老年股骨转子间骨折股骨近端防旋髓内钉内固定失效后钢板固定和关节置换的疗效比较

Efficacy comparison of plate fixation and joint replacement after failure of proximal femoral nail antirotation internal fixation of senile intertrochanteric fracture

目的探讨股骨近端锁定加压钢板(LPFP)翻修术及人工髋关节重建翻修术治疗老年股骨转子间骨折股骨近端防旋髓内钉(PFNA)内固定失效的疗效。方法采用回顾性病例对照研究分析2014年3月—2018年10月河南省人民医院收治的43例老年股骨转子间骨折PFNA内固定失效患者临床资料,其中男23例,女20例;年龄65~83岁[(71.2±2.0)岁]。病程60~267 d[(83.1±3.6)d]。骨折Evans分型:Ⅱ型11例,Ⅲ型13例,Ⅳ型19例。23例行人工髋关节重建翻修术(人工关节翻修组),20例行LPFP翻修术(LPFP翻修组)。记录两组手术时间、术中出血量、术后住院时间和总住院时间;采用Harris评分评价髋关节功能;观察并发症情况。结果患者均获随访12~28个月,平均13.6个月。人工关节翻修组和LPFP翻修组手术时间和术中出血量差异均无统计学意义(P>0.05),术后住院时间分别为(7.1±3.2)d和(13.2±2.9)d(P<0.05),总住院时间分别为(10.2±2.8)d和(16.4±3.4)d(P<0.05)。人工关节翻修组术前髋关节功能Harris评分为(21.7±3.2)分,术后1,2,3,6,9,12个月分别为(70.7±4.8)分、(74.6±4.1)分、(78.6±3.3)分、(82.9±5.2)分、(83.8±5.8)分、(84.9±6.4)分;LPFP翻修组术前髋关节功能Harris评分为(21.1±3.7)分,术后1,2,3,6,9,12个月分别为(59.9±2.1)分、(64.79±3.4)分、(70.1±4.2)分、(73.9±4.2)分、(76.2±6.3)分、(77.9±6.8)分。人工关节翻修组术后髋关节功能Harris评分较LPFP翻修组逐渐提高(P<0.05)。术后两组各出现1例伤口浅表感染,经换药后伤口愈合;人工关节翻修组1例发生股骨骨折,LPEP翻修组3例发生股骨骨折,均给予钢丝捆扎固定后愈合。结论对于老年股骨转子间骨折PFNA内固定失效患者,人工髋关节重建翻修术手术时间和术中出血量与LPFP内固定翻修术相当,但前者可缩短住院时间,更能促进髋关节功能恢复。

Objective To investigate the clinical efficacy of locking proximal femur plates(LPFP)revision and artificial hip joint revision after failure of proximal femoral nail antirotation(PFNA)internal fixation in elderly patients with intertrochanteric fracture.Methods A retrospective case control study was conducted on the clinical data of 43 patients with PFNA internal fixation failure in the elderly admitted to Henan Provincial People's Hospital between March 2014 and October 2018.There were 23 males and 20 females,aged 65-83 years[(71.2±2.0)years].The course of disease was 60-267 days[(83.1±3.6)days].According to Evans classification,there were 11 patients with type II fractures,13 with type III and 19 with type IV.There were 23 patients in artificial hip joint revision group and 20 patients in LPFP revision group.The operation time,intraoperative blood loss,postoperative hospitalization time,total hospitalization time,Harris score and complications were recorded and evaluated in two groups.Results All patients were followed up for 12-28 months,with an average of 13.6 months.Between artificial joint revision group and LPFP revision group,the operation time and intraoperative blood loss were similar(P>0.05),but there were significant difference in postoperative hospitalization time[(7.1±3.2)days vs.(13.2±2.9)days]and total hospitalization time[(10.2±2.8)days vs.(16.4±3.4)days](P<0.05).In artificial joint revision group,the Harris hip score was(21.1±3.7)points preoperatively,and was respective(70.7±4.8)points,(74.6±4.1)points,(78.6±3.3)points,(82.9±5.2)points,(83.8±5.8)points and(84.9±6.4)points at postoperative 1,2,3,6,9,12 months.In LPFP revision group,the Harris score was(21.7±3.2)points preoperatively,and was respective(59.9±2.1)points,(64.79±3.4)points,(70.1±4.2)points,(73.9±4.2)points,(76.2±6.3)points and(77.9±6.8)points at postoperative 1,2,3,6,9,12 months.The Harris score in artificial joint revision group was gradually improved compared with LPFP revision group(P<0.05).One patient with superficial wound infection occurred in each group,and the wound healed after frequent dressing changes.Distal femoral fractures occurred in one patient of artificial joint revision group and distal femoral fractures in three patients of LPFP revision group,but all patients were healed after being fixed with wire.Conclusion For elderly patients with PFNA internal fixation failure of intertrochanteric fracture,artificial hip revision has shorter hospital stay and better hip joint function recovery than LPFP internal fixation,although the effect in operation time and intraoperative blood loss are similar.