解剖型髓内钉内固定和股骨近端防旋髓内钉内固定治疗老年股骨转子间骨折的比较研究

A comparative study of internal fixation with Zimmer natural nail versus proximal femoral nail antirotation for treatment of intertrochanteric fractures in the aged

目的:比较解剖型髓内钉(Zimmer natural nail,ZNN)内固定和股骨近端防旋髓内钉(proximal femoral nail antirotation,PFNA)内固定治疗老年股骨转子间骨折的临床疗效和安全性。方法:对122例老年股骨转子间骨折患者的病例资料进行回顾性分析,接受ZNN内固定治疗的62例为ZNN组,接受PFNA内固定治疗的60例为PFNA组。比较2组患者手术时间、术中X线透视次数、术中出血量、住院时间、骨折愈合时间、下地行走时间、完全负重时间、并发症发生率,以及术后3个月和术后12个月时的髋部疼痛视觉模拟量表(visual analogue scale,VAS)评分和Harris髋关节评分。结果:①一般结果。与PFNA组相比,ZNN组手术时间和住院时间短[(70.11±6.16)min,(81.53±7.57)min,t=5.326,P=0.000;(6.43±1.45)d,(8.25±1.37)d,t=3.326,P=0.000],术中X线透视次数和出血量少[(3.16±0.57)次,(5.75±1.28)次,t=4.834,P=0.000;(180.01±12.64)mL,(202.84±11.23)mL,t=4.574,P=0.000]。②疗效评价结果。2组患者骨折均愈合,ZNN组骨折愈合时间较PFNA组短[(4.27±0.82)周,(6.46±0.98)周,t=6.890,P=0.000],下地行走时间和完全负重时间均较PFNA组早[(16.35±3.16)d,(22.54±3.37)d,t=5.642,P=0.000;(22.46±4.36)周,(29.74±5.32)周,t=6.323,P=0.000]。术后3个月,2组患者髋部疼痛VAS评分和Harris髋关节评分比较,组间差异均无统计学意义[(5.21±2.12)分,(5.22±1.73)分,t=0.251,P=0.523;(52.52±3.43)分,(54.51±2.76)分,t=0.532,P=0.243];术后12个月,ZNN组髋部疼痛VAS评分低于PFNA组[(1.22±0.26)分,(3.75±0.68)分,t=5.623,P=0.000],Harris髋关节评分高于PFNA组[(93.51±4.23)分,(81.95±3.99)分,t=8.431,P=0.000];与术后3个月相比,术后12个月时2组患者髋部疼痛VAS评分均降低(t=4.523,P=0.000;t=7.654,P=0.000),Harris髋关节评分均提高(t=7.534,P=0.000;t=8.564,P=0.000)。③安全性评价结果。ZNN组并发切口感染1例,应用抗生素后感染控制。PFNA组并发切口感染5例,应用抗生素后感染控制;并发髋关节骨关节炎2例,经康复训练后,髋关节功能有所改善。ZNN组并发症发生率与PFNA组相比,差异无统计学意义(χ^(2)=3.523,P=0.061)。结论:ZNN内固定治疗老年股骨转子间骨折,比PFNA内固定手术时间和住院时间短,术中X线透视次数和出血量少,骨折愈合快,术后下地行走和完全负重早,更有利于缓解髋部疼痛和恢复髋关节功能,但二者安全性相当。

Objective:To compare the clinical efficacy and safety of internal fixation with Zimmer natural nail(ZNN)versus proximal femoral nail antirotation(PFNA)for treatment of intertrochanteric fractures(ITFs)in the aged.Methods:The medical records of 122 aged patients with ITFs were analyzed retrospectively.Sixty-two patients were treated with ZNN internal fixation(ZNN group),while the others with PFNA internal fixation(PFNA group).The operative time,intraoperative X-ray exposure,intraoperative blood loss,hospital stays,fracture healing time,bed rest time,complete weight-bearing walk start time and complication incidence rate were compared between the 2groups,furthermore,the hip pain visual analogue scale(VAS)score and Harris hip score measured at 3 and 12 months after the surgery were compared between the 2 groups.Results:(1)The operative time and hospital stays were shorter,the intraoperative X-ray exposure was fewer and the intraoperative blood loss was less in ZNN group compared to PFNA group(70.11±6.16 vs 81.53±7.57 minutes,t=5.326,P=0.000;6.43±1.45 vs 8.25±1.37 days,t=3.326,P=0.000;3.16±0.57 vs 5.75±1.28 times,t=4.834,P=0.000;180.01±12.64vs 202.84±11.23 mL,t=4.574,P=0.000).(2)All fractures healed in the 2 groups,and the fracture healing time was shorter in ZNN group compared to PFNA group(4.27±0.82 vs 6.46±0.98 weeks,t=6.890,P=0.000),and the bed rest time and complete weightbearing walk start time were shorter in ZNN group compared to PFNA group(16.35±3.16 vs 22.54±3.37 days,t=5.642,P=0.000;22.46±4.36 vs 29.74±5.32 weeks,t=6.323,P=0.000).There was no statistical difference in hip pain VAS score and Harris hip score between the 2 groups at 3 months after the surgery(5.21±2.12 vs 5.22±1.73 points,t=0.251,P=0.523;52.52±3.43 vs54.51±2.76 points,t=0.532,P=0.243).The hip pain VAS score was lower while the Harris hip score was higher in ZNN group compared to PFNA group at 12 months after the surgery(1.22±0.26 vs 3.75±0.68 points,t=5.623,P=0.000;93.51±4.23 vs 81.95±3.99 points,t=8.431,P=0.000).The hip pain VAS score decreased and the Harris hip score increased in the 2 groups at 12 months after the surgery compared with that at 3 months after the surgery(t=4.523,P=0.000;t=7.654,P=0.000;t=7.534,P=0.000;t=8.564,P=0.000).(3)The incision infection was found in 1 patient in ZNN group and 5 cases in PFNA group,and the infection was controlled after application of antibiotics.Moreover,the hip osteoarthritis was found in 2 patients in PFNA group,and the hip function was improved after rehabilitation training.There was no statistical difference in complication incidence rate between the 2 groups(χ;=3.523,P=0.061).Conclusion:ZNN internal fixation has such advantages as shorter operative time,hospital stays,bed rest time and complete weight-bearing walk start time,fewer intraoperative X-ray exposure,less intraoperative blood loss and faster fracture healing,furthermore,it can be more conducive to hip pain remission and hip function recovery compared to PFNA internal fixation in treatment of ITFs in the aged,whereas the two methods are similar to each other in the safety.