动力髋螺钉置入内固定治疗骨质疏松性转子间骨折110例

背景：动力髋螺钉置入内固定是治疗转子间骨折最常用手术方式，但对于骨质疏松患者易发生螺钉切出股骨头，导致手术失败。 目的：回顾性分析导致骨质疏松性转子间骨折动力髋螺钉置入内固定失败的危险因素。 方法：对127例接受切开复位，135°动力髋螺钉置入内固定，对病历资料完整110例股骨转子间骨折患者进行回顾性分析。采用Evans骨折分型，采用Singh分级评定骨的质量，采用尖顶距评价拉力螺钉在股骨头的位置。选择年龄、骨质疏松程度、骨折类型、复位稳定性、内固定的植入位置作为分析变量，采用t检验及χ2检验对危险因素进行分析。 结果与结论：所有患者获得3~24个月随访，16例患者内固定失败。内固定失败者平均年龄77.5岁(63~88岁)，较骨折愈合组者年长8.5岁(P=0.03)。骨质疏松轻重程度以及尖顶距值大小间差异均存在显著性意义(P=0.01)。骨折稳定与否对内固定成败有显著性意义(P < 0.05)。良好复位与功能复位之间差异无显著性意义(P=0.31)。结果提示，年龄、骨折类型、骨骼质量、螺钉置入内固定的置入位置(尖顶距)以及内侧骨皮质复位质量是导致螺钉置入内固定失败的危险因素。功能复位并不增加螺钉置入内固定失败的风险。对于高龄、严重骨质疏松的不稳定骨折不宜应用动力髋螺钉置入内固定。对于采用动力髋螺钉置入内固定的一般患者应力求使尖顶距值< 25 mm，功能复位即可，但应力求使后内侧骨皮质良好复位。

Dynamic hip screw fixation for intertrochanteric fracture in 110 osteoporotic patients

BACKGROUND: Dynamic hip screw is the most widely used device for intertrochanteric fractures but in the patients with osteoporosis there are high risks of lag screw cut-out from the femoral head, resulting operation failure. OBJECTIVE: To evaluate the risk factors leading to the failure of dynamic hip screw fixation for senile intertrochanteric fracture with various osteoporosis. METHODS: A total of 127 osteoporotic patients with an intertrochanteric fracture were treated with a 135° sliding compression hip screw. 110 patients with complete data were retrospectively analyzed. The fractures were classified on preoperative radiographs according to the Evens classification system. The bone quality was classified by Singh rating system. Tip-apix distance (TAD) was used to assess the position of placement of lag screw. Five possible factors (age, Singh's index, reduction states, type of fractures, implant placement) were analyzed using t-test and Chi-square test. RESULTS AND CONCLUSION: All cases were followed up for 3 to 24 months, and 16 cases got fixation failure. The average age of failed cases were 77.5 years (63-88 years, 8.5 older than the cured group (P=0.03). The difference between the degree of osteoporosis and the magnitude of TAD was significant (P=0.01) Stable fracture was of significance for operation success (P < 0.05). There was no significance between the two groups in anatomical reduction or functional reduction (P=0.31). Results showed that age, Singh's index, reduction states, type of fractures, implant placement had statistical relations to the failure of dynamic hip screw fixation. Functional reduction did not increase the risk of internal fixation. Dynamic hip screw is not the first choice for the elder cases of unstable fractures combined with severe osteoporosis. As for the application of dynamic hip screw fixation, the TAD value should be not higher than 25 mm for the general patients. It might be inadvisable to overemphasize anatomical reduction, but an anatomical reduction with posteromedial apposition is necessary.