内固定治疗股骨粗隆间骨折失败原因分析及翻修手术策略

Failure causes of internal fixation for intertrochanteric fractures and revi-sion surgery

目的分析股骨粗隆间骨折患者的临床资料和内固定治疗失败原因,分享翻修手术策略。方法回顾性分析2012年9月至2014年9月期间解放军总医院骨科收治的8例内固定治疗失败并接受翻修手术的股骨粗隆间骨折患者的临床资料。通过病历、手术记录、术后随访及X线片等临床资料,分析骨折内固定失败的原因,并针对性提出翻修手术策略。结果2例钢板治疗患者中,断板和骨折不愈合各1例。6例股骨近端(防旋)髓内钉(PFN/PFNA)治疗患者中,头钉切出3例,穿凿1例,退钉1例,断钉1例。内固定失败原因:头钉位置不良(5/6),股骨内侧壁或外侧壁失支撑(6/8),未能解剖复位(6/8),软组织过度剥离(1/8),感染(2/8)。针对失败原因,翻修手术方式包括全髋关节置换术(5/8)、钢板固定(1/8)、PFNA固定(1/8)、PFN固定(1/8)。2例患者因骨感染一期行抗生素骨水泥占位器治疗,1例患者因骨质较差,辅以自体松质骨植骨。结论股骨粗隆间骨折内固定失败均为多种危险因素造成,主要为头钉位置不理想、复位不良及内外侧壁失支撑等。因此,解剖复位、内置物正确选择和良好放置是防止内固定失败的重要举措。应针对患者一般情况和失败原因,为其选择恰当的翻修手术方式。

Objective To analyze the clinical characteristics,failure causes and revision methods of the patients undergoing revision surgery after failure of internal fixation for intertrochanteric fractures.Methods Clinical data of 8 patients who underwent revision surgery after internal fixation of intertrochanteric fractures in the orthopedic department of our medical center from September 2012 to September 2014 were collected and retrospectively analyzed.Their medical and surgical records,results of postoperative follow-up examinations,X-ray film and other detailed clinical data were employed to analyze the failure causes for internal fixation.Revision surgical strategies were analyzed and proposed.Results Among the 2 patients treated with plate,1 experienced broken plate and the other fracture nonunion.In the 6 patients treated with proximal femoral nail/proximal femoral nail anti-rotation(PFN/PFNA),there were 3 cases of nail cut-out,1 of cut-through,1 of back screw,and 1 of broken screw.The reasons for failure of internal fixation included inappropriate position of screw(5/6),loss of support from the medial/lateral wall of the femur(6/8),non-anatomical reduction(6/8),excess dissection of soft tissue(1/8),and infection(2/8).For reasons of failure,revision procedures included total hip arthroplasty(5/8),plate fixation(1/8),PFNA fixation(1/8),and PFN fixation(1/8).Among them,2 patients were treated with antibiotic-loaded cement in the first stage due to bone infection,and 1 patient was treated with autologous cancellous bone graft because of poor bone quality.Conclusion Failure of intertrochanteric fracture internal fixation attributes to multiple risk factors,mainly including inappropriate position of screw,poor reduction and loss of support of the medial/lateral wall of the femur.Therefore,anatomical reduction,proper selection and good placement of implants are important measures to prevent the failure of intertrochanteric fracture internal fixation.According to the reason of failure and condition of the patients,we need to choose an appropriate revision surgery procedure.