探讨股骨转子间骨折髓内固定治疗失败病例的可能原因、人工髋关节置换手术策略及临床疗效。

回顾性分析2010年1月至2017年12月暨南大学附属第一医院骨关节外科收治的因髓内固定手术治疗股骨转子间骨折失败而行人工关节置换手术的41例患者。纳入标准：单侧股骨转子间骨折股骨近端髓内固定术后，症状、体征及影像学检查证实内固定失败，患者有手术治疗意愿。排除标准：无法耐受再次手术，非人工髋关节置换术式，明确或可疑感染。男15例，女26例；年龄49～87岁，平均(71±7)岁；骨折按Evans分型，Ⅲ型4例，Ⅳ型14例，Ⅴ型23例；人工股骨头置换术治疗12例，人工全髋关节置换术治疗29例；股骨侧骨水泥柄固定7例，非骨水泥柄标准干骺端固定15例，非骨水泥柄远端固定19例。手术相关指标、治疗前后髋关节功能评分的组间比较行独立样本t检验，同组患者术前与术后评分的比较行配对样本t检验。

人工全髋关节置换术组手术时间、术中失血量、术后引流量大于人工股骨头置换术组，差异有统计学意义(t ＝9.548，P <0.01；t＝4.374，P<0.05；t ＝10.048，P<0.01)。41例患者在8～86个月、平均(43±16)个月随访期内，髋关节Harris评分从术前(43±6)分，提高到(83±4)分，人工股骨头置换术组及人工全髋关节置换术组末次随访Harris评分均显著高于翻修术前，差异有统计学意义(t＝11.532，P<0.01; t＝14.713，P<0.01)。置换术后髋关节功能优良率87.8%。

针对股骨转子间骨折髓内固定手术失败病例的具体特点选择人工全髋关节置换术或人工股骨头置换术，均能有效缓解患者症状，改善髋关节功能，中期随访临床疗效满意。

To investigate the possible causes of internal fixation failures in intertrochanteric fractures with proximal femoral nail (PFN) and proximal femoral nail anti-rotation (PFNA), as well as the strategy of hip arthroplasty and clinical efficacy.

From January 2010 to December 2017, a retrospective study was done on 41 cases, 15 males and 26 females, aged from 49 to 87 years, average(71±7)years, who received salvage surgery of hip arthroplasty for intramedullary internal fixation failure for intertrochanteric fractures in the ward of bone and joint surgery, the first affiliated hospital of Jinan University. Inclusion criteria: after intramedullary internal fixation for unilateral intertrochanteric fractures; symptoms, signs, and imaging examinations confirmed that the internal fixation failed; the patient had the willingness to receive salvage surgery. Exclusion criteria: the patient was unable to tolerate reoperation; salvage surgery was not hip arthroplasty; confirmed or suspected infection. According to Evans classification, four patient was with type Ⅲ, 14 were type Ⅳ, and 23 were type Ⅴ. Among 41cases, 12 cases were performed with bipolar hemiarthroplasty, 29 cases were with total hip arthroplasty. Seven cases were performed with cemented standard stem, 15 cases were with cementless standard metaphyseal locking stem, 19 cases were with cementless diaphyseal locking stem. The independent sample Student’ t-test was applied in the comparison of surgical related indicators and the preoperative and postoperative scores of hip function. The paired sample Student’ t-test was applied in the comparison of preoperative and postoperative scores of the same group.

The operation time, intraoperative blood loss volume, and postoperative drainage volume in the total hip arthroplasty group were greater than those in the bipolar hemiarthroplasty group; the differences were statistically significant (t =9.548, P<0.01; t=4.374, P<0.05; t=10.048, P<0.01). A total of 41 cases were followed-up from eight to 86 months, (43±16) months on average. Hip joint Harris score was elevated from preoperative (43±6) to (83±4). The Harris scores at the last follow-up of the bipolar hemiarthroplasty group and the total hip arthroplasty group were significantly higher than those before the salvage surgery (t=11.532, P <0.01; t=14.713, P<0.01). The satisfaction rate of hip arthroplasty was 87.8%.

Analyzing the characteristics of PFN/PFNA failure cases and selecting appropriate procedure of total hip arthroplasty or hemiarthroplasty salvage surgery can effectively improve the patients’ symptoms and the function of hip joint, which shows a satisfactory outcome of the mid-term clinical efficacy.