股方肌骨瓣转移联合多枚加压空心螺纹钉与AO多枚加压空心螺纹钉置入
内固定修复中青年股骨颈骨折

doi:10.3969/j.issn.2095-4344.2014.48.015

摘要/Abstract

摘要：

背景：股骨颈骨折临床上还没有统一的治疗标准，股方肌骨瓣转移移植联合多枚加压空心螺纹钉内固定法与AO多枚加压空心螺纹钉内固定均为股骨颈骨折常用治疗方法，但两者均有优缺点。
目的：探讨股方肌骨瓣转移移植联合多枚加压空心螺纹钉内固定法与AO多枚加压空心螺纹钉内固定治疗中青年股骨颈骨折GardenⅢ，Ⅳ型效果及并发症发生率。
方法：将60例中青年股骨颈骨折患者根据治疗方法的不同分为观察组和对照组，观察组应用开放复位股方肌骨瓣转移移植联合多枚加压空心螺纹钉内固定法，对照组应用闭合复位AO多枚加压空心螺纹钉内固定，比较两组患者骨折愈合时间、愈合率、功能优良率、股骨头坏死率及远期塌陷率。
结果与结论：①观察组患者骨折愈合时间明显少于对照组，骨折愈合率及功能优良率明显高于对照组(P < 0.05)。②观察组患者骨折愈合时间明显少于对照组，骨折愈合率及功能优良率明显高于对照组(P < 0.05)。说明应用股方肌骨瓣转移移植联合多枚加压空心螺纹钉内固定法治疗中青年股骨颈骨折GardenⅢ，Ⅳ型效果良好。

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, 骨植入物, 空心钉内固定, 股方肌骨瓣移植, 股骨颈骨折, 中青年, 股骨, 骨折, 股骨头坏死, 并发症

Abstract:

BACKGROUND: There is no unified treatment standard for femoral neck fracture in the clinic. Quadratus femoris muscle pedicle bone flap transplantation combined with hollow compression screw fixation and AO hollow compression screw fixation are common methods for treatment of femoral neck fracture, but both of them have their advantages and disadvantages.
OBJECTIVE: To investigate the effects and complication rates of quadratus femoris muscle pedicle bone flap transplantation combined with hollow compression screw fixation and AO hollow compression screw fixation in young and middle-aged patients with Garden III and IV types of femoral neck fracture.
METHODS: A total of 60 young and middle-aged patients with femoral neck fracture were divided into observation group and control group according to the different treatment methods. The observation group was treated with quadratus femoris muscle pedicle bone flap transplantation combined with hollow compression screw fixation. The control group was treated with AO hollow compression screw fixation. Fracture healing time, healing rate, excellent and good rate, the rate of avascular necrosis and late collapse rate were compared between the two groups.
RESULTS AND CONCLUSION: (1) The fracture healing time of the observation group was less than that of the control group. The healing rate and the excellent and good rate were significantly higher in the observation group than those in the control group (P < 0.05). (2) Fracture healing time in patients of the observation group was less than that of the control group, but the healing rate and the excellent and good rate of fracture was significantly higher than those in the control group (P < 0.05). These data suggested that the quadratus femoris muscle pedicle bone flap transplantation combined with hollow compression screw fixation have good effects in the treatment of Garden III and IV types of femoral neck fracture in the young and middle-aged patients.

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: femoral fractures, internal fixators, bone nails, femur head

中图分类号:

R318

查庆林，张鸿程，庐成云，朱玉科. 股方肌骨瓣转移联合多枚加压空心螺纹钉与AO多枚加压空心螺纹钉置入
内固定修复中青年股骨颈骨折[J]. 中国组织工程研究, 2014, 18(48): 7792-7796.

Zha Qing-lin, Zhang Hong-cheng, Lu Cheng-yun, Zhu Yu-ke. Quadratus femoris muscle pedicle bone flap transplantation combined with hollow compression screw fixation versus AO hollow compression screw fixation in the repair of femoral neck fracture in young and middle-aged patients [J]. Chinese Journal of Tissue Engineering Research, 2014, 18(48): 7792-7796.

图/表（结果） 3

参考文献

[1] 李波,邹正,罗文中.不同股骨颈骨折分型与中青年股骨颈骨折预后的相关性研究[J].重庆医学,2013,42(3):297-298,301.
[2] Vaishya R, Shrestha SK, Vaish A. A Galeazzi-variant type fracture-dislocation in adults. Chin J Traumatol. 2013;16(6): 344-346.
[3] Maeda H, Yoshida K, Doi R, et al. Combined Monteggia and Galeazzi fractures in a child: a case report and review of the literature. J Orthop Trauma. 2003;17(2): 128-131.
[4] Stoffelen D, Fortems Y, De Smet L, et al. Dislocation of the distal radioulnar joint associated with a transstyloid radiocarpal fracture dislocation. A case report and review of the literature. Acta Orthop Belg. 1996;62(1):52-55.
[5] Lee K. Global trends in maxillofacial fractures. Craniomaxillofac Trauma Reconstr. 2012;5(4):213-222.
[6] Perron AD, Hersh RE, Brady WJ, et al. Orthopedic pitfalls in the ED: Galeazzi and Monteggia fracture-dislocation. Am J Emerg Med. 2001;19(3):225-228.
[7] Lee K. Global trends in maxillofacial fractures. Craniomaxillofac Trauma Reconstr. 2012;5(4):213-222.
[8] Carlsen BT, Dennison DG, Moran SL. Acute dislocations of the distal radioulnar joint and distal ulna fractures. Hand Clin. 2010;26(4):503-516.
[9] Lee KH, Snape L, Steenberg LJ, et al. Comparison between interpersonal violence and motor vehicle accidents in the aetiology of maxillofacial fractures. ANZ J Surg. 2007;77(8): 695-698.
[10] Yoffe T, Shohat I, Shoshani Y, et al. Etiology of maxillofacial trauma--a 10-year survey at the Chaim Sheba Medical Center, Tel-Hashomer. Harefuah. 2008;147(3):192-196, 280.
[11] Mijiti A, Ling W, Tuerdi M, et al. Epidemiological analysis of maxillofacial fractures treated at a university hospital, Xinjiang, China: A 5-year retrospective study. J Craniomaxillofac Surg. 2014;42(3):227-233.
[12] Gandhi S, Ranganathan LK, Solanki M, et al. Pattern of maxillofacial fractures at a tertiary hospital in northern India: a 4-year retrospective study of 718 patients. Dent Traumatol. 2011;27(4):257-262.
[13] Rahman RA, Ramli R, Rahman NA, et al. Maxillofacial trauma of pediatric patients in Malaysia: a retrospective study from 1999 to 2001 in three hospitals. Int J Pediatr Otorhinolaryngol. 2007;71(6):929-936.
[14] van den Bergh B, Karagozoglu KH, Heymans MW, et al. Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg. 2012;40(6):e165-169.
[15] Ozgursoy OB, Muderris T, Yorulmaz I, et al. Demographic, epidemiologic, and surgical characteristics of maxillofacial fracture repair in a developing country. Ear Nose Throat J. 2009;88(4):E20-24.
[16] Martini MZ, Takahashi A, de Oliveira Neto HG, et al. Epidemiology of mandibular fractures treated in a Brazilian level I trauma public hospital in the city of São Paulo, Brazil. Braz Dent J. 2006;17(3):243-248.
[17] 张德宝,王铁军,谷贵山.高龄股骨颈骨折患者行全髋关节置换与人工双极股骨头置换的比较[J].中国组织工程研究与临床康复, 2008,12(9):1651-1654.
[18] 刘志雄.常用骨科分类法和功能评定[M]. 北京:科学技术出版社, 2010:221-230.
[19] 陈跃平,高辉,陈亮,等.关节置换与植入物内固定治疗老年移位型股骨颈骨折的系统评价[J].中国组织工程研究,2012,16(9): 1656-1660.
[20] 魏杰,张登君,郭秀生,等.股方肌骨瓣移位空心钉内固定治疗青壮年股骨颈骨折的中长期疗效[J].中华显微外科杂志,2012, 35(5): 370-373.
[21] 谢延华,王凤龙,林潮炫,等.空心钉内固定与联合股方肌骨瓣治疗青壮年股骨颈骨折的疗效比较[J].广东医学院学报,2013,31(5): 571-573.
[22] 韵向东,夏亚一,万麟,等.股方肌骨瓣移植术治疗青壮年股骨颈骨折中远期随访[J].中国骨伤,2010,23(3)164-166.
[23] Zahid M, Bin Sabir A, Asif N, et al. Fixation using cannulated screws and fibular strut grafts for fresh femoral neck fractures with posterior comminution. J Orthop Surg (Hong Kong). 2012; 20(2):191-195.
[24] Raaymakers EL. Fractures of the femoral neck: a review and personal statement. Acta Chir Orthop Traumatol Cech. 2006; 73(1):45-59.
[25] Sen RK, Tripathy SK, Goyal T, et al. Osteosynthesis of femoral-neck nonunion with angle blade plate and autogenous fibular graft. Int Orthop. 2012;36(4):827-832.
[26] Chen Z, Wang G, Lin J, et al. Efficacy comparison between dynamic hip screw combined with anti-rotation screw and cannulated screw in treating femoral neck fractures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2011;25(1): 26-29.
[27] Sahin S, Ertürer E, Oztürk I, et al. Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotation (PFNA) in the treatment of unstable intertrochanteric femoral fractures. Acta Orthop Traumatol Turc. 2010;44(2):127-134.
[28] Dewei Z, Xiaobing Y. A retrospective analysis of the use of cannulated compression screws and a vascularised iliac bone graft in the treatment of displaced fracture of the femoral neck in patients aged < 50 years. Bone Joint J. 2014;96-B(8): 1024-1028.
[29] Rawall S, Bali K, Upendra B, et al. Displaced femoral neck fractures in the young: significance of posterior comminution and raised intracapsular pressure. Arch Orthop Trauma Surg. 2012;132(1):73-79.
[30] Tian W, Cui Z, Kan S. Comparison of cannulated screws fixation with different reduction methods at different time points for displaced femoral neck fractures in terms of fracture healing. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009; 23(4):440-443.
[31] LeCroy CM, Rizzo M, Gunneson EE, et al. Free vascularized fibular bone grafting in the management of femoral neck nonunion in patients younger than fifty years. J Orthop Trauma. 2002;16(7):464-472.
[32] Asnis SE, Wanek-Sgaglione L. Intracapsular fractures of the femoral neck. Results of cannulated screw fixation. J Bone Joint Surg Am. 1994;76(12):1793-1803.
[33] Rodríguez-Merchán EC. In situ fixation of nondisplaced intracapsular fractures of the proximal femur. Clin Orthop Relat Res. 2002;(399):42-51.
[34] Cho MR, Lee SW, Shin DK, et al. A predictive method for subsequent avascular necrosis of the femoral head (AVNFH) by observation of bleeding from the cannulated screw used for fixation of intracapsular femoral neck fractures. J Orthop Trauma. 2007;21(3): 158-164.
[35] Haidukewych GJ, Rothwell WS, Jacofsky DJ, et al. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004; 86-A(8):1711-1716.
[36] Nikolopoulos KE, Papadakis SA, Kateros KT, et al. Long-term outcome of patients with avascular necrosis, after internal fixation of femoral neck fractures. Injury. 2003;34(7):525-528.
[37] Mao YJ, Wei J, Zhou L, et al. Related factor analysis of avascular necrosis of the femoral head after internal fixation with cannulated screws in femoral neck fractures. Zhonghua Yi Xue Za Zhi. 2005;85(46):3256-3259.
[38] Lin SQ, Peng LP, Yao ZC. Case-control study on cannulated screw fixation and percutaneous autogenous bone marrow grafting for the treatment of femoral neck fractures. Zhongguo Gu Shang. 2010;23(9):675-678.
[39] Staeheli JW, Frassica FJ, Sim FH. Prosthetic replacement of the femoral head for fracture of the femoral neck in patients who have Parkinson disease. J Bone Joint Surg Am. 1988; 70(4):565-568.
[40] Nowotarski PJ, Turen CH, Brumback RJ, et al. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82(6):781-788.
[41] Tidermark J, Zethraeus N, Svensson O, et al. Quality of life related to fracture displacement among elderly patients with femoral neck fractures treated with internal fixation. J Orthop Trauma. 2002;16(1):34-38.
[42] Pelet S, Leyvraz PF, Garofalo R, et al. Sub- or intertrochanteric fracture following screw fixation of an intracapsular proximal femoral fracture: true complication or technical error? Swiss Surg. 2003;9(2):82-86.
[43] Staeheli JW, Frassica FJ, Sim FH. Prosthetic replacement of the femoral head for fracture of the femoral neck in patients who have Parkinson disease. J Bone Joint Surg Am. 1988; 70(4):565-568.
[44] 王满宜,危杰.股骨颈骨折临床研究的若干问题与新概念[J].中华创伤骨科杂志,2003,5(1):5.

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2002年4月至2013年4月在楚州中医院中医骨科完成。

对象：选取2002年4月至2013年4月间楚州中医院收治的中青年股骨颈骨折患者。

纳入标准：①有明确的外伤史。②均经X射线或CT检查确诊为股骨颈骨折。③患者及家属对试验及治疗方案知情同意。

排除标准：①病理性骨折。②凝血功能不全及严重肝肾功能障碍者。③过敏病史者。④糖尿病等可能影响骨折愈合的疾病。

最终收集60例股骨颈骨折患者，其中男43例，女17例，年龄14-50岁，平均(42.37±7.2)岁。按患者骨折错位程度临床分型采用Garden法^[16]：GardenⅢ型患者39例，GardenⅣ型患者21例；按骨折部位分类：头下型17例、头颈型38例、经颈型15例。根据治疗方法的不同分为观察组和对照组，各30例。观察组包括男21例，女9例，平均年龄(41.98±6.8)岁，骨折分型：GardenⅢ型患者19例、GardenⅣ型患者11例；对照组包括男22例，女8例，平均年龄(42.76±6.88)岁，骨折分型：GardenⅢ型患者20例，GardenⅣ型患者10例。试验经楚州中医院医学伦理委员会批准。

材料：空心螺纹钉由天津市威曼医疗器械有限公司提供，材质为不锈钢，钉径4.5 mm，螺纹径6.5 mm，长度8 cm。

方法：

内固定治疗：所有患者均于入院后1周内行内固定治疗。

股方肌骨瓣转移移植联合多枚加压空心螺纹钉内固定：观察组患者麻醉成功后，健侧卧位，术野消毒铺巾，取患髋Moor切口长14-16 cm，切开各层后显露股方肌并凿取股方肌蒂骨瓣3.5 cm(长)×1.2cm(宽)×0.8cm(深)，游离蒂部。继显露股骨颈骨折部及股骨上端外侧面，术中常见股骨颈骨折端错位明显，颈后方及颈下缘有碎骨块，为不稳定骨折。于股骨上端与大粗隆交界处的下方约1.0 cm的前外侧、后外侧及下3.5 cm股骨外侧面正中呈倒等腰三角形向股骨颈钻入导针，屈髋内收内旋位显露骨折远侧断端，直视下查看导针，确认上方2枚导针位于颈中上1/3的前、后方，下方导针位于股骨距上方0.5 cm、侧位在颈的中部，3枚导针在颈中也呈三角形。再行骨折端的撬拨牵引复位，骨折端呈解剖复位，继钻入上述3枚克氏导针，C臂机透视显示：骨折解剖复位，导针呈三角形固定，针尖距股骨头软骨约0.5 cm，空心钻仅钻通骨皮质，攻丝后拧入合适长度的7.3 cm或7.0 cm钛制空心加压螺钉，暂不拧紧加压。沿股骨颈后方纵轴中线跨骨折线凿骨槽并于股骨头对应部位凿挖0.6 cm深骨洞，整个骨槽与修整后的骨瓣相匹配，将凿下的及骨瓣修整后所剩的皮质骨和松质骨植于骨槽上下缘骨折端及缺损处，骨植充分。再将股方肌骨瓣植入头颈的骨槽、洞中，卡入良好，再拧紧空心钉加压使骨折端间隙变小，骨瓣植入牢固，不须螺钉固定，再次透视：骨折解剖复位，空心钉距软骨约0.5 cm。

AO多枚加压空心螺纹钉内固定：对照组患者平卧骨科牵引床，患侧臀部垫高15°，先伸直位牵引患肢，C臂机透视：骨折端间隙已牵开，端缩畸形已矫正，颈干角良好，然后逐渐外展外旋患肢约30°再内旋20°即可复位。如骨折复位不满意或难以复位，在髋部消毒后，透视下于髋关节前方股动脉外侧1枚2.5 mm克氏针固定股骨头控制旋转并调整方向，再行患肢牵引屈曲旋转复位，复位满意后患肢固定于骨科牵引床，消毒铺巾于股骨上端外侧经皮钻入3枚克氏导针呈三角形固定且克氏导相互平行，针尖距股骨头软骨约0.5 cm，C臂机透视股骨颈骨折正侧位良好，克氏导针位置良好，沿导针切小切口，空心钻钻孔后拧入3枚长度适宜的7.3或7.0 mm空心加压螺纹钉固定即可(图1)。

骨折愈合的判定：骨折恢复标准参照AO原则及国际骨循环研究会判定标准^[17]：①骨头缺血坏死：X射线下显示为股骨头密度改变，出现囊性变、硬化带、密度不均等特征性表现，MRI有线样征及坏死区域。②股骨头晚期塌陷：X射线下除坏死特征表现外，还有股骨头扁平改变。③骨折不愈合：固定后达到或超过8个月，X射线片仍可见到清晰骨折间隙。

试验同时记录患者骨折愈合时间和愈合率。

下肢功能的评价：于内固定后6个月时参考文献[5]以Harris评分评价2组患者下肢功能的变化。

Harris评分优秀：90-100分，良：70-89分，差：< 70分。优秀率为Harris评分为优秀和良的患者所站的百分率。

主要观察指标：患者骨折愈合时间、愈合率及功能优良率。

统计学分析：采用SPSS 17.0统计学软件(美国SPSS公司)处理，正态分布的各统计指标均以x(_)±s表示，组间数值比较采用t 检验，率比较采用χ²检验，P < 0.05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

关于股骨颈骨折治疗方法，目前临床上普遍较为接受的观点为：老年有位移的股骨颈骨折患者，由于机体恢复能力差、骨质疏松，行骨折复位内固定方法治疗容易出现股骨头坏死、骨不连等并发症，故关节置换往往为首选方法^[18]。而中青年股骨颈骨折与老年股骨颈骨折不同，往往是由于车祸、压砸等机械损伤以及高空坠落伤等，多为高能量创伤，骨折十分严重而且常伴有其它骨折。由于患者年龄青、骨质坚固，恢复能力较强，临床上常用复位内固定法治疗^[19]。防止骨折不愈合及股骨头缺血坏死是临床上治疗中青年患者的关键，研究认为，治疗中青年股骨颈骨折的关键包括两点：一为复位，二为内固定。并且复位标准不低于Garden复位指数，正位片与侧位片复位指数应该在155°-180°；而内固定要兼顾固定物对骨折稳定维持性能及对病变部位血运干扰两个方面上^[20]。

空心加压螺纹钉内固定目前在国际上已成为治疗股骨颈骨折的首先方法，作用于股骨颈断面上的力是垂直方向的压缩力、水平方向的剪切力的复合力，用于固定股骨颈骨折的材料要求能抗扭曲力及剪切力，对股骨颈骨折既要损伤小又不能破坏股骨头、颈的血供。大量研究表明股骨颈骨折治愈率与骨折的复位质量，骨折的固定强度和固定方法有关^[21]。3枚加压空心螺纹钉内固定手术方式应用最为广泛，由于采用3枚螺钉呈三角固定，使骨折端能够有良好的压力，而且螺钉与骨组织结构有共同的立体框架构架，符合力学原理，使固定后的病变骨骼能够有较大的抗弯、抗剪及抗扭曲力。并且加压空心螺钉内固定治疗股骨颈手术操作相对简单，有利于股骨头血运的早期改善，促进了骨折愈合，固定后患者恢复快，早期就可以进行不负重简单活动，有效减少并发症的发生。

青壮年股骨颈骨折创伤机制多为高能量暴力、骨折线由股骨头、颈交界的外上方斜向股骨颈中、下部内侧，Pauwel角大于50°，呈斜型不稳定骨折；且股骨颈后内侧多有粉碎骨块、丧失了后内侧有效骨性支撑，常发生复位失败以至骨折不愈合。因此，有人主张对有后内侧粉碎的股骨颈骨折，可考虑一期进行植骨^[22-30]。由于股方肌营养血脉较多，将其移植至病变部位能够增加股骨头的再血管化及再骨化营养来源，刺激骨折端成骨作用，还可以有效的填充骨折缺损的部位，利用手术过程中修整骨瓣及凿骨槽所产生的小骨块在骨折端间充分植骨，增加受压区结构的稳定性和骨折固定作用，骨折端无缺损，间隙明显缩小，一定程度上加强了内固定；骨折开放复位，骨折端基本都能解剖复位，控制了股骨头的旋转从而有效防止圆韧带旋转而影响其所提供的血供；同时有利于清除关节囊内的凝血块和出血，解除关节囊内的压力，避免发生“填塞效应”有利于保持股骨头的血供，降低了骨折不愈合及坏死率。有学者指出对于所有股骨颈骨折均应解剖复位，但青壮年股骨颈骨折常为暴力所伤，骨折错位明显，股骨颈后方有碎骨片，骨折闭合难以解剖复位，且复位后骨折不稳定，内固定也难以抵消股骨颈后内侧骨缺损所造成的不稳定，固定后经常出现退钉、股骨颈短缩骨折、再移位等并发症^[31-44]。试验发现，在应用空心钉内固定加股方肌骨瓣移植治疗的患者骨折愈合时间、愈合率及Harris评分都明显优于仅仅应用空心钉进行内固定的患者，并且联合骨瓣移植的患者股骨头坏死及股骨头塌陷率也明显低于后者，说明空心钉内固定加股方肌骨瓣移植治疗是治疗中青年股骨颈骨折的良好术式，值得在临床上推广应用。

综上所述，应用股方肌骨瓣转移移植联合多枚加压空心螺纹钉内固定法治疗中青年股骨颈骨折效果良好，值得在临床上推广应用。

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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