腹侧加压张力带钢丝布线技术治疗全髋关节置换术中大转子骨折

Treatment of trochanter fractures in total hip arthroplasty with ventral compression steel wire tension band

目的建立全髋关节置换术中股骨大转子骨折分型,探讨根据骨折分型采用对应的腹侧加压张力带钢丝布线技术治疗的临床疗效。方法2013年3月至2019年6月期间共行1280例初次全髋关节置换手术,术中21例发生股骨大转子骨折。男11例,女10例;年龄(65.81±6.45)岁(范围42~76岁);均为单侧,左侧11例,右侧10例。术前诊断:髋关节发育不良继发骨关节炎11例,髋关节骨关节炎4例,股骨头无菌性坏死4例,股骨颈骨折2例。术中根据大转子骨折线部位提出新的骨折分型,根据分型采用对应的腹侧加压张力带钢丝布线技术进行固定。观察指标包括Harris髋关节功能评分、Parker活动评分、疼痛视觉模拟评分(visual analogue scale,VAS),摄X线片评估骨折愈合、假体位置,以及松动、脱位等并发症的发生情况。结果股骨大转子骨折分型:A型为骨折线自大转子尖至梨状窝水平的横断骨折,共4例;B型为骨折线自大转子尖至大转子基底部小转子水平以上的斜形骨折,再根据骨折线的位置和骨块移位方向不同分为B1和B2型,B1型4例,B2型6例;C型为骨折线自大转子至转子下平面,共7例。21例患者中早期死亡1例,失访2例,余18例获得随访,随访时间为(30.7±7.6)个月(范围12~45个月)。18例手术时间为(110.0±20.0)min(范围85~150 min),术中出血量为(356.9±115.7)ml(范围250~650 ml)。术前Harris评分为(35.26±5.52)分,术后3个月为(65.7±6.42)分,末次随访时为(87.75±6.21)分,差异有统计学意义(F=377.23,P<0.001)。术前Parker评分为(2.17±0.98)分,术后3个月为(5.94±1.11)分,末次随访时为(8.01±0.77)分,差异有统计学意义(F=170.96,P<0.001)。术前VAS评分为(6.22±1.11)分,术后3个月为(2.61±0.92)分,末次随访时为(1.28±0.67)分,差异有统计学意义(F=139.71,P<0.001)。术后发生深静脉栓塞l例;异位骨化1例。1例术后12个月随访时发现骨不连、钢丝断裂,患者有跛行但疼痛不明显,拒绝再次手术;余患者大转子骨折处均愈合,愈合时间为(7.6±0.87)个月(范围5~11个月),大转子外侧均未出现滑囊炎等慢性疼痛表现。结论提出全髋关节置换术中股骨大转子骨折的分型,根据分型采用相应的腹侧加压张力带钢丝布线技术固定可以获得良好的临床效果。

Objective To evaluate the various wire tension belt ventral compression wiring technologiesfor treating several types of femoral greater trochanter fractures in total hip replacement,according to the different types of greater trochanter of femur fractures.Methods From March 2013 to June 2019,a total of 1280 cases of primary total hip arthroplasty were completed in our hospital,21 patients with greater trochanter fractures were identified in total hip replacement.There were 11 males and 10 females with an average age of 65.81±6.45 years(range 42-76 years).All of them were unilateral.There were 11 cases on the left and 10 cases on the right.There were 11 cases of osteoarthritis secondary to hip dysplasia,4 cases of hip osteoarthritis,4 cases of aseptic necrosis of femoral head and 2 cases of femoral neck fracture.Different wire tension belt ventral compression wiring technologies were used for each fracture type.Harris hip function score,Parker activity score,and visual analogue scale(VAS)score of hip pain were evaluated during follow-up.X-ray films were taken to evaluate the fracture healing,prosthesis position,loosening and dislocation.Results Three new fracture types were proposed:A transverse fracture from the greater trochanter tip to the base(4 cases);B oblique fracture from the greater trochanter tip to the base according to the fracture line direction,type B was further divided into types B1(4 cases)and B2(6 cases);and C fracture line from the greater trochanter to subtrochanteric plane(7 cases).Among the 21 patients,one died at an early stage,two were lost during follow-up,and 18 were followed up for an average of 30.7±7.6 months.In 18 patients,the mean operation time was 110.0±20.0 min,and the mean intraoperative blood loss was 356.9±115.7 ml.The patients'Harris score was 35.26±5.52 at the preoperative,65.7±6.42 at the 3 months after operation,and 87.75±6.21 at the final follow-up.The difference was statistically significant(F=377.23,P<0.001).The patients'Parker score was 2.17±0.98 at the preoperative,5.94±1.11 at the 3 months after operation,and 8.01±0.77 at the final follow-up.The difference was statistically significant(F=170.96,P<0.001).The patients'VAS score was 6.22±1.11 at the preoperative,2.61±0.92 at the 3 months after operation,and 1.28±0.67 at the final follow-up.The difference was statistically significant(F=139.71,P<0.001).Deep vein embolism,heterotopic ossification was noted in one and another patient,respectively.The patient with non-union refused reoperation and had a broken steel wire,lower-limb limp,and no notable pain at the 12-month follow-up examination.Radiographs of 17 patients showed good location of the femoral prosthesis and no chronic pain.Conclusion Different types of greater trochanter fractures in total hip arthroplasty were proposed,using different wire tension belt ventral compression wiring technologies for the various types of femoral greater trochanter fractures during total hip replacement can improve clinical outcomes.