空心钉与髓内钉治疗青壮年股骨颈不稳定骨折的疗效观察

doi:10.3877/cma.j.issn.1674-134X.2018.06.001

目的

分析在直接前侧入路(DAA)辅助下空心螺钉与Intertan髓内固定治疗青壮年移位不稳型股骨颈骨折的临床疗效。

方法

回顾分析浙江新安国际医院骨科2014年1月至2016年12月采用DAA入路切开复位治疗青壮年移位不稳定型(Garden Ⅲ、Ⅳ型)股骨颈骨折患者，资料均为GardenⅢ、Ⅳ不稳定型股骨颈骨折，24 h之内完成手术，年龄<60岁且随访资料完整；排除同侧转子间骨折、转子下骨折、股骨干骨折，长期使用大剂量激素或酗酒患者。DAA辅助空心钉螺钉内固定组(空心钉组)90例，DAA辅助Intertan髓内钉固定组(髓内钉组)89例，采用SPSS 21.0统计学软件对数据进行统计学分析。采取t检验和χ²检验比较手术时间、透视次数、出血量、住院日、骨折愈合时间、骨折不愈合及股骨头缺血性坏死率、Harris评分。

结果

两组在年龄、性别、Garden分型比较上，差异无统计学意义(均P>0.05)，有可比性。空心钉组在手术时间(45.4±15.6)min、透视次数(6.5±3.4)次、出血量(90.5±24.5)ml方面优于髓内钉组[分别为(75.2±12.4)min，(9.3±4.6)次，(159.7±40.2)ml](均为P<0.01)；空心钉组在住院日(7.2±2.1)d方面与髓内钉组(8.2±1.3)d没有差异(t＝－1.567，P>0.05)。髓内钉组愈合时间(2.8±0.8)月，短于空心钉组[(3.8±0.7)月，(t＝5.375，P<0.01)]。髓内钉组骨折不愈合、股骨头缺血性坏死4例明显少于空心钉组15例(χ²＝6.005，P<0.05)；Harris评分优良率空心钉组低于髓内钉组(χ²＝7.338，P<0.01)。

结论

青壮年移位不稳定型股骨颈骨折早期采用DAA辅助入路Intertan髓内固定方法治疗可在直视下完成骨折复位，术后恢复快，骨折愈合率高，股骨头坏死发生率低，疗效满意。

关键词: 股骨颈骨折, 手术入路, 内固定术, 青壮年

Objective

To analyze the clinical efficacy of direct anterior approach(DAA)-assisted cannulated screw and Intertan intramedullary fixation in the treatment of unstable femoral neck fractures in young adults.

Methods

From January 2014 to December 2016, 179 cases of displaced unstable (Garden III or IV)femoral neck fractures in young adults were treated by open reduction of direct anterior approach (DAA). Inclusion creteria: surgery is completed within 24 hours, age<60 years old and follow-up data intact; exclusion creteria: ipsilateral intertrochanteric fractures, subtrochanteric fractures, femoral shaft fractures, long-term use of large doses of hormones or alcohol abuse patients.Ninety cases were treated by DAA-assisted cannulated screw fixation in group A and 89 cases were treated by DAA-assisted Intertan intramedullary fixation in group B. Data were statistically analyzed using SPSS 21.0 statistical software with t test and χ² test to compare the operation time, the number of fluoroscopy, the amount of bleeding, the hospitalization day, the fracture healing time, the fracture nonunion, the avascular necrosis rate of the femoral head, and the Harris score.

Results

There was no significant difference in age, gender, and Garden classification between the two groups (all P>0.05), which was comparable. Group A was superior to group B in terms of operation time[group A (35.4±15.6) min, group B(55.2±12.4) min], number of X-ray exminations [group A (6.5±3.4) times, group B(9.3±4.6) times], and bleeding volume[group A (70.5±24.5) ml, group B(129.7±40.2) ml](all P<0.01). Group A did not differ from group B in hospitalization day[(7.2±2.1)d vs. (8.2±1.3)d, t =-1.567, P>0.05]. The healing time of group B (2.8±0.8) months was shorter than that of group A (3.8±0.7) months(t=5.375, P<0.01). In group B, nonunion and avascular necrosis of the femoral head occurred in four cases, which were significantly less than those in group A (15 cases)(χ² =6.005, P<0.05). In group B, three cases were poor in Harris score, which were less than group A (15 cases were poor)(χ² =7.338, P<0.01).

Conclusion

Young adults with unstable femoral neck fracture treated with DAA-assisted Intertan intramedullary fixation can achieve completely reduction of bone under direct vision, with fast postoperative recovery, high healing rate, and low incidence of femoral head necrosis; the effect is satisfactory.

Key words: Femoral neck fractures, Surgical procedure, Internal fixators

图1 手术基本步骤。图A为确定DAA切口；图B为显露旋股外动脉结扎；图C为显露股骨颈骨折处，克氏针"遥感技术"复位；图D为透视下临时固定股骨头影像；图E为术中透视下Intertan髓内钉

表1 两组患者一般资料比较

?	例数	年龄[岁，(±s)]	性别(男/女)	Garden分型(Ⅲ型/Ⅳ型)
空心钉组	90	30±13	62/28	55/35
Intertan髓内钉组	89	32±13	60/29	56/33
统计值	?	t＝0.258	χ²＝0.045	χ²＝0.062
P值	?	>0.05	>0.05	>0.05

表1 两组患者一般资料比较

?	例数	年龄[岁，(±s)]	性别(男/女)	Garden分型(Ⅲ型/Ⅳ型)
空心钉组	90	30±13	62/28	55/35
Intertan髓内钉组	89	32±13	60/29	56/33
统计值	?	t＝0.258	χ²＝0.045	χ²＝0.062
P值	?	>0.05	>0.05	>0.05

表2 两组结果及预后比较

?	例数	手术时间[min，(±s)]	透视次数[次，(±s)]	出血量[ml，(±s)]	住院日[d，(±s)]	骨折愈合时间[个月，(±s)]	失败率[例(%)]	术后1年Harris评分优良率(%)
空心钉组	90	45.4±15.6	6.5±3.4	90.5±24.5	7.2±2.1	3.8±0.7	15(16.6)	83.3
Intertan髓内钉组	89	75.2±12.4	9.3±4.6	159.7±40.2	8.2±1.3	2.8±0.8	4(4.5)	96.6
统计值	?	t＝－5.325	t＝－7.024	t＝－8.223	t＝－1.567	t＝5.375	χ²＝6.005	χ²＝7.338
P值	?	<0.01	<0.01	<0.01	>0.05	<0.01	<0.05	<0.01

表2 两组结果及预后比较

?	例数	手术时间[min，(±s)]	透视次数[次，(±s)]	出血量[ml，(±s)]	住院日[d，(±s)]	骨折愈合时间[个月，(±s)]	失败率[例(%)]	术后1年Harris评分优良率(%)
空心钉组	90	45.4±15.6	6.5±3.4	90.5±24.5	7.2±2.1	3.8±0.7	15(16.6)	83.3
Intertan髓内钉组	89	75.2±12.4	9.3±4.6	159.7±40.2	8.2±1.3	2.8±0.8	4(4.5)	96.6
统计值	?	t＝－5.325	t＝－7.024	t＝－8.223	t＝－1.567	t＝5.375	χ²＝6.005	χ²＝7.338
P值	?	<0.01	<0.01	<0.01	>0.05	<0.01	<0.05	<0.01

图2 典型病例术前影像图。图A为术前骨盆X线正位片，示左股骨颈骨折；图B～E分别为骨盆CT水平位、矢状位、冠状位、三维重建图，示左股骨颈骨折处

图6 术后12个月左股骨颈正侧位X线片，未见股骨头塌陷、坏死及股骨头高度丢失

图7 术后18个月左股骨颈CT，显示水平位、冠状位、矢状位均无明显股骨头缺血性坏死

图8 术后18个月左股骨颈MRI，显示水平位、T1和T2冠状位股骨头无塌陷，无缺血性坏死

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Comparison between directed anterior appoach assisted cannulated screw and intramedullary fixation for young adults with unstable femoral neck fractures

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Comparison between directed anterior appoach assisted cannulated screw and intramedullary fixation for young adults with unstable femoral neck fractures