骨科机器人辅助股骨近端外展截骨动力髋螺钉固定治疗中青年股骨颈骨折不愈合的临床疗效分析

目的 探讨骨科机器人辅助下股骨近端外展截骨动力髋螺钉（DHS）固定治疗中青年股骨颈骨折不愈合患者的临床效果。方法 横断面研究。纳入2020年4月—2021年4月北京积水潭医院创伤骨科中青年股骨颈骨折不愈合患者8例。8例均为男性,年龄17~52岁（平均34.1岁）,均采用骨科机器人辅助股骨近端外展截骨DHS固定治疗。患者此次外展截骨DHS固定手术与其初次股骨颈骨折内固定手术间隔时间为4~26个月,平均10.1个月。观察手术时间、出血量及围术期并发症发生情况、患者的骨折愈合情况、Pauwels角及颈干角矫正情况、肢体长度差异及Harris髋关节评分。结果 8例患者均顺利完成手术,手术时间为80~240 min,平均134 min。术中出血量200~750 mL,平均为356 mL。手术切口均Ⅰ期愈合,未见切口及深部感染。本组8例患者术后随访13~23个月,平均18.6个月。末次随访时X线检查均未见明显股骨头缺血性坏死或塌陷。经股骨近端外展截骨DHS固定手术治疗后,8例患者股骨颈骨折不愈合处以及小粗隆截骨部位均达到骨折愈合,愈合时间3~5个月,平均3.7个月。末次随访时,8例患者颈干角和Pauwels角分别由术前的113.13°±4.64°和67.50°±6.19°改善至140.75°±2.38°和40.50°±2.56°,两侧肢体长度差异由术前的（1.21±0.79）cm减少至（0.36±0.18）cm,Harris评分由术前的66.50（65.00,69.50）分提高至97.00（92.75,99.25）分,差异均有统计学意义（t=25.87、17.08、3.35,Z=-2.53,P值均<0.05）。结论 股骨近端外展截骨结合DHS内固定术,通过矫正颈干角降低骨折端剪切力,可以有效治疗中青年患者股骨颈骨折不愈合;骨科机器人导航定位系统的应用有助于手术更精准地实施。

Analysis of the efficacy of valgus intertrochanteric osteotomy with dynamic hip screw fixation assisted by robot navigation for treatment of middle-aged and young patients with femoral neck fracture nonunion

Objective This study aims to investigate the surgical technique and primary clinical outcomes of intertrochanteric valgus osteotomy using a dynamic hip screw assisted by robot navigation for treatment of femoral neck nonunion in middle-aged and young patients. Methods A cross-sectional study was conducted. The clinical data of eight middle-aged and young patients with postoperative nonunion of femoral neck fracture who met the selection criteria in Beijing Jishuitan Hospital from April 2020 and April 2021 were analyzed. The patients were all males and had an average age of 34.1 years (range, 17-52 years). The average duration from the initial osteosynthesis surgery was 10.1 months (range, 4-26 months). They were treated with robot navigation-assisted intertrochanteric valgus osteotomy and fixation with dynamic hip screw. The outcomes analyzed included perioperative general conditions, radiological outcomes in terms of improvement in Pauwels angle, neck-shaft angle, and evidence of radiological union at the nonunion site and osteotomy site. The other outcomes were measurement of limb length discrepancy and functional outcome assessment with Harris score. Results The operation was successfully performed in all patients, and the operation time was 80-240 min, with an average of 134 min. The intraoperative blood loss was 200-750 mL, with an average of 356 mL. All incisions had stage I healing. All patients were followed up 13-23 months, with an average of 18.6 months. Union at the nonunion site and the osteotomy site was achieved in all patients, and the healing time was 3.0-5.0 months, with an average of 3.7 months. X-ray evidence of avascular necrosis of the femoral head and collapse was unavailable. At the last follow-up, the cervical stem angle and Pauwels angle of the patients improved from 113.13°±4.64° and 67.50°±6.19° to 140.75°±2.38° and 40.50°±2.56°, respectively. The difference in the limb length between the two sides decreased from (1.21±0.79) cm to (0.36±0.18) cm, and the Harris score increased from 66.50 (65.00, 69.50) to 97.00 (92.75, 99.25). The differences were statistically significant (t=25.87, 17.08, 3.35, Z=-2.53, all P values <0.05).Conclusion Valgus intertrochanteric osteotomy using a dynamic hip screw is a reliable solution for treatment of ununited femoral neck fractures in middle-aged and young patients with excellent results of reduced shear forces at the fracture and corrected neck-shaft angle. Robot navigation may be feasible for clinical practice.