两种髓内钉固定老年不稳定型转子间骨折比较△

Comparison of two kinds of intramedullary nail fixation for unstable intertrochanteric fracture in the elderly

摘要:

[目的] 比较股骨近端交锁髓内钉（intertan nail, IN） 与股骨近端防旋髓内钉（proximal femoral nail anti-rotation, PF-NA） 治疗老年不稳定型股骨转子间骨折（intertrochanteric femur fracture, IFF） 的临床疗效。[方法] 2019 月1 月—2021 年12 月对114 例老年不稳定型IFF 患者行手术治疗，采用随机数字法将患者分为IN 组58 例，PFNA 组56 例。比较两组围术期指标、随访及影像结果。[结果] PFNA 组手术时间[(45.3±8.0) min vs (49.6±7.9) min, P＜0.05]、切口总长度[(4.5±1.2) cm vs (5.0±1.3) cm,P＜0.05]、术中出血量[(81.7±10.3) ml vs (127.6±20.0) ml, P＜0.05]、术中透视次数[(11.7±2.4) 次vs (13.0±2.2) 次, P＜0.05]、扶拐下地时间[(6.5±1.2) d vs (7.6±1.4) d, P＜0.05]、切口愈合时间[(12.0±2.3) d vs (13.4±3.1) d, P＜0.05]、住院时间[(5.9±0.9) d vs (7.1±1.3) d,P＜0.05] 均显著优于IN 组（P＜0.05）；两组临床骨折愈合时间的差异无统计学意义（P＞0.05）。与术后6 个月相比，术后12 个月两组Harris 评分、髋伸屈ROM、髋内-外旋ROM 均显著增加（P＜0.05）；相应时间点，两组间Harris 评分、髋伸屈ROM、髋内-外旋ROM 的差异均无统计学意义（P＞0.05）。影像方面，两组骨折复位质量、骨折愈合情况的差异无统计学意义（P＞0.05）。相应时间点，两组间颈干角、前倾角的差异均无统计学意义（P＞0.05），末次随访IN 组TAD 值[(23.4±2.5) mm vs (25.2±2.8) mm, P＜0.05] 显著小于PFNA 组。[结论] IN 与PFNA 内固定术均可恢复老年不稳定型IFF 患者髋关节功能，促进骨折愈合，但PFNA 治疗术中出血量、透视次数少，手术时间、住院时间短，更适用于耐受力差的老年患者，而IN 髓内钉治疗具有更佳的生物力学优势。

Abstract:

[Objective] To compare the clinical efficacy of Intertan Nail (IN) versus Proximal Femoral Nail Anti-rotation (PFNA) in thetreatment of unstable intertrochanteric femur fracture (IFF) in the elderly. [Methods] A total of 114 elderly patients with unstable IFF weretreated by operation from January 2019 to December 2021. The patients were divided into 58 cases in the IN group and 56 cases in the PF-NA group by random number method. Perioperative, follow-up and imaging data were compared between the two groups. [Results] The PF-NA group proved significantly superior to the IN group in terms of operation time [(45.3±8.0 min) vs (49.6±7.9) min, P＜0.05], the total inci-sion length [(4.5±1.2) cm vs (5.0±1.3) cm, P＜0.05], blood loss [(81.7±10.3) ml vs (127.6±20.0) ml, P＜0.05], intraoperative fluoroscopy times[(11.7±2.4) times vs (13.0±2.2) times, P＜0.05], ambulation time [(6.5±1.2) days vs (7.6±1.4) days, P＜0.05], incision healing time [(12.0±2.3) days vs (13.4±3.1) days, P＜0.05] and hospital stay [(5.9±0.9) days vs (7.1±1.3) days, P＜0.05], despite of insignificant difference in clini-cal fracture healing time between the two groups (P＞0.05). Compared with those 6 months after surgery, the Harris score, hip extension-flex-ion ROM and internal-external rotation ROM significantly increased in both groups at 12 months after surgery (P＜0.05), whereas whichwere not statistically significant between the two groups at any time points accordingly (P＞0.05). Radiographically, there were no significantdifferences in the quality of fracture reduction and fracture healing between the two groups (P＞0.05). In addition, there were no statisticallysignificant differences in shaft-neck angle and anteversion between the two groups at any time points accordingly (P＞0.05). However, theIN group had significantly less tip-apex distance (TAD) than the PFNA group at the last follow-up [(23.4±2.5) mm vs (25.2±2.8) mm, P＜0.05]. [Conclusion] Both IN and PFNA used for internal fixation of unstable IFF do restore hip function and promote fracture healing in the elderly. By comparison, the PFNA is more suitable for elderly patients with poor tolerance due to less intraoperative blood loss, fluoroscopytimes, short operation time and hospital stay, while IN takes better biomechanical advantages.