基于股骨近端外侧壁完整性的股骨近端骨折分型方法:附888例病例分析

Proposal of a new proximal femoral fracture classification system based on the integrity of proximal lateral femoral wall:a retrospective analysis of 888 patients

背景:目前股骨转子部骨折的分型系统均存在一定局限性,反转子间骨折和转子下骨折存在分型交叉,而且目前的分型系统均未将转子部外侧壁包含在内。目的:提出股骨转子部骨折的区域分型法,分析新分型系统中各型临床特点。方法:根据股骨转子部外侧壁是否完整以及后内侧是否存在蝶形骨折块建立区域分型法。回顾性分析2005年4月至2016年12月收治的行内固定治疗的股骨转子部骨折患者共888例,分析区域分型系统中各分型患者基础资料以及骨折愈合时间、最终随访时Harris评分等。结果:Ⅰ~Ⅳ型骨折分别占79.8%(709例)、12.7%(113例)、3.2%(28例)和4.3%(38例)。各型患者间年龄、性别、受伤原因、复位方法、手术时间和术中出血量差异均有统计学意义(P均<0.01)。ⅠA型骨折髓内固定与动力髋螺钉(DHS)相比,最终随访时Harris评分、内固定物相关并发症发生率差异均无统计学意义。ⅠB型骨折髓内固定与微创内固定系统(R-LISS)相比,内固定相关并发症发生率差异有统计学意义(P<0.05)。Ⅱ型骨折采用转子间顺行髓内钉(InterTan)和股骨近端锁定接骨板(PFP)固定的患者,最终随访时Harris评分优良率分别为81.8%、62.5%,高于其他内固定物。Ⅲ型骨折髓内固定与R-LISS固定最终随访时Harris评分优良率分别为58.8%、50.0%。Ⅳ型骨折髓内固定与R-LISS固定最终随访时Harris评分优良率分别为76.9%、45.5%。结论:区域分型法可以较好的反映各型转子部骨折的特点,并指导内固定物的选择和提示预后。对于ⅠA型骨折,推荐采用DHS或髓内固定治疗;ⅠB型骨折推荐使用髓内固定治疗;Ⅱ型骨折因外侧壁不完整,推荐使用PFP或者InterTan治疗;Ⅲ型及Ⅳ型骨折推荐使用髓内固定治疗。

Background:There are some limitations in common classification systems for femoral trochanteric fractures.The reverse trochanteric fracture and subtrochanteric fracture cannot be well defined.The lateral wall of the femur is not included in the classification systems.Objective:To propose the regional classification system of the trochanteric fractures,and to ana lyze the clinical features of every fracture type in the new classification system.Methods:The regional classification system of trochanteric fractures was established according to the integrity of the lateral wall and the existence of the butterfly fragment in the medial wall.A total of 888 patients with femoral trochanteric fractures treated from April 2005 to December 2016 were ana lyzed retrospectively.General information,fracture healing time and Harris score were analyzed.Results:TypeⅠ-Ⅳfrac tures accounted for 79.8%(709),12.7%(113),3.2%(28)and 4.3%(38),respectively.There were significant differences in the age,gender,injured causes,reduction method,operation time and intraoperative bleeding between patients with various frac ture types(P<0.01).No significant difference was found in Harris score or the incidence of complications associated with inter nal fixation between the intramedullary fixation and dynamic hip screw(DHS)in patients with typeⅠA fractures.For typeⅠB fractures,there was significantly statistic difference in the incidence of complications associated with internal fixation be tween the intramedullary fixation and the reverse less invasive stabilization system(R-LISS,P<0.05).The excellent rate of the Harris score in typeⅡfracture patients treated with intertrochanteric antegrade nail(InterTan)and proximal femoral locking plates(PFP)were 81.8%and 62.5%respectively,which were higher than other internal fixations.For typeⅢfractures,the ex cellent rate of the Harris scores for the intramedullary fixation and R-LISS were 58.8%and 50.0%.And the rate were 76.9%and 45.5%for typeⅣfractures.Conclusions:This regional classification system can well reflect the characteristics of various types of trochanteric fractures.DHS and intramedullary fixation is recommended for typeⅠA fractures.Intramedullary fixation is suitable for type ⅠB fractures. PFP or InterTan may be fit for type Ⅱ fractures. Intramedullary fixation is appropriatefor both type Ⅲ and Ⅳ fractures.