两种关节评分联用评价两种手术治疗老年股骨粗隆间骨折

doi:10.3877/cma.j.issn.1674-134X.2024.03.005

目的

将Parker活动度评分与髋关节状况评估中常用的Harris评分结合，比较股骨近端防旋髓内钉内固定术和双动人工股骨头置换术两种手术治疗老年不稳定型股骨粗隆间骨折的效果。

方法

纳入选定时间跨度内北京市隆福医院收治的年龄≥65岁Evans-Jensen分型Ⅲ~Ⅴ型的低能量单侧股骨不稳定型粗隆间骨折患者92位作为研究对象，排除髋部严重疾病、合并下肢其他部位骨折、病理性骨折、不适合在入院48 h内接受手术的内科等疾病者。其中46位接受了闭合复位股骨近端防旋髓内钉内固定术（CRIF-PFNA）治疗，另46位接受了双动头人工股骨头置换术（HA-BFHP）治疗。对患者进行了为期2年的疗效临床跟踪，并使用Harris髋关节评分和Parker活动度评分、采用重复测量方差分析来评估、比较不同手术患者恢复情况。

结果

与HA-BFHP治疗相比，CRIF-PFNA手术操作相对简单、时间短、出血少，但患者卧床恢复期长。在术后第3个月时，接受CRIF-PFNA治疗与接受HA-BFHP治疗的患者相比，Harris髋关节评分更低（t=−8.88，P<0.001），Parker活动度评分减少值更大（t=2.58，P=0.013）。术后第6、12、24个月两组患者的Harris髋关节评分差异无统计学意义（t=1.31、0.52、0.96，均为P>0.05），而术后第12、24个月CRIF-PFNA组患者Parker活动度评分减少值（相比骨折发病前）低于HA-BFHP组，差异有统计学意义（t=2.29、2.18，均为P<0.05）。

结论

对于老年股骨粗隆间骨折，两种手术方法各有优势。HA-BFHP治疗更利于术后快速恢复，短期治疗效果更佳，而CRIF-PFNA手术整体风险小，适用性更广，对于非严重骨质疏松者长期效果更好。

关键词: 髋骨折, 骨折固定术, 半关节成形术

Objective

To compare efficacies of closed reduction and internal fixation with proximal femur nail antirotation (CRIF-PFNA) and hemiarthroplasty with bipolar femoral head prosthesis (HA-BFHP) for geriatric unstable intertrochanteric fractures by combining the Parker mobility score with the Harris hip score.

Methods

Ninety-two patients aged ≥65 years old with Evans-Jensen classification Ⅲ~Ⅴ low energy unilateral femoral unstable intertrochanteric fracture admitted to Beijing Longfu Hospital during the selected time span were included as the study subjects; the patients with other severe hip diseases, lower limb fractures at other sites, pathological bone fractures and diseases not suitable for surgery within 48 h were excluded. Forty-six of whom received the treatment of closed reduction proximal femoral anti-screwing intramedullal nail internal fixation (CRIF-PFNA). Another 46 patients underwent double head artificial femoral head replacement (HA-BFHP). Clinical follow-up was performed for two years. The Harris hip score and Parker mobility score were used, and repeated measure ANOVA was used to evaluate and compare the recovery of patients with different operations.

Results

Compared with HA-BFHP, the operation of CRIF-PFNA was relatively simple, the time was short, the bleeding was less, but the patient's bed recovery period was longer. At three months after surgery, patients treated with CRIF-PFNA had lower Harris hip scores (t=−8.88, P<0.001) and greater reductions in Parker mobility scores (t=2.58, P=0.013) compared with those treated with HA-BFHP. There was no significant difference in Harris hip score between the two groups at six, 12 and 24 months after surgery (t=1.31, 0.52, 0.96, all P>0.05). However, the reduction value of Parker activity score in the CRIF-PFNA group at 12 and 24 months after surgery (compared with the onset of fracture) was lower than that in the HA-BFHP group, and the difference was statistically significant (t=2.29, 2.18, both P<0.05).

Conclusion

The two surgical methods have their own merits and demerits in treating geriatric unstable intertrochanteric fractures, in which HA-BFHP is conducive to rapid postoperative recovery to a relatively ideal status, and CRIF-PFNA has lower overall surgical risk, wider applicability, and can achieve better long-term recuperation for non-serious osteoporosis patients.

Key words: Hip fractures, Fracture fixation, Hemiarthroplasty

表1 纳入患者的一般资料

Table 1 General information of the enrolled patients

指标Indices		CRIF-PFNA组	HA-BFHP组	统计值Statistical value	P值
例数Number of cases		46	46
年龄Age［岁，（）］		75.6±5.3	74.3±5.5	t=0.935	>0.05
性别Gender	男Male	16	19	χ²=0.415	>0.05
性别Gender	女Female	30	27	χ²=0.415	>0.05
Evans-Jensen分型 Evans-Jensen classification	Ⅲ型	14	12	χ²=0.773	>0.05
	Ⅳ型	26	25
	Ⅴ型	6	9
身体质量指数［kg/m²，（）］ Body mass index		23.7±1.8	23.5±2.1	t=0.478	>0.05
ASA分级 ASA classification	Ⅰ~Ⅱ级	33	35	χ²=0.225	>0.05
ASA分级 ASA classification	Ⅲ~Ⅳ级	13	11	χ²=0.225	>0.05
术前血红蛋白［g/L，（）］ Preoperative hemoglobin		129.5±12.1	128.8±12.5	t=0.301	>0.05
术前C反应蛋白［mg/L，（）］ Preoperative C reactive protein		46.3±11.9	45.4±11.5	t=0.347	>0.05
术前白蛋白［g/L，（）］ Preoperative albumin		37.7±6.1	38.9±6.4	t=−0.909	>0.05
骨折至手术时间间隔［h，（）］ Time from injury to surgery		36.0±7.1	37.0±6.9	t=−0.572	>0.05

表1 纳入患者的一般资料

Table 1 General information of the enrolled patients

指标Indices		CRIF-PFNA组	HA-BFHP组	统计值Statistical value	P值
例数Number of cases		46	46
年龄Age［岁，（）］		75.6±5.3	74.3±5.5	t=0.935	>0.05
性别Gender	男Male	16	19	χ²=0.415	>0.05
性别Gender	女Female	30	27	χ²=0.415	>0.05
Evans-Jensen分型 Evans-Jensen classification	Ⅲ型	14	12	χ²=0.773	>0.05
	Ⅳ型	26	25
	Ⅴ型	6	9
身体质量指数［kg/m²，（）］ Body mass index		23.7±1.8	23.5±2.1	t=0.478	>0.05
ASA分级 ASA classification	Ⅰ~Ⅱ级	33	35	χ²=0.225	>0.05
ASA分级 ASA classification	Ⅲ~Ⅳ级	13	11	χ²=0.225	>0.05
术前血红蛋白［g/L，（）］ Preoperative hemoglobin		129.5±12.1	128.8±12.5	t=0.301	>0.05
术前C反应蛋白［mg/L，（）］ Preoperative C reactive protein		46.3±11.9	45.4±11.5	t=0.347	>0.05
术前白蛋白［g/L，（）］ Preoperative albumin		37.7±6.1	38.9±6.4	t=−0.909	>0.05
骨折至手术时间间隔［h，（）］ Time from injury to surgery		36.0±7.1	37.0±6.9	t=−0.572	>0.05

图1 CRIF-PFNA（闭合复位股骨近端防旋髓内钉内固定）术前术后X线影像。图A为术前左髋正侧位片，示股骨粗隆间骨折；图B为术后左髋正侧位片，示复位良好、固定牢固

Figure 1 X-ray images before and after CRIF-PFNA (closed reduction and internal fixation with proximal femur nail antirotation). A is image of left hip at anteroposterior and lateral positions before operation, showing intertrochanteric fracture; B is image of left hip at anteroposterior and lateral positions after operation, showing good reduction and fixation

图2 HA-BFHP（双动人工股骨头半置换）术前后X线影像。图A为术前左髋正侧位片，示股骨粗隆间骨折；图B为术后左髋正侧位片，示复位良好、假体稳定牢固

Figure 2 X-ray images before and after HA-BFHP (hemiarthroplasty with bipolar femoral head prosthesis). A is image of left hip at anteroposterior and lateral positions before operation, showing intertrochanteric fracture; B is image of left hip at anteroposterior and lateral positions after operation, showing good reduction and stable prosthesis

表2 CRIF-PFNA组与HA-BFHP组围手术期指标

Table 2 Perioperative data of CRIF-PFNA group and HA-BFHP group

组别 Groups	例数 Number of cases	手术时间［min,（）］ Operation time	手术静脉出血量［ml,（）］ Intraoperative blood loss of vein	术后住院时间［d,（）］ Length of hospital stay after operation	住院期间并发症［例（%）］ Complications during hospital stay
CRIF-PFNA组	46	56.7±6.3	152.8±27.2	17.9±2.2	15(32.6)
HA-BFHP组	46	75.6±6.7	296.8±38.6	13.3±1.9	6(13.0)
统计值 Statistical value		t=−11.24	t=−16.72	t=8.63	χ²=5.00
P值		<0.001	<0.001	<0.001	0.025

表2 CRIF-PFNA组与HA-BFHP组围手术期指标

Table 2 Perioperative data of CRIF-PFNA group and HA-BFHP group

组别 Groups	例数 Number of cases	手术时间［min,（）］ Operation time	手术静脉出血量［ml,（）］ Intraoperative blood loss of vein	术后住院时间［d,（）］ Length of hospital stay after operation	住院期间并发症［例（%）］ Complications during hospital stay
CRIF-PFNA组	46	56.7±6.3	152.8±27.2	17.9±2.2	15(32.6)
HA-BFHP组	46	75.6±6.7	296.8±38.6	13.3±1.9	6(13.0)
统计值 Statistical value		t=−11.24	t=−16.72	t=8.63	χ²=5.00
P值		<0.001	<0.001	<0.001	0.025

表3 CRIF-PFNA组与HA-BFHP组随访资料（

）

Table 3 Follow-up data of CRIF-PFNA group and HA-BFHP group

组别 Groups	例数 Number of cases	术后首次负重行走时间（d） First ambulance with load after surgery	HHS评分
组别 Groups	例数 Number of cases	术后首次负重行走时间（d） First ambulance with load after surgery	3个月 Three months	6个月 Six months	12个月 Twelve months	24个月 Twenty-four months
CRIF-PFNA组	46	40.6±4.8	61.1±4.3	79.5±7.3	84.7±7.9	86.4±8.3
HA-BFHP组	46	13.5±2.9	74.5±6.8	82.2±8.2	83.6±8.5	84.2±8.9
t值		25.84	−8.88	1.31	0.52	0.96
P值		<0.001	<0.001	>0.05	>0.05	>0.05
F值		-	主效应: 4.43		交互效应: 21.21
P值		-	主效应: 0.040		交互效应: <0.001
组别 Groups	例数 Number of cases	-	PMS评分减少值^*Reduction in PMS
组别 Groups	例数 Number of cases	-	3个月 Three months	6个月 Six months	12个月 Twelve months	24个月 Twenty-four months
CRIF-PFNA组	46	-	2.7±0.8	1.8±1.0	1.3±0.7	1.1±1.1
HA-BFHP组	46	-	2.1±0.9	2.0±0.9	1.8±0.9	1.8±1.1
t值		-	2.58	0.85	2.29	2.18
P值		-	0.013	>0.05	0.026	0.034
F值		-	主效应：0.68		交互效应：30.98
P值		-	主效应：>0.05		交互效应：<0.001

表3 CRIF-PFNA组与HA-BFHP组随访资料（

）

Table 3 Follow-up data of CRIF-PFNA group and HA-BFHP group

组别 Groups	例数 Number of cases	术后首次负重行走时间（d） First ambulance with load after surgery	HHS评分
组别 Groups	例数 Number of cases	术后首次负重行走时间（d） First ambulance with load after surgery	3个月 Three months	6个月 Six months	12个月 Twelve months	24个月 Twenty-four months
CRIF-PFNA组	46	40.6±4.8	61.1±4.3	79.5±7.3	84.7±7.9	86.4±8.3
HA-BFHP组	46	13.5±2.9	74.5±6.8	82.2±8.2	83.6±8.5	84.2±8.9
t值		25.84	−8.88	1.31	0.52	0.96
P值		<0.001	<0.001	>0.05	>0.05	>0.05
F值		-	主效应: 4.43		交互效应: 21.21
P值		-	主效应: 0.040		交互效应: <0.001
组别 Groups	例数 Number of cases	-	PMS评分减少值^*Reduction in PMS
组别 Groups	例数 Number of cases	-	3个月 Three months	6个月 Six months	12个月 Twelve months	24个月 Twenty-four months
CRIF-PFNA组	46	-	2.7±0.8	1.8±1.0	1.3±0.7	1.1±1.1
HA-BFHP组	46	-	2.1±0.9	2.0±0.9	1.8±0.9	1.8±1.1
t值		-	2.58	0.85	2.29	2.18
P值		-	0.013	>0.05	0.026	0.034
F值		-	主效应：0.68		交互效应：30.98
P值		-	主效应：>0.05		交互效应：<0.001

［1］	Uzun M，Ertürer E，Oztürk I，et al. Long-term radiographic complications following treatment of unstable intertrochanteric femoral fractures with the proximal femoral nail and effects on functional results［J］. Acta Orthop Traumatol Turc，2009,43(6): 457-463.
［2］	Moriya M，Uchiyama K，Takahira N，et al. Evaluation of bipolar hemiarthroplasty for the treatment of steroid-induced osteonecrosis of the femoral head［J］. Int Orthop，2012,36(10): 2041-2047.
［3］	Shen L，Zhang Y，Shen Y，et al. Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: a meta-analysis of randomized controlled studies［J］. Orthop Traumatol Surg Res，2013,99(4): 377-383.
［4］	Rodop O，Kiral A，Kaplan H，et al. Primary bipolar hemiprosthesis for unstable intertrochanteric fractures［J］. Int Orthop，2002,26(4): 233-237.
［5］	陈江涛，霍建军，荀传辉，等. 单极与双极股骨头置换治疗老年股骨颈骨折的Meta分析［J］. 中华创伤杂志，2014,30(9): 917-923.
［6］	刘振刚，杨超，施建东，等. 人工股骨头置换术与髓内钉内固定治疗老年骨质疏松性不稳定股骨粗隆间骨折的比较［J］. 中国骨与关节损伤杂志，2021,36(2): 158-160.
［7］	蔺海山，米尔阿里木·木尔提扎，赵巍，等. 双动头人工股骨头置换术与PFNA内固定治疗老年不稳定股骨粗隆间骨折的疗效比较［J］. 中国骨与关节损伤杂志，2020,35(10): 1058-1060.
［8］	郑晓锋，孙天祥. 两种术式治疗老年股骨粗隆间骨折比较［J］. 中国矫形外科杂志，2021,29(24): 2290-2292.
［9］	王建年. 双极股骨头半髋置换治疗老年不稳定粗隆间骨折的疗效及预后影响因素［J］. 实用临床医药杂志，2016,20(11): 116-117,128.
［10］	Thakur A，Lal M. Cemented hemiarthroplasty in elderly osteoporotic unstable trochanteric fractures using fracture window［J］. Malays Orthop J，2016,10(1): 5-10.
［11］	Karaman Ö，Özkazanlı G，Orak MM，et al. Factors affecting postoperative mortality in patients older than 65 years undergoing surgery for hip fracture［J］. Turk J Trauma Emerg Surg，2015,21(1): 44-50.
［12］	中华医学会骨质疏松和骨矿盐疾病分会. 原发性骨质疏松症诊疗指南（2017）［J］. 中国全科医学，2017,20(32): 3963-3982.
［13］	Söderman P，Malchau H. Is the Harris hip score system useful to study the outcome of total hip replacement？［J］. Clin Orthop Relat Res，2001(384): 189-197.
［14］	Hoeksma HL，Van Den Ende CHM，Ronday HK，et al. Comparison of the responsiveness of the Harris Hip Score with generic measures for hip function in osteoarthritis of the hip［J］. Ann Rheum Dis，2003,62(10): 935-938.
［15］	Parker MJ，Palmer CR. A new mobility score for predicting mortality after hip fracture［J］. J Bone Joint Surg Br，1993,75(5): 797-798.
［16］	Kristensen MT，Kehlet H. Most patients regain prefracture basic mobility after hip fracture surgery in a fast-track programme［J/OL］. Dan Med J，2012,59(6): A4447. PMID: 22677245.
［17］	Hulsbæk S，Larsen RF，Troelsen A. Predictors of not regaining basic mobility after hip fracture surgery［J］. Disabil Rehabil，2015,37(19): 1739-1744.
［18］	Zhou S，Liu J，Zhen P，et al. Proximal femoral nail anti-rotation versus cementless bipolar hemiarthroplasty for unstable femoral intertrochanteric fracture in the elderly: a retrospective study［J/OL］.BMC Musculoskelet Disord，2019,20(1): 500. DOI: 10.1186/s12891-019-2793-8.
［19］	Chu X，Liu F，Huang J，et al. Good short-term outcome of arthroplasty with Wagner SL implants for unstable intertrochanteric osteoporotic fractures［J］. J Arthroplasty，2014,29(3): 605-608.
［20］	Soylemez MS，Uygur E，Poyanli O. Effectiveness of distally slotted proximal femoral nails on prevention of femur fractures during and after intertrochanteric femur fracture surgery［J］. Injury，2019,50(11): 2022-2029.
［21］	Chan KC，Gill GS. Cemented hemiarthroplasties for elderly patients with intertrochanteric fractures［J］. Clin Orthop Relat Res，2000(371): 206-215.
［22］	Parker MJ，Handoll HHG. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults［J/OL］. Cochrane Database Syst Rev，2006,2006(2): CD000086. DOI: 10.1002/14651858.CD000086.pub2.
［23］	Karthik K，Natarajan M. Unstable trochanteric fractures in elderly osteoporotic patients: role of primary hemiarthroplasty［J］. Orthop Surg，2012,4(2): 89-93.
［24］	中华人民共和国国家卫生健康委员会医政司. 老年髋部骨折诊疗与管理指南（2022年版）［J］. 中华创伤骨科杂志，2023,25(4): 277-283.
［25］	Chouhan D，Meena S，Kamboj K，et al. Distal locked versus unlocked intramedullary nailing in intertrochanteric fracture: a systematic review and meta-analysis of randomized and non-randomized trials［J］. Bull Emerg Trauma，2020,8(2): 56-61.
［26］	Sinno K，Sakr M，Girard J，et al. The effectiveness of primary bipolar arthroplasty in treatment of unstable intertrochanteric fractures in elderly patients［J］. N Am J Med Sci，2010,2(12): 561-568.
［27］	高明宏，刘安庆，杨李敏. 47例髋关节置换术后股骨假体周围骨折的治疗分析［J］. 中华骨与关节外科杂志，2019,12(1): 45-48.

[1]	欧梁, 齐麒, 胡伟伟, 卢敏, 黄彦昌, 黄维琛, 匡建军. 股骨颈动力交叉钉系统与其它内固定治疗股骨颈骨折对比[J]. 中华关节外科杂志(电子版), 2024, 18(01): 92-105.
[2]	中华医学会骨科学分会关节外科学组, 广东省医学会骨质疏松和骨矿盐疾病分会, 广东省佛山市顺德区第三人民医院. 中国髋部脆性骨折术后抗骨质疏松药物临床干预指南(2023年版)[J]. 中华关节外科杂志(电子版), 2023, 17(06): 751-764.
[3]	刘瀚忠, 黄生辉, 万俊明, 李家春, 舒涛. 髌上入路和髌旁外侧入路髓内钉治疗胫骨骨折疗效比较[J]. 中华关节外科杂志(电子版), 2023, 17(06): 795-801.
[4]	周春林, 韩元龙, 丁飞, 吴玮杰. 踝关节骨折内固定术后形态变化及功能影响因素[J]. 中华关节外科杂志(电子版), 2023, 17(05): 736-740.
[5]	刘丹丹, 宋鸣, 李霞, 徐夏君. 老年髋部骨折术后便秘的影响因素及其列线图预测模型[J]. 中华关节外科杂志(电子版), 2023, 17(05): 607-612.
[6]	夏效泳, 王立超, 朱治国, 丛云海, 史宗新. 深度塌陷性胫骨平台骨折的形态特点和治疗策略[J]. 中华关节外科杂志(电子版), 2023, 17(05): 625-632.
[7]	齐伟亚, 方杰, 吴衡, 刘波. 掌侧小切口联合腕关节镜治疗AO－C型桡骨远端骨折[J]. 中华关节外科杂志(电子版), 2023, 17(04): 577-582.
[8]	王波, 许珂, 刘林, 张斌飞, 庄岩, 许鹏. 全髋关节置换术在老年髋臼骨折中的应用[J]. 中华关节外科杂志(电子版), 2023, 17(03): 385-390.
[9]	吴祥, 黄必留, 雷彦文, 彭松根, 李胜山, 刘敏, 黄海燕, 黎世洲, 廖松南, 郭桥鸿, 张敬良. 腕关节镜联合3D打印微创治疗桡骨远端骨折[J]. 中华关节外科杂志(电子版), 2023, 17(02): 179-185.
[10]	王晓伟, 王晔来, 徐宇航, 征华勇, 张建政, 刘智, 孙天胜. 老年髋部骨折后血钠紊乱与死亡风险的相关研究[J]. 中华关节外科杂志(电子版), 2023, 17(02): 186-194.
[11]	王竹, 王庚启, 郑军, 端磊, 徐冰, 唐熙晨, 吴泊逸, 王秋根, 王建东, 曹雷, 毕春, 邓国英. 肘关节外侧入路治疗肱骨小头骨折的治疗体会及经验总结[J]. 中华肩肘外科电子杂志, 2023, 11(03): 235-241.
[12]	张琳袁, 吴佳俊, 崔煦, 沈超, 付备刚, 崔崟, 王秀会, 蔡攀. 大结节解剖钢板与PHILOS内固定治疗伴肩关节脱位的Mutch I/II型肱骨大结节骨折的疗效差异[J]. 中华肩肘外科电子杂志, 2023, 11(02): 139-145.
[13]	金宇杰, 虞宵, 周晓强, 李志强, 徐人杰, 张向鑫, 陈广祥. 动力交叉钉系统治疗股骨颈骨折其内固定位置与临床疗效的相关性研究[J]. 中华老年骨科与康复电子杂志, 2023, 09(04): 193-200.
[14]	邓京骐, 李涛, 朱振华, 李嘉成, 陈社强, 莫嘉俊, 廖奕岚, 刘沛一, 樊仕才. 改良LC-Ⅱ螺钉固定钉道的数字化分析与验证[J]. 中华老年骨科与康复电子杂志, 2023, 09(03): 129-137.
[15]	江起庭, 姚翔, 何兵, 邱福平, 程健, 王斌, 杨玲玲. 双“8”字捆绑联合双克氏针在陈旧性骨性锤状指中的临床应用[J]. 中华临床医师杂志(电子版), 2024, 18(01): 24-29.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Combined evaluation of two surgical treatments of intertrochanteric femoral fractures in elderly patients with two joint scores

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Combined evaluation of two surgical treatments of intertrochanteric femoral fractures in elderly patients with two joint scores