难复性股骨转子间骨折的解剖分型与复位策略

Classification and reduction strategies for irreducible intertrochanteric femoral fracture based on anatomy

背景:如何快速、微创、有效实现满意复位是难复性股骨转子间骨折的手术难点。骨折分型有助于术前制定合理的复位方案,但目前缺乏简单易行的难复性股骨转子间骨折的分型方法。目的:探讨难复性股骨转子间骨折的解剖分型及复位策略。方法:选择2006年6月至2020年5月四川省医学科学院·四川省人民医院收治的难复性股骨转子间骨折患者531例,其中男187例,女344例,年龄60-101岁,根据术前髋关节正侧位X射线片大小转子与骨折近端的关系将难复性股骨转子间骨折分为:Ⅰ型(近端游离)、Ⅱ型(大转子连续)、Ⅲ型(小转子连续)、Ⅳ型(大小转子均连续)。采用骨膜剥离器、止血钳和/或骨钩辅助复位,并以髋部联合加压交锁髓内钉系统或股骨近端防旋髓内钉置入内固定。术后随访拍摄X射线片,评估骨折复位质量与骨折愈合情况;末次随访时,通过Harris评分评估患者髋关节功能恢复情况。结果与结论:①531例难复性股骨转子间骨折患者中,Ⅰ、Ⅱ、Ⅲ、Ⅳ型分别为357,87,13,74例,其中489例(92.1%)达到满意复位;②531例患者中,26例失访,23例在骨折愈合前因肺炎、心力衰竭等病因死亡,剩余482例患者随访1年以上,骨折平均愈合时间4.7个月;③术后随访过程中,未发生与内固定材料相关的不良反应;④末次随访时,482例患者的Harris评分为95.7±4.8,其中433例(89.8%)评估结果为优;⑤结果表明,对于难复性股骨转子间骨折,采用该分型方法和相应辅助复位技术可获得满意的复位效果和髋关节功能。

BACKGROUND:How to achieve satisfactory reduction quickly,minimally invasively and effectively is difficult in the operation of irreducible intertrochanteric femoral fracture.Fracture classification helps to formulate a reasonable reduction plan before surgery,but a simple and feasible classification of irreducible intertrochanteric femoral fracture is still lacking currently.OBJECTIVE:To explore the classification and reduction strategy of irreducible intertrochanteric femoral fracture based on anatomy.METHODS:The clinical data of 531 patients with irreducible intertrochanteric fracture treated in Sichuan Academy of Medical Sciences&Sichuan Provincial People’s Hospital from June 2006 to May 2020 were analyzed retrospectively,including 187 males and 344 females,at the age of 60-101 years old.According to whether the greater trochanter/lesser trochanter was connected to the proximal end of the fracture,the irreducible intertrochanteric fractures were divided into type I(proximal free),type II(greater trochanter connected),type III(lesser trochanter connected),and type IV(both greater and lesser trochanters connected).Periosteum stripper,hemostatic forceps and/or bone hook were used to assist the reduction,and InterTan or proximal femoral nail anti-rotation was used for internal fixation.X-ray films were taken during postoperative follow-up to assess the quality of fracture reduction and fracture healing.At the last follow-up,the patient’s hip function recovery was assessed by Harris score.RESULTS AND CONCLUSION:(1)Among the 531 cases of irreducible femoral intertrochanteric fractures,the types I,II,III,and IV were 357,87,13,and 74 cases respectively,and 489 cases(92.1%)achieved satisfactory reduction.(2)Of the 531 patients,26 were lost to follow-up,and 23 died of pneumonia,heart failure and other causes before the fracture healing.482 patients were followed up for more than one year,and all fractures healed with an average time of 4.7 months.(3)During the postoperative follow-up,there was no adverse event related to internal fixation materials.(4)At the last follow-up,the Harris score of 482 patients was 95.7±4.8,of which 433 cases(89.8%)had excellent evaluation results.(5)These results confirm that for irreducible intertrochanteric fractures,satisfactory reduction and hip joint function can be obtained by adopting our classification and reduction techniques.