转子间骨折手术治疗的回顾性分析及长短髓内钉固定效果比较

发布时间：2018-03-20 06:41

  本文选题：转子间骨折　切入点：髓外固定　出处：《天津医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:(1)回顾性分析手术治疗股骨转子间骨折的效果,明确髓内、髓外固定的优缺点及适应症。(2)通过随机对照试验对比分析不同长度髓内钉治疗股骨转子间骨折时的临床效果及并发症。方法:(1)回顾性地分析了2011年1月至2014年10月份于我科就诊并手术治疗的转子间骨折患者的住院资料。纳入及排除标准如下:纳入本研究的患者需具有完善的资料记录;影像资料证实为转子间骨折;股骨转子间区域不存在转移性癌症等病理性改变。记录患者的基本信息包括:年龄、性别、骨折侧别及AO分型及骨密度值;记录患者的手术相关信息:手术方式、手术持续时间、术前及术后24小时血红蛋白及红细胞压积、输血量、住院时间、并发症等情况。(2)按照随机数据表将参与试验的患者随机分配到长、短髓内钉固定组。术前记录患者的基本信息包括:年龄、性别、骨折侧别及AO分型;AO分型由两位主治医师术前独立依据患者的髋部正侧位片进行判断。记录患者的手术相关信息,包括手术持续时间、术前及术后24小时血红蛋白及红细胞压积,记录患者术中失血量及术后引流量,住院时间、并发症等情况。结果:(1)回顾性分析了上述时间段之间在我科治疗的转子间骨折246例患者,排除不合格病例,最后共168例患者纳入回顾性分析。男性62例,女性106例,平均年龄分别为(65±13.4,74±9.4岁)。发生在左侧为88例,右侧80例。其中71~80岁组的患者数最多,60~90岁的患者占据了总人数的绝大多数,约81%。根据AO/OTA分型31-A1型患者数量为54例,31-A2型为100例,31-A3型为14例,各自比例分别为32.1%、59.5%及8.4%。髓外固定组(动力髋螺钉及经皮加压钢板)患者男性22例,女性32例,平均年龄分别为(71±13.8,72±8.1)岁。全部为31-A1型患者,31-A1.1型10例,31-A1.2型36例,31-A1.3型8例。动力髋螺钉及经皮加压钢板组患者术前一天平均HGB分别为(116.9±9.2,124.2±14.5)g/L,平均HCT为(35±3,36.5±3.7)%。手术时间为(81.1±17.4,86.1±17.6)min,未见明显差异。术后24小时复查HGB分别为(101.6±6.1,114.2±13.7)g/L,平均HCT分别为(30.1±2.4,33.3±3.7)%,经皮加压钢板固定组术后HGB及HCT高于动力髋螺钉固定组患者。两组术后需要输血的患者及总输血量未见明显差异。髓内固定组(PFNA及Gamma 3钉)患者共114例,其中男性患者50例,女性64例,平均年龄分别为(65±12.7,75±10)岁。31-A1型32例,31-A2型68例,此外尚有少量31-A3型的患者,共14例。PFNA及Gamma 3钉组患者术前一天平均HGB分别为(116.4±17,120.6±15.4)g/L,平均HCT为(34.3±4.8,35.3±3.9)%。手术时间为(84.5±24.7,78.3±23.1)min,未见明显差异。术后24小时复查HGB分别为(106.4±13.8,108.7±11.6)g/L,平均HCT分别为(32.1±3.6,31.3±3.1)%,上述各个指标二者并无明显统计学差异。髓外固定最常见的并发症为术后切口感染,髓外固定术后的并发症包括股骨再骨折、髋内翻等。(2)随机对照研究共纳入2014年1月至2015年4月间56例老年股骨转子间骨折患者,平均随访时间14.5(12-18)个月。长、短髓内钉固定组患者各为28例,平均年龄分别为(72.4±6.7,72.7±6.4)岁,长髓内钉固定组中,31-A1型患者数量为9例,31-A2型患者的数量为14例,A3型患者为5例。其中Gamma钉固定16例,PFNA固定12例。短髓内钉固定组中,31-A1型患者数量为9例,31-A2型患者的数量为15例,3型患者为4例。其中Gamma钉固定11例,PFNA固定17例。长、短髓内钉固定组患者术前一天HGB为(125.6±17.0,125.3±16.5)g/L,平均HCT为(34.2±4.7,35.1±4.3)%。平均手术时间为(61.5±11.8,45.3±9.2)min。C型臂透视次数平均为(30.2±9.9,32.5±9.3)次,总失血量为(627.2±217.1,507.0±134.6)m L,术后HGB为(96.5±10.2,102.1±11.8)g/L,平均HCT为(30.1±3.4,32.2±3.8)%。术后12月Harris功能评分为(84.8±5.6,84.2±5.6)。随访期间长髓内钉出现6例内固定相关并发症:1例患者出现了髋内翻,后期发生螺钉切出股骨头;1例发生股骨近端外侧壁劈裂;2例患者因再次摔倒出现假体尖端股骨骨折;1例患者出现髓内钉断裂情况。短钉固定出现5例内固定相关并发症,其中1例髋内翻,未出现切出现象;2例术中出现股骨外侧壁劈裂;1例假体尖端股骨骨折;1例患者出现近端骨折不愈合,主钉断钉。结论:(1)严格选择合适的病例进行髓外固定,可以获得良好的治疗效果,无论动力髋螺钉或经皮加压钢板均可有效治疗稳定型转子间骨折,避免术后内固定相关并发症;(2)长、短髓内钉治疗股骨转子间骨折时,短髓内钉可以缩短手术时间,减少手术失血。二者在手术并发症方面并无明显区别。
[Abstract]:Objective: (1) retrospective analysis of surgical treatment of intertrochanteric fractures, intramedullary clear, the advantages and disadvantages of the extramedullary fixation and indications. (2) through the analysis of randomised controlled trials comparing the clinical effect and complications of the treatment of femoral intertrochanteric fracture with different length of intramedullary nail. Methods: (1) review based on the analysis of the data of hospitalized patients from January 2011 to 2014 October in our hospital and surgical treatment of intertrochanteric fractures. The inclusion and exclusion criteria are as follows: patients enrolled in the study with perfect records; image data confirmed the intertrochanteric fracture; femoral intertrochanteric region without metastatic cancer and other pathological changes to record the basic information of patients including age, gender, side and AO classification and bone mineral density of fractures; records of surgery related information of patients: surgery, duration of surgery, preoperative and postoperative 24 hours of hemoglobin and red blood cells Cell hematocrit, blood transfusion, hospitalization time, complications and so on. (2) according to the patients were randomly assigned to random data table will participate in the test to the long and short intramedullary nail fixation group. The preoperative records the basic information of patients including age, gender, side and AO type AO type of fracture; by two physicians independently according to patient's preoperative hip radiographs were recorded. The related information of patients, including the duration of surgery, preoperative and postoperative 24 hours of hemoglobin and hematocrit, blood loss in patients with volume and postoperative drainage, hospitalization time and complications. Results: (1) were retrospectively analyzed between the time when the rotor treated in our department between 246 cases of patients with fracture, eliminate unqualified cases, a total of 168 patients were enrolled in the retrospective analysis. 62 cases were male, 106 were female, the average age was (65 + 13.4,74 + 9.4) occurred in the left in 88. Cases, 鍙充晶80渚，

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