内钉联合钢缆内固定治疗股骨转子下粉碎性骨折的临床研究

Internal fixation with long proximal femoral nail antirotation and wirerope for treatment of femoral subtrochanteric comminuted fracture: a clinical study

目的:观察加长型股骨近端防旋髓内钉(proximal femoral nail antirotation,PFNA)联合钢缆内固定治疗股骨转子下粉碎性骨折的临床疗效及安全性。方法:将74例股骨转子下粉碎性骨折患者随机分为2组,每组37例。分别采用加长型PFNA联合钢缆内固定(髓内钉组)和股骨近端解剖锁定钢板(proximal femoral locking plate,PFLP)联合钢缆内固定(锁定钢板组)治疗。记录并比较两组患者的手术时间、术中出血量、术后完全负重开始时间、骨折愈合时间、Harris髋关节功能评分和并发症发生情况。结果:所有患者均获随访,随访时间6个月至2年,中位数8个月。髓内钉组有6例植骨,锁定钢板组有8例植骨。2组患者的手术时间比较,差异无统计学意义[(127. 76±25. 76) min,(133. 28±22. 68) min,t=3. 226,P=0. 317];髓内钉组的术中出血量少于锁定钢板组[(113. 89±20. 97) m L,(133. 45±19. 82) m L,t=5. 537,P=0. 037],术后完全负重开始时间和骨折愈合时间均短于锁定钢板组[(2. 31±0. 45)个月,(3. 13±0. 66)个月,t=6. 089,P=0. 034;(3. 32±0. 60)个月,(3. 78±0. 71)个月,t=5. 411,P=0. 042]。髓内钉组切口感染1例、髋内翻1例、深静脉血栓1例、内固定失败1例,锁定钢板组切口感染2例、髋内翻3例、深静脉血栓3例、骨折不愈合2例、内固定失败1例,髓内钉组的并发症发生率低于锁定钢板组(χ~2=4. 097,P=0. 043)。3例切口感染者,采用抗生素治疗后均治愈; 4例髋内翻畸形者,2例行楔形截骨矫正术后髋关节功能恢复,2例未进行治疗; 4例深静脉血栓形成者,1例行抗凝治疗、2例行溶栓治疗、1例穿戴弹力袜治疗,均好转; 2例骨折不愈合者,行髓内钉固定联合异体骨植骨后骨折愈合; 2例内固定失败者,行翻修手术后效果良好。术后6个月采用Harris髋关节功能评分评价综合疗效,髓内钉组(87. 64±16. 37)分,优19例、良12例、可4例、差2例;锁定钢板组(81. 39±12. 86)分,优11例、良15例、可4例、差7例;髓内钉组的综合疗效优于锁定钢板组(Z=-2. 061,P=0. 039)。结论:与PFLP联合钢缆内固定治疗相比,加长型PFNA联合钢缆内固定治疗股骨转子下粉碎性骨折,术中出血量少、术后可早期完全负重、骨折愈合时间短、综合疗效好、安全性高。

Objective:To observe the clinical curative effects and safety of internal fixation with long proximal femoral nail antirotation(PFNA)and wirerope for treatment of femoral subtrochanteric comminuted fracture.Methods:Seventy-four patients with femoral subtrochanteric comminuted fractures were randomly divided into 2 groups,37 cases in each group.The patients were treated with internal fixation with long PFNA and wirerope(intramedullary nail group)and internal fixation with proximal femoral locking plate(PFLP)and wirerope(locking plate group)respectively.The operative time,intraoperative blood loss,postoperative full weight-bearing start time,fracture healing time,Harris hip function scores and complication incidences were recorded and compared between the 2 groups.Results:All patients in the 2 groups were followed up for 6-24 months with a median of 8 months.Bone grafting was performed on 6 patients in intramedullary nail group and 8 patients in locking plate group.There was no statistical difference in operative time between the 2 groups(127.76+/-25.76 vs 133.28+/-22.68 min,t=3.226,P=0.317).The intraoperative blood loss was less,and the postoperative full weight-bearing start time and fracture healing time were shorter in intramedullary nail group compared to locking plate group(113.89+/-20.97 vs 133.45+/-19.82 mL,t=5.537,P=0.037;2.31+/-0.45 vs 3.13+/-0.66 months,t=6.089,P=0.034;3.32+/-0.60 vs 3.78+/-0.71 months,t=5.411,P=0.042).Incision infection(1),coxa vara(1),deep venous thrombosis(1)and failed internal fixation(1)were found in intramedullary nail group;while incision infection(2),coxa vara(3),deep venous thrombosis(3),fracture nonunion(2)and failed internal fixation(1)were found in locking plate group.The complication incidence was lower in intramedullary nail group compared to locking plate group(χ^2=4.097,P=0.043).The three patients with incision infection were cured after antibiotic treatment.Two patients with coxa vara deformity were treated with wedge-shaped osteotomy and their hip functions were recovered,and the other 2 patients with coxa vara deformity were untreated.Anticoagulant therapy,thrombolytic therapy and elastic socks therapy were performed on 1,2 and 1 patient with deep vein thrombosis respectively,and their deep vein thrombosis were improved.Combination therapy of intramedullary nail fixation and allogeneic bone grafting were performed on the 2 patients with nonunion of fracture,and the fractures were healed.Revision surgery was performed on the 2 patients with failed internal fixation and they obtained a good result.The total clinical curative effects were evaluated according to Harris hip function scores at 6 months after the surgery,and the scores were 87.64+/-16.37 points in intramedullary nail group and 81.39+/-12.86 points in locking plate group.Nineteen patients obtained an excellent result,12 good,4 fair and 2 poor in intramedullary nail group;while 11 patients obtained an excellent result,15 good,4 fair and 7 poor in locking plate group.The intramedullary nail group surpassed the locking plate group in the total clinical curative effect(Z=-2.061,P=0.039).Conclusion:Internal fixation with long PFNA and wirerope has the advantages of less intraoperative blood loss,earlier postoperative full weight-bearing activities,shorter fracture healing time,better total clinical curative effect and higher safety compared to internal fixation with PFLP and wirerope in treatment of femoral subtrochanteric comminuted fracture.