股骨转子间骨折双柱理论分型和内固定选择

New double-column theoretical classification supporting choice of internal fixation for femoral intertrochanteric fracture

目的探讨股骨转子间骨折双柱理论分型指导内固定治疗的临床效果。方法根据正常髋关节影像学资料将股骨转子部分为两柱,以髓腔中线为界,中线以外的大转子部作为外侧柱,中线以内的小转子部作为内侧柱;股骨转子间骨折后根据分量原理:由股骨头颈传导下来的负重应力在股骨转子间分为水平和垂直应力,内侧柱主要分担垂直应力,外侧柱主要分担水平应力。将骨折复位后,连续性恢复,且能有效传导应力的柱定义为稳定柱,反之为不稳定柱;整个转子部,如内外侧两个柱均为稳定柱,就是稳定的转子部(A型);如其中一个柱为稳定柱,另一个柱不稳定,就是部分稳定的转子部(B型),B1型为外侧柱不稳定,B2型为内侧柱不稳定。如内外侧两个柱均为不稳定柱,就是不稳定的转子部(C型)。2011年3月至2014年10月清华大学第一附属医院骨科收治60岁及以上的股骨转子间骨折手术住院患者128例,根据双柱理论分为A型50例,B1型18例,B2型52例,C型8例。然后根据分型结果选择固定方式:A、B1、B2型采用股骨近端防旋螺钉(PFNA)固定,C型采用联合拉力交锁髓内钉系统(Inter-TAN)固定治疗。术后1、2、3、6、12、24个月时进行门诊复诊,通过X线片了解骨折愈合及有无内固定失败情况。术后髋关节功能评价采用Harris评分方法。结果128例患者获得随访,随访时间为6~24个月,平均(16.0 ± 0.9)个月。骨折愈合时间为12~26周,平均(14.5 ± 2.0)周,无骨折不愈合病例。无内固定钉松脱,髋内翻,股骨头切割,断钉病例。末次随访时Harris评分为78~96分,平均(88 ± 4)分,其中优76例、良44例、可8例,优良率93.8%。结论股骨转子间骨折双柱理论简单易记,有助于选择理想的内固定和获得良好的临床疗效。

Objective To study the clinical effect of the internal fixation of femoral intertrochanteric fracture guiding by double-column theoretical classification. Methods According to the normal anteroposterior X - ray of the hip joint, the femoral trochanter was divided into two columns. The greater trochanter lateral to the midline was defined as the lateral column, and the minor trochanter which medial to the midline was defined as the medial column. After the fracture reduction, the continuity recovered, and can effectively conduct stress column was defined as a stable column, on the contrary for the unstable column. If the medial and lateral columns were stable, this was defined as stable femoral trochanter (type A). If one column was stable, the other column was unstable, that was defined as partial stable femoral trochanter (type B), among which type B1 was unstable lateral column, type B2 was unstable medial column. Both meidal and lateral columns were unstable, it was defined as unstable femoral trochanter (type C). From March 2011 to October 2014, there were 128 patients with intertrochanteric fractures in line with research standards treated in department of orthopedics in First Affiliated Hospital of Tsinghua University. According to the double-column theory classification, the patients were divided into type A(50 cases), type B1(18 cases), type B2 (52 cases), type C(eight cases), and were fixed according to the results of classification: type A, B1, B2 using proximal femoralnail antirotation (PFNA) fixation, type C using Inter-TAN fixation. Regular follow-up was performed on postoperative one, two, three, six, 12, and 24 months. The fracture healing was evaluated and the internal fixation failure was assessed by X-ray films. Harris score was used to evaluate hip function. Results A total of 128 patients were followed up for six to 24 months with an average of(16.0±0.9)months. Fracture healing time was 12 to 26 weeks, an average of(14.5± 2.0) weeks, no cases of nonunion. No screws or nails loose, no hip varus, no femoral head cut, no screws broken cases. Harris scores at the last follow-up are 78 to 96 points, an average of 88 points, of which 76 cases are excellent, 44 cases are good, 8 cases are fair, excellent and good rate are 93.8%. Conclusion The double- column theoretical classification of the femoral intertrochanteric fractures , which was simple and comprehensive, can benefit to internal fixation selection and clinical outcome.