单纯髓内钉与髓内钉附加钢板固定股骨粗隆下粉碎性骨折的对比

Intramedullary nail only versus the nail combined with additional plate for comminuted femoral subtrochanteric fractures

[目的]探讨和对比单纯髓内钉固定与髓内钉附加锁定钢板固定治疗股骨粗隆下粉碎性骨折的疗效。[方法]回顾性分析2013年1月~2017年12月本院手术治疗的股骨粗隆下IV、V型粉碎性骨折患者46例。术中先行闭合牵引复位,若透视显示骨折复位不满意,则行髓内钉附加锁定钢板手术,共27例;若透视复位满意,则行常规的单髓内钉置入手术,共19例。比较两组围手术期、随访与影像资料。[结果]两组手术均顺利完成。所有患者无血管、神经损伤等并发症。复合固定组手术时间、切口长度、术中失血量、术后引流量和输血量均显著大于单髓内钉组,差异有统计学意义(P<0.05)。但复合固定组术后卧床伤肢主动活动时间显著早于单髓内钉组(P<0.05)。平均随访时间(15.59±5.15)个月,随术后时间推移,两组下肢功能均逐步恢复。复合固定组术后完全负重行走显著早于单髓内钉组,差异有统计学意义(P<0.05)。随术后时间推移,两组患者的髋关节伸-屈ROM和Harris评分显著增加,而VAS评分显著减少,不同时间点间差异均有统计学意义(P<0.05)。术后3个月时,复合固定组的ROM和Harris评分显著大于单髓内钉组(P<0.05),而VAS评分显著小于单髓内钉组(P<0.05),但是两组间差异在6个月和末次随访时无统计学意义(P>0.05)。影像评估方面,复合固定组骨折愈合时间为(3.89±0.80)个月,而单髓内钉组为(4.53±0.80)个月,两组间差异有统计学意义(P<0.05)。至末次随访时,两组患者均未发生内固定松动、断裂,未发生骨不连、再骨折。[结论]髓内钉附加锁定钢板固定治疗股骨粗隆下粉碎性骨折具有髋关节功能恢复快、骨折愈合时间短等优点。但不可避免会延长手术时间,并增加输血率。

[Objective]To compare the clinical outcomes of intramedullary nail only versus the nail combined with an addi⁃tional plate for comminuted femoral subtrochanteric fractures.[Methods]A retrospective study was conducted on 46 patients who underwent surgical treatment for Type IV and V femoral subtrochanteric fractures from January 2013 to December 2017.During operation close reduction was firstly conducted with traction in fracture table.Based on close fracture reduction revealed by fluoroscopy,27 patients who got improper close reduction received internal fixation with intramedullary nail combined with an additional plate(the combined group),while the remaining 19 patients who got proper close reduction had fractures fixed with nail only(the nail group).The perioperative,follow-up and radiographic documentations were compared between the two groups.[Results]All the patients in both groups had operation finished smoothly without serious complications,such as neuro⁃vascular injuries.Although the combined group consumed significantly longer operation time,associated with larger incision,more blood loss,more drainage volume and more transfusion than the nail group(P<0.05),the former returned to active motion of affected limb in bed significantly earlier than the latter(P<0.05).During the follow-up period of(15.59±5.15)months on average,the patients in both group recovered gradually.The combined group returned to full weight bearing ambula⁃tion significantly earlier than the nail group(P<0.05).The flexion-extension ROM and Harris score significantly in⁃creased,whereas VAS score significantly decreased over time in both groups,which were statistically significant among different time points(P<0.05).The combined group got significantly higher ROM and Harris score,whereas significantly lower VAS score than the nail group at 3 months postoperatively(P<0.05),despite of the fact that the differences became statistically insignificant at 6 months and the latest follow up(P>0.05).In term of radiographic evaluation,the bony healing of fractures achieved at(3.89±0.80)months in the combined group,while(4.53±0.80)months in the nail group,which proved of statistical significance(P<0.05).To the latest follow up,no fracture nonunion,displacement,and fixation failure occurred in any patient of both groups.[Conclusion]The intramedullary nail combined with an additional plate is a safe and effective method to treat comminuted subtrochanteric fracture,and achieve improved hip joint function with shortened fracture healing time and less pain,regardless of longer operation time,larger incision and more bleeding with greater blood transfusion.