中国修复重建外科杂志

中国修复重建外科杂志

第三代 Gamma 钉与防旋股骨近端髓内钉治疗股骨粗隆间骨折术后股骨近端短缩的比较研究

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目的 比较第 3 代 Gamma 钉(the third generation of Gamma nail,TGN)与防旋股骨近端髓内钉(proximal femoral nail anti-rotation,PFNA)内固定治疗股骨粗隆间骨折术后发生股骨近端短缩(proximal femoral shortening,PFS)的差异。 方法 回顾分析 2014 年 1 月—2015 年 12 月行 TGN 或 PFNA 内固定治疗的 158 例股骨粗隆间骨折患者临床资料,其中 TGN 组 69 例,PFNA 组 89 例。两组患者性别、年龄、骨密度、致伤原因、骨折国际内固定研究协会(AO/ASIF)分型、合并疾病、受伤至手术时间等一般资料比较,差异无统计学意义(P>0.05)。术后 2 d 摄正侧位 X 线片,根据 Chang 等的方法将骨折复位分为阳性皮质支撑、中立位皮质支撑、阴性皮质支撑 3 种类型;术后 18 个月摄双髋正位 X 线片,测量水平方向 PFS(记为 X)、垂直方向 PFS(记为 Y),计算总 PFS(记为 Z);将 PFS 值以≤1.0 mm、1.0~4.9 mm、5.0~9.9 mm 和≥10.0 mm 划分为 4 个等级,比较两组间X、Y、Z值及其构成差异。比较两组术后内固定失败及正常愈合患者间、不同骨折复位类型患者间的X、Y、Z值差异。比较两组间颈干角。 结果 TGN 组阳性皮质支撑 34 例、中立位皮质支撑 30 例、阴性皮质支撑 5 例,PFNA 组分别为 45、33、11 例;两组比较无统计学差异(Z=–1.06,P=0.29)。两组患者均随访至术后 18 个月。术后 18 个月两组患者X、Y、Z值构成比比较,差异均有统计学意义(P<0.05);其中,TGN 组患者各 PFS 值以 1.0~4.9 mm 以及 5.0~9.9 mm 范围为主,PFNA 组以≥10.0 mm 范围为主。术后 18 个月 TGN 组 X、Y、Z 值均显著低于 PFNA 组(P<0.05),两组颈干角比较差异无统计学意义(t=0.47,P=0.64)。术后 3 个月内 TGN 组和 PFNA 组分别发生内固定失败 6 例,两组内内固定失败与正常愈合患者 X、Y、Z 值比较差异均无统计学意义(P>0.05)。两组复位效果为阳性皮质支撑患者中,TGN 组患者 X、Y、Z 值均显著低于 PFNA 组(P<0.05),但两组中立位皮质支撑及阴性皮质支撑患者,其X、Y、Z 值组间比较差异均无统计学意义(P>0.05);两组组内比较,阴性皮质支撑患者 X、Y、Z 值均显著高于中立位皮质支撑和阳性皮质支撑患者(P<0.05)。 结论 PFS 是股骨粗隆间骨折术后常见并发症,闭合复位内固定治疗时应根据术中复位结果选择内固定方式,阳性皮质支撑时应用 TGN 内固定,可减少 PFS 程度。

Objective To explore the difference of the proximal femoral shortening (PFS) between the third generation of Gamma nail (TGN) and the proximal femoral nail anti-rotation (PFNA) in treating intertrochanteric fracture of femur. Methods The clinical data of 158 patients with intertrochanteric fracture of femur who underwent TGN and PFNA internal fixation between January 2014 and December 2015 were retrospectively analysed. The patients were divided into TGN group (69 cases) and PFNA group (89 cases) according to surgical operation.There was no significant difference in gender, age, bone mineral density, causes of injury, AO/Association for the Study of Internal Fixation (AO/ASIF) classification, accompanied disease, and the time from injury to operation between 2 groups (P>0.05). The result of fracture reduction was divided into 3 types: positive medial cortex support, neutral position cortex support, and negative medial cortex support according to the method of Changet al. At 18 months postoperatively, bilateral hip anteroposterior X-ray films were taken to measure horizontal PFS (marked as X), vertical PFS (marked as Y), and calculate the total PFS (marked as Z). The PFS values were divided into 4 grades according to ≤1.0 mm, 1.0-4.9 mm, 5.0-9.9 mm, and ≥10.0 mm, and the constituent ratio was calculated and compared between 2 groups. The X, Y, Z values and the collodiaphyseal angles of 2 groups at 18 months postoperatively were compared. The X, Y, Z values of the 2 groups of patients with failed fixation and normal healing within 18 months after operation were recorded and compared. The X, Y, Z values of 2 groups of the patients with different cortex support types were also compared. Results There were 34 cases of positive medial cortex support, 30 cases of neutral cortical support, and 5 cases of negative medial cortex support in TGN group, and there were 45, 33, and 11 cases in PFNA group respectively, showing no significant difference between 2 groups (Z=–1.06, P=0.29). All patients were followed up to 18 months after operation. At 18 months after operation, the incidences of PFS had significant differences between 2 groups (P<0.05). The incidence of shortening of 1-4.9 mm and 5-9.9 mm in TGN group was obviously higher than that in PFNA group; the incidence of shortening of ≥10 mm in PFNA group was obviously higher than that in TGN group. There were significant differences of X, Y, and Z values between 2 groups (P<0.05), but no significant difference of the collodiaphysial angle was found between 2 groups (t=0.47, P=0.64). Six cases of internal fixation failed in TGN group and PFNA group respectively within 3 months after operation, and there was no significant difference of X, Y, and Z values between failed fixation and normal healing patients within 2 groups (P>0.05). When the reposition effect was the positive medial cortex support, the X, Y, and Z values of TGN group were significantly lower than those in PFNA group (P<0.05); but no significant difference of X, Y, and Z values was found between 2 groups when the reposition effect was the neutral position cortex support or negative medial cortex support (P>0.05). At 18 months after operation, the X, Y, and Z values of the negative medial cortex support patients were significantly higher than those of the positive medial cortex support or the neutral position cortex support patients within 2 groups (P<0.05). Conclusion PFS is a common complication of the intertrochanteric fracture of the femur after treated by internal fixation. During operation, the selection of internal fixation should be based on the results of intraoperative reduction, TGN should be applied to reduce PFS if positive medial cortex support happened.

关键词: 股骨粗隆间骨折; 股骨近端短缩; 第 3 代 Gamma 钉; 防旋股骨近端髓内钉

Key words: Intertrochanteric fracture of the femur; proximal femoral shortening; the third generation Gamma nail; proximal femoral nail anti-rotation

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