【作者】 王建华；

【导师】 彭阿钦；

【作者基本信息】 河北医科大学 ， 外科学， 2016， 硕士

【摘要】 目的:高龄转子间骨折的发病率高,严重影响着我国老年人的身体健康。其保守治疗卧床时间长,合并症多,致残率高,现多采用手术治疗,对高龄转子间骨折的最佳手术治疗方法一致存在争议,目前常用的是闭合复位PFNA内固定和人工关节置换。本研究通过对PFNA内固定和人工关节置换两种治疗方法进行比较,试图确定两种方法各自的适应症,为临床工作提供指导,提高手术疗效及该类疾患病人的生活质量,有效降低高龄转子间骨折的致残、致死率,促进社会更和谐、健康的发展。方法:将2013年10月至2016年02月间我院治疗的51例高龄(75岁以上)不稳定型转子间骨折的患者分为两组:分别为PFNA内固定组和关节置换组。其中,PFNA内固定组共计26例,关节置换组共计25例,两组手术术者及第一助手均相同,观察两组患者手术所需时间、围手术期隐性失血量(术后第3日)、术后早期并发症(术后3个月内),根据髋关节Harris临床评定标准,评定两组患者术后恢复情况,其中90~100分为优、80~89分为良、70~79分为中、70分以下为差,两组分别随诊15.2个月和16.1个月。分别计算出内固定组与关节置换组的优良率,并进行统计学检验。采用SPSS 21.0统计软件对所有数据进行统计学分析,所有计量资料均以均数±标准差((?)±s)表示,计量资料采用t检验和卡方检验及方差分析,检验水准取α=0.05,P<0.05时差异有统计学意义。结果:内固定组手术时间平均为51.38士10.08min,关节置换组为72.01士10.23min,两组相比差异有显著性(P=0.00);内固定组围手术期隐性失血量(术后第3日)为708.85士121.40ml,关节置换组为918.00士154.24ml。两组相比差异有显著性(P=0.00);在术后3个月内内固定组有1例出现皮下脂肪液化,1例出现皮缘坏死,给予切口清创后,切口均愈合,2例出现髋内翻畸形,2例出现骨折延期愈合,随访12个月时所有骨折皆愈合,平均愈合时间为3.5个月;关节置换组伤口愈合良好,1例出现关节脱位,并于硬膜外麻醉下行闭合复位术,术后恢复良好。术后1年半Harris髋关节临床评分,内固定术组91.69士2.81分,关节置换组为92.08士2.43分,两组相比差异无明显差别(P>0.05)。结论:PFNA内固定术与关节置换术在治疗高龄不稳定型转子间均能取得良好的疗效。其中PFNA内固定术式适应了现代微创外科的先进理念,操作简单,手术时间短,失血量少,符合股骨近端生物力学特点,但术后需根据骨折愈合情况决定患肢完全负重时间,适用于非严重骨质疏松,且术前合并症多,手术耐受性相对较差,不宜接受较长手术时间的患者;人工关节置换术术后患者可早期功能锻炼,早期并发症少,但创伤较PFNA内固定术大,更适用于严重骨质疏松、内侧支撑破坏较严重,不适合内固定术式且预期寿命较短的患者。术者在制定手术方案时应仔细考虑,结合术者手术习惯及患者本人的具体情况,来为患者制定具体化的治疗方案。更多还原

【Abstract】 Objective: It is a high incidence of intertrochanteric fractures,which influence old people’s physical health seriously.Because of a long time in bed、much complications and high morbidity for the conservative treatment,we always take surgery now.However,there is controversial for the best surgical treatment of elderly fracture,at present,we commonly used is closed reduction PFNA internal fixation and the artificial joint replacement.To compare the clinical curative effect of PFNA Internal fixations and double acting femoral head replacementof unstable intertrochanteric fractures in the elderly,to explore reasonable operation scheme for senile unstable intertrochanteric fractures.Methods: 51 cases of patients over the age of 75 unstable intertrochanteric fractures between October 2013 to February 2016 were divided into PFNA internal fixation group and joint replacement group.PFNA internal fixation group has 26 cases and joint replacement group has 25 patients,two groups of operation performer and first assistant are all the same.Observing operation time for two groups of patients with surgery,hidden blood loss(3 days after postoperative),early postoperative complications(3 months after postoperative),and according to the Harris evaluation criteria,evaluating postoperative recovery of two groups,which is divided into optimal of 90~100 points,good of 80~89 points,middle of 70~79 points,poor of 70 points.we took the follow-up of two groups for 15.2 months and 16.1 months respectively,and calculate the excellent rate、statistical inspection of internal fixation group and the joint replacement group.All data using SPSS 21.0 statistical software analysis,The data of the research was expressed as mean((?)±2s),95% confidence interval was set to((?)±2s).T-test and χ2‐test were used for the comparisons of fetuses,which have the same quantity and gestational age but with different sex.Difference was statistically significant at P<0.05.Results: Internal fixation group operating time averaged 51.38 士 10.08 minutes,joint replacement group was 72.01 士 10.23 minutes,there was a significant difference compared with the two groups(P = 0.00);Internal fixation group of hidden blood loss,(3 days after postoperative)was 708.85 士121.40 ml,joint replacement group was 918.00 士 154.24 ml.There was a significant difference compared with the two groups(P = 0.00);Internal fixation group within 3 months after surgery had 1 case of subcutaneous fat liquefaction,1 cases with skin necrosis,after giving debridement,incision were healed.2 cases with hip varus deformity,2 cases with delayed healing of fracture,all fractures healed when followed up for 12 months,and the average healing time was 3.5 months.Joint replacement group wound healing is good,but 1 case of a joint dislocation,and through closed reduction,it recovered well after surgery.One and a half years after Harris hip score,clinical fixation group was 91.69 士 2.81,joint replacement group was 92.08 士 2.43,there was no evident difference between the two groups(P > 0.05).Conclusion: PFNA internal fixation and joint replacement are effective treatment for Elderly Unstable Intertrochanteric Fractures.For the PFNA internal fixation,the operation conform to the modern idea of minimally invasive surgery because of simple operation,short operation time,less blood loss,and have the characteristic of proximal femur biomechanics,Suitable for the severe osteoporosis,and preoperative complications,surgical tolerance is poor,unfavorable in patients undergoing a long operation time;Joint replacement have the advantages of early functional exercise,fewer complications,but big trauma than PFNA internal fixation.More suitable for the severe osteoporosis,the medial support damage is serious,not suitable for the patients with fixed way and a shorter life expectancy.When making operation scheme,performer should take more attention to the operation habit and his patients,and formulate specific treatment for the patients.更多还原