Gamma3 型髓内钉治疗股骨转子间骨折手术并发症的原因分析

 目的 分析 Gamma3 型髓内钉治疗股骨转子间骨折术后发生并发症的原因。方法 回顾性分析 2006 年 5 月至 2011 年 7 月应用 Gamma3 型髓内钉治疗股骨转子间骨折 186 例患者资料，其中 24 例出现手术并发症，男 19 例，女 5 例；年龄 42～81 岁，平均（69.00±3.27）岁。根据 AO/OTA 分型：A1 型 8 例，A2.1 型 1 例，A3 型 15 例；稳定性骨折 9 例，占 37.5%（9/24）；不稳定性骨折 15 例，占 62.5%（15/24）；均为新鲜骨折，排除病理性骨折。手术均采用闭合复位的方式进行固定，内固定器材为史赛克公司生产的短 Gamma3 型髓内钉。入院至手术时间为 3～12 d，平均 6 d；术后 3～16 d 出院。根据术中、术后随访的 X 线片及 Harris 功能评价标准对术后疗效进行评价，总结 Gamma3 型髓内钉在股骨转子间骨折应用中的并发症。结果 24 例患者手术时间为 45～160 min，平均 80 min；失血量为 300～800 ml，平均 600 ml；下地时间为术后 35～106 d。Harris 评分为 75～92 分，平均 81 分。24 例患者术后发生并发症的原因：1 例因未安装保护套筒而导致防旋钉进入大腿内侧肌间隙；3 例在闭合复位时进钉点偏外，扩髓时造成股骨外侧壁缺失；5 例因插入主钉前扩髓不充分而导致进钉时股骨干近端劈裂；6 例反转子间粉碎骨折，小转子嵌入骨折断端，致非解剖复位下置钉，对位欠佳；2 例难复型骨折术后出现再移位；3 例股骨外侧壁骨折，术后骨折移位；3 例骨折粉碎严重、大小转子分离移位明显者选用短 Gamma3 钉固定，术后发生拉力钉切出；1 例股骨干远端锁钉处再骨折。结论 对于 AO 分型中某些特殊类型的骨折，闭合复位短 Gamma3 钉固定具有较高并发症发生率，这多由复位方法、适应证选择不当以及非规范化使用器械造成，因此应明确长、短不同 Gamma 钉的适用范围及复位方法，尽量规避并发症发生。

Causes of the complications in the patients with femoral peritrochanteric fractures with gamma3 nail

Objective To evaluate the causes of complications of patients with femoral Intertrochanteric fractures after gamma3 nail fixation. Methods A retrospective analysis was conducted to summarize the treatment of intertrochanteric fractures in 186 cases with Gamma3 nail from May 2006 to July 2011. Complications occurred in 24 cases during the operations. 19 were males, 5 females, with the age from 42 to 81, the average age of 69.00?3.27 years. According to AO/OTA classification, 8 cases were type A1, 1 case were type A2.1, 15 cases were type A3. All patients included were acute fractures, while pathological fractures were excluded. Supine position were selected during operation, close reduction were performed in traction bed. Gamma3 nail made by Stryker Company was used to fix fractures through small incisions. Operational times were from 45 to 160 minutes, averaged by 80 min. Blood lose were 300-800 ml in average. No patient need blood transfusion. The procedure from hospitalized to operation is from 3 to 12 days, 6 days in average, discharged from 3 to 16 days after operation. According to the intraoperative and postoperative follow-up evaluation of the X-ray and Harris evaluation criteria, Gamma3 nail complications were summarized in the application. Results Time of surgery in 24 cases were 45-160 min, average 80 min. Blood loss were 300-800 ml, average 600 ml, walking time 35-106 d. Harris evaluation were 75-91 point, average 81 point. The anti-spiral nail dropped into inner thigh muscles occurred in 1 case, causing defects of femoral lateral wall in 3 cases. Splitting fractures occurred in the proximal femoral shaft during the operations in 5 cases, poor fracture reduction during closed reduction in 6 cases. Fracture site were shifted lately postoperative in 5 cases, lag screw cut-out in 3cases and refracture in the site of distal femoral interlocking nail in 1 case. Conclusion Higher incidence of complications were occurred in some special types of AO classification when using close reduction and short Gamma3 nail. The reduction method, wrong indication selection and unreasonable application of equipment may result in the occurence of complications. We, therefore, should use long or short Gamma nail according to their respective induction method and scope of its application, aiming to avoid complications.