股骨近端髓内钉与人工髋关节置换修复股骨转子间骨折的对比

doi:10.3969/j.issn.2095-4344.2015.13.003

摘要/Abstract

摘要：

背景：股骨转子间骨折多发于骨质疏松的老年患者，常用的治疗方法有髓内、外固定治疗和关节置换等。
目的：对比股骨近端髓内钉与人工髋关节置换两种方法治疗股骨转子间骨折的临床疗效。
方法：将菏泽市立医院在2009年8月至2013年8月收治的股骨转子间骨折患者198例，分为股骨近端髓内钉固定组和人工髋关节置换组，各99例。股骨近端髓内钉固定组和人工髋关节置换组患者分别采用股骨近端髓内针固定和人工髋关节置换治疗。
结果与结论：股骨近端髓内钉固定组患者手术时间、术中出血量和住院时间均显著少于人工髋关节置换组，但骨折愈合时间显著长于人工髋关节置换组；但2组患者治疗后1年时的Harris评分、髋关节功能优良率和总并发症发生率差异无显著性意义。提示采用股骨近端髓内钉固定和人工髋关节置换治疗老年股骨近端骨折均有良好的生物相容性，均可取得良好的临床效果，2种方法虽各有优缺点，临床上均可根据患者病情需要制定合适的治疗方案。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

关键词: 植入物, 人工假体, 股骨转子间骨折, 髓内钉, 髋关节置换, 内固定, Harris评分, 临床疗效

Abstract:

BACKGROUND: Intertrochanteric fracture is often found in osteoporotic elderly patients, the commonly used treatment includes intramedullary and extramedullary fixations, and joint replacement.
OBJECTIVE: To compare the clinical effect of proximal femoral intramedullary nail and hip arthroplasty in the treatment of intertrochanteric fracture.
METHODS: 198 patients of intertrochanteric fracture recruited from Heze Municipal Hospital from August 2009 to August 2013, were divided into two groups. Each group had 99 patients, receiving proximal femoral intramedullary nail and hip arthroplasty, respectively.
RESULTS AND CONCLUSION: The average operation time, intraoperative blood loss and hospital stays in the proximal femoral intramedullary nail group were significantly shorter, while the healing time of fracture was significantly longer than that in the hip arthroplasty group. At postoperative 1 year, there was no statistical difference in the Harris score, the excellent and good rate of hip function, and the overall incidence of complications between the two groups. Experimental findings indicate that, both proximal femoral intramedullary nail and hip arthroplasty are biocompatible and effective in the treatment of intertrochanteric fracture, and each technique has their advantages and disadvantages, we should choose the proper technique according to the patient’s condition.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: Hip Fractures, Femoral Fractures, Bone Nails, Arthroplasty, Replacement, Hip

中图分类号:

R318

李现军. 股骨近端髓内钉与人工髋关节置换修复股骨转子间骨折的对比[J]. 中国组织工程研究, 2015, 19(13): 1979-1983.

Li Xian-jun. Comparison of proximal femoral intramedullary nail and hip arthroplasty in the treatment of intertrochanteric fracture[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(13): 1979-1983.

图/表（结果） 1

参考文献

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引言

材料方法

1 对象和方法 Subjects and methods

设计：同期非随机对比观察。

时间及地点：试验于2009年8月到2013年8月在菏泽市立医院完成。

对象：选取菏泽市立医院骨科2009年8月到2013年8月期间收治的股骨转子间骨折患者。

诊断标准：参照文献[5]诊断股骨转子间骨折。

纳入标准：①符合诊断标准。②年龄大于60岁。③患者及家属均了解试验目的并签署知情同意书。

排除标准：①存在神经或精神方面异常。②不能完成随访者。

最终收集股骨转子间骨折患者198例，其中男86例，女112例，年龄62-78岁。患者按照治疗方法分为股骨近端髓内钉固定组和人工髋关节置换组，各99例。其中股骨近端髓内钉固定组，男42例，女57例；年龄62-78岁，平均(67.9±4.1)岁；致伤原因：车祸伤31例，摔伤45例，其他伤23例；骨折Ecans-Jensen分型：Ⅰ型34例，Ⅱ型39例，Ⅲ型16例，Ⅳ型10例。人工髋关节置换组，男44例，女55例；年龄63-77岁，平均(68.2±3.5)岁；致伤原因：车祸伤33例，摔伤41例，其他伤25例；骨折Ecans-Jensen分型：Ⅰ型37例，Ⅱ型36例，Ⅲ型18例，Ⅳ型8例。两组患者在性别、年龄、致伤原因和骨折Ecans-Jensen分型等方面差异均无显著性意义(P > 0.05)，具有可比性。

方法：

手术前治疗方法：所有患者治疗前均进行降血压、血糖、纠正酸碱失衡及水电解质紊乱等常规治疗，并给予皮牵引治疗。

股骨近端髓内钉固定：股骨近端髓内钉固定组患者行股骨近端髓内钉固定(图1A)，具体操作如下：患者取仰卧式，并保持下肢与躯干呈20°角，硬膜外麻醉，通过前C臂X射线机对患者进行闭合复位，于患者股骨大转子顶点向近端纵行切口3-5 cm，充分暴露大转子顶点，然后从大转子顶点中间插入导针，扩髓后置入股骨近端髓内钉，术后

行常规抗生素治疗。

人工髋关节置换：人工髋关节置换组患者行人工髋关节置换(图1B)，具体操作如下：患者取侧卧式，全身麻醉，髋关节前外侧入路，于大转子上方向下弧形切口5-8 cm。钝性分离臀大肌，游离阔筋膜张肌并充分暴露大转子骨折部位，取出股骨头对小转子骨折部位进行复位后利用钢丝环进行固定，然后切开髋关节囊，用摆锯截断股骨颈头，对股骨髓腔进行扩髓，根据患者的具体情况选择合适的股骨柄假体进行股骨头置换。

术后于患者切口内放置引流管引流一两天，并行常规抗生素治疗。两组患者术后均进行髋关节功能锻炼。并定期随访复查1年，评定其髋关节功能恢复情况。

手术治疗的评价：观察记录两组患者的手术时间、术中出血量、骨折愈合时间和住院时间等手术指标。

随访观察：术后随访1年，记录并比较分析两组患者并发症发生情况。

髋关节功能恢复情况的评价：根据Harris评分评定患者的髋关节功能恢复情况^[6]，< 70分为差，71 <评分< 89为良，90 <评分< 100为优。优良率=(优+良)/总例数×100%。

主要观察指标：患者的髋关节功能。

统计学分析：采用SPSS 18.0计量软件进行数据处理，计数资料采用χ²检验；计量数据用x(_)±s表示，数据差异采用两样本t 检验，组间差异采用组间t 检验，P < 0.05时为差异有显著性意义。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

讨论

近年来，随着社会老龄化的加剧，股骨转子间骨折的发病率呈现逐渐上升的趋势。股骨转子间骨折作为老年患者常见的骨折类疾病之一，占髋部骨折的40%-50%。由于其发病部位相对特殊，且大多数老年患者存在骨质疏松症状，其骨组织微结构逐渐退化，骨强度较弱，皮质骨较薄，骨骼较脆弱，使该类骨折患者的预后往往较差，易引发肢体短缩、髋内翻等并发症，严重影响患者的生活质量及生存率^[7-19]。

临床上对于股骨转子间骨折的治疗常用的治疗方式包括保守治疗和手术治疗。而相比于保守治疗的疗效局限性和较高的并发症发生率和病死率，手术治疗尤其是髓内固定术以其显著的优势被越来越多的应用于股骨转子间骨折的治疗^[20]。

股骨近端髓内钉固定多为闭合复位内固定，是一种“生物性”内固定技术，可以降低患者骨量的丢失，分散压应力，避免局部压应力过大，创伤小，术后并发症较少。这些优势使其成为治疗各种股骨转子间骨折的首先方法^[11]。股骨近端髓内钉在结合Gamma钉力臂短、弯矩小的基础上，通过2枚交锁螺钉固定股骨干近端，提高了股骨头的旋转稳定性，采用长杆状凹槽口将近端交锁螺钉与远端相连接，使髓内钉的可屈性得以增加。同时，随着骨科医生临床经验的积累和内固定装置设计的不断优化，也进一步降低了股骨近端髓内钉固定后并发医源性骨折、股骨干骨折等并发症的概率^[22]。

此外，长期临床研究表明，人工髋关节置换作为另一种简单有效的手术方式，对患者髋关节功能的恢复同样具有显著的疗效，尤其是对于伴有严重骨质疏松的新鲜骨折患者、股骨转子间骨折晚期并发创伤性关节炎等多种并发症的高龄患者以及内固定失败的患者具有显著疗效^[23-44]。

总的来说，人工髋关节置换在股骨干骨折的治疗中具有以下几点优势：①通过髋前外侧入路，充分暴露骨折部位，术野较清晰，能够达到骨折解剖复位，便于医师及时掌握患者的骨折及复位情况。②术中采用钢丝缝合骨折碎片，维持骨折断端供血，避免了骨折周围形成血肿。③可以维持股骨颈基底部位稳定性，尽可能的保留患者的髋关节动力，有利于患者关节功能，可以实现早期下床活动^[45-46]。

试验结果显示，利用股骨近端髓内钉固定的股骨近端髓内钉固定组手术时间、术中出血量、骨折愈合时间和住院时间均显著少于采用人工髋关节置换的人工髋关节置换组，表明股骨近端髓内钉固定是一种更加简单有效的方式。这可能是因为股骨近端髓内钉固定作为一种标准化的手术，操作相对简单，术中切口较小，对血运破坏少，能够有效缩短手术时间和骨折愈合时间。而人工髋关节置换中暴露范围大，需对患者骨膜及周围软组织进行广泛剥离，切口相对较大，增加了术中出血量，术后并发切口感染的概率也较高^[47]。2组患者Harris评分、髋关节功能优良率以及总并发症发生率差异无显著性意义。提示2种手术方式均具有明显疗效，无论是髓内钉固定还是人工髋关节置换，只要术中规范操作，术后积极早期功能锻炼，均能使关节功能恢复良好，提高患者生活质量。

综上所述，采用股骨近端髓内钉固定和人工髋关节置换治疗老年股骨近端骨折，植入物与宿主均有良好的生物相容性，均可取得良好的临床效果，2种修复方法各有优缺点，临床上应根据患者病情需要制定合适的治疗方案。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程
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