股骨转子间骨折髓内钉固定术后稳定性X线三柱评分标准的提出及其临床应用

目的提出股骨转子间骨折髓内钉固定术后稳定性的X线三柱评分标准,并探讨其临床应用价值。方法回顾性分析2015年1月至2019年6月期间山东省临沂市人民医院骨科采用股骨近端防旋髓内钉固定治疗的378例股骨转子间骨折患者资料。男161例,女217例;年龄为60~97岁,平均72.5岁;骨折AO分型:31-A1型109例,31-A2型188例,31-A3型81例。内固定术后即刻行髋关节正、侧位X线片检查,稳定性评估采用自行制定的三柱评分标准:内侧柱4分,中间柱2分,外侧柱2分;单柱满分为柱稳定,三柱均稳定为优,二柱稳定为良,一柱稳定为可,三柱均不稳定为差。并根据评定结果采取相应的康复训练:优者早期完全负重,良者早期部分负重,可或差者早期禁止负重。记录患者的骨折愈合时间和内固定失效率等,并计算内固定失效与术后X线三柱评分的相关性。结果378例患者术后获6~24个月(平均10.4个月)随访。365例患者骨折获愈合,愈合时间平均为4.3个月(3~7个月);内固定失效13例,失效率为3.4%(13/378)。术后X线三柱评分标准评定为优的129例患者无一例失效;193例评定为良的患者中,4例失效;56例评定为可的患者中,9例失效。内固定失效与术后X线三柱评分密切相关(r=-0.986,P=0.006),与柱稳定密切相关(r=-1.000,P=0.033)。结论股骨转子间骨折髓内钉固定术后X线三柱评分标准能够准确反映骨折的稳定性,可以指导患者进行康复锻炼及判断预后。

Three-column scoring system for postoperative X-ray stability of intertrochanteric fracture after intramedullary nailing

Objective To evaluate the clinical significance of our self-designed three-column scoring system for postoperative X-ray stability of intertrochanteric fracture after intramedullary nailing.Methods A retrospective study was conducted of the 378 patients with intertrochanteric fracture who had been treated between January 2015 and June 2019 at Department of Orthopaedics,Linyi People's Hospital by internal fixation with proximal femoral nail antirotation(PFNA).They were 161 males and 217 females,aged from 60 to 97 years(average,72.5 years).By the AO classification,there were 109 cases of type 31-A1,188 cases of type 31-A2 and 81 cases of type 31-A3.Anteroposterior and lateral X-ray examinations of the hip were performed immediately after internal fixation to evaluate the fracture stability using our self-designed three-column scoring system by which the medial column is given 4 points,middle column 2 points and lateral column 2 points.A single column scoring full points is rated as stable,3-column stability as excellent,2-column stability as good,one-column stability as fair,and 3-column unstability as poor.Rehabilitation programs were carried out according to the results of stability evaluation:full weight bearing at an early stage was indicated for excellent patients,partial weight bearing at an early stage for good patients and weight bearing at an early stage contraindicated for fair or poor patients.Fracture union time and failure of internal fixation were recorded.The relationship between internal fixation failure and our three-column scoring system was calculated.Results The 378 patients were followed up for 6 to 24 months(mean,10.4 months).Of them,365 obtained fracture union after an average time of 4.3 months(from 3 to 7 months).Internal fixation failure occurred in 13 patients,giving a failure rate of 3.4%(13/378).Of the 129 excellent patients by our three-column scoring system for post-operative X-ray stability of intertrochanteric fracture,none failed in internal fixation;of the 193 good patients,4 failed;of the 56 fair patients,9 failed.Internal fixation failure was closely related to our three-column scoring system for postoperative X-ray stability of intertrochanteric fracture(r=-0.986,P=0.006),as well as to the column stability(r=-1.000,P=0.033).Conclusion Our self-designed three-column scoring system for postoperative X-ray stability of intertrochanteric fracture after intramedullary nailing can accurately reflect the fracture stability so that it can be used to guide rehabilitation programs for the patients and judge their prognosis.