【摘要】 目的 探讨股骨大转子分离骨块对股骨转子间骨折内固定治疗效果的影响。方法 回顾分析 2021 年 5 月至 2023 年 5 月 82 例采用股骨近端髓内钉内固定术治疗，伴有股骨大转子后方分离骨块的股骨转子间骨折患者。根据愈合位置满意情况，分为 A 组 (愈合位置满意) 38 例和 B 组 (愈合位置欠佳) 44 例，比较两组术后 1 年的 Harris 髋关节评分 (Harris hip score，HHS)、视觉模拟评分 (visual analog scale，VAS) 及患侧髋关节外展活动度。结果 82 例患者接受手术治疗，术后影像显示内固定良好，部分患者股骨大转子后方有分离或骨皮质不连续，术后 3～4 个月 81 例骨折愈合良好，1 例术后 6 个月愈合，平均愈合时间 3.9 个月。术后 1 年，14.6% 的患者股骨大转子后方骨块愈合不良，未见内固定失效，15 例患者有轻微股骨远端内翻畸形。术后 1 年两组 HHS 和 VAS 差异无统计学意义 (P > 0.05)，但 B 组髋关节外展活动度明显小于 A 组[(26.11±5.09) ° vs.(30.22±5.12) °]，差异有统计学意义 (P < 0.05)。术后测量颈干角 A 组 (135.6±5.8) ° 显著大于 B 组(130.5±6.1) °，前倾角 A 组 (10.3±2.9) ° 显著小于 B 组 (14.2±3.5) °，差异均有统计学意义 (P < 0.001)；术后 A3 型骨折的颈干角改善程度 (8.2±3.1) ° 显著低于 A1 型 (12.1±2.8) ° 与 A2 型 (10.5±3.3) °，差异均有统计学意义 (P=0.003，P=0.021)；前倾角偏移量在 A3 型中最大，为 (4.3±1.9) °，显著高于 A1 / A2 型 (2.1±0.8) ° (P < 0.05)。A 组与 B 组相比，A3 型仍维持更优的颈干角[(133.8±6.2) ° vs.(128.7±5.9) °]及更小前倾角偏移[(1.8±0.7) ° vs.(3.9±1.5) °]，差异均有统计学意义 (t=2.17，P=0.013；t=5.02，P < 0.001)。结论股骨大转子后方分离骨块影响骨折内固定效果，术后 HHS 和 VAS 差异无统计学意义，但愈合位置不佳的患者髋关节外展受限，骨块愈合位置影响术后功能恢复，尤其是外展活动，进行髓内钉内固定术时，应重视骨块复位和固定，以改善功能恢复。更多还原

【Abstract】 Objective To investigate the effects of internal fixation on intertrochanteric fracture of the femur with separated greater trochanter.Methods Review and analyse 82 patients treated with proximal femoral intramedullary nailing for intertrochanteric fractures associated with posterior separation of the greater trochanter from May 2021 to May 2023.Patients were divided into Group A (satisfactory healing position) with 38 cases and Group B (unsatisfactory healing position) with 44 cases based on the satisfaction of the healing location.The Harris hip score (HHS) for hip joint function,pain (Visual Analog Scale,VAS) scores,and external rotation range of the affected hip joint at one year post-surgery were compared between the two groups.Results Eighty-two patients underwent surgical treatment,and postoperative imaging showed good internal fixation.Some patients had separation or discontinuity of the bone cortex behind the greater trochanter of the femur.Eighty-one patients had good fracture healing 3 to 4 months after surgery,with one patient healing 6 months postoperatively.The average healing time was 3.9 months.One year after surgery,14.6% of patients had poor healing of the bone mass behind the greater trochanter of the femur,but no failure of internal fixation was observed.Fifteen patients had mild distal femoral varus deformity.There was no statistically significant difference in HHS and VAS scores between the two groups one year after surgery (P > 0.05),but the hip joint abduction range of motion in Group B was significantly smaller than in Group A[(26.11±5.09) °vs.(30.22±5.12) °],with statistically significant differences (P < 0.05).The neck-shaft angle in Group A was significantly larger than Group B postoperatively[(135.6±5.8) ° vs.(130.5±6.1) °],while the anteversion angle was smaller[(10.3±2.9) ° vs.(14.2±3.5) °],with statistically significant differences (P < 0.001).Postoperative improvement of the neck-shaft angle in A3-type fractures (8.2±3.1) ° was significantly lower than that in A1-type (12.1±2.8) ° and A2-type (10.5±3.3) °,with statistically significant differences (P=0.003,P=0.021).The anteversion angle deviation was the greatest in A3-type at (4.3±1.9) °,which was significantly higher than inA1 / A2-type (2.1±0.8) ° with statistically significant differences (P < 0.05).Compared with Group B,Group A still maintained a better neck-shaft angle[(133.8±6.2) ° vs.(128.7±5.9) °]and a smaller anteversion angle deviation[(1.8±0.7) ° vs.(3.9±1.5) °],with statistically significant differences (t=2.17,P=0.013;t=5.02,P < 0.001).Conclusions The separation of bone fragments behind the greater trochanter of the femur affects the internal fixation outcome of fractures.There is no significant difference in postoperative HHS and VAS scores for hip joint function,but patients with poor healing positions experience limited hip abduction.The healing position of bone fragments impacts postoperative functional recovery,especially in abduction activities.When performing intramedullary nail fixation,it is important to emphasize the reduction and fixation of bone fragments to improve functional recovery.更多还原