应用动力髋螺钉、Gamma钉与股骨近端髓内钉治疗高龄患者股骨转子间

目的：对比观察动力髋螺钉、Gamma钉与股骨近端髓内钉治疗高龄患者股骨转子间骨折的生物相容性及临床疗效。 方法：选择2006-06/2008-03解放军第二军医大学长海医院骨科收治的股骨转子间骨折患者95例，男26例，女69例，年龄70~88岁。根据Evans分型系统，95例患者随机分为3组，动力髋螺钉内固定治疗组(n=30)，Gamma钉内固定治疗组(n=30)和股骨近端髓内钉内固定治疗组(n=35)，3组患者分别采用动力髋螺钉、Gamma钉和股骨近端髓内钉进行治疗。记录术中、术后出血量，手术时间，住院时间；观察骨折愈合情况、术后并发症及材料与宿主的组织相容性；术后9个月采用Harris评分标准对患髋进行评估。 结果：3组患者均获得随访。①Gamma钉内固定治疗组和股骨近端髓内钉内固定治疗组术中出血量少于动力髋螺钉内固定治疗组(P < 0.05)；各组间手术时间两两相比差异无显著性意义(P > 0.05)，但统计结果显示，动力髋螺钉内固定治疗组相对最长，股骨近端髓内钉内固定治疗组相对最短。3组患者住院时间差异无显著性意义(P > 0.05)。②动力髋螺钉内固定治疗组并发髋内翻1例，伤肢短缩1例。Gamma钉内固定治疗组术后股骨干骨折1例，无伤肢短缩等并发症。股骨近端髓内钉内固定治疗组伤口全部Ⅰ期愈合，无并发症发生。Gamma钉内固定治疗组中2例切开组织液化，2例切开表浅感染，无切开深部感染；动力髋螺钉组中3例出现切开组织液化，2例切开表浅感染，1例切开深部感染。均未出现内固定物切出股骨头或断裂等内固定失效现象。③髋关节Harris功能评分显示，动力髋螺钉内固定治疗组优23例，良4例，可3例，优良率90.0%。Gamma钉内固定治疗组优24例，良4例，可2例，优良率93.3%。股骨近端髓内钉内固定治疗组优32例，良2例，可1例，优良率97.1%。3组间差异无显著性意义(P > 0.05)。 结论：应用动力髋螺钉、Gamma钉和股骨近端髓内钉治疗老年股骨转子间骨折，在疗效方面无明显差异。Gamma钉和股骨近端髓内钉可缩短手术时间、减少术中出血量及术后并发症。对于稳定性骨折，3种内固定装置均可选择，而动力髋螺钉具有价格便宜的优点；对于不稳定性骨折，股骨近端髓内钉、Gamma钉由于生物力学上的优势，都是不错的选择。

Dynamic hip screw, Gamma nail and proximal femoral nail in treating intertrochanteric fractures in the elderly: A prospective randomized biocompatibility study of 95 patients

OBJECTIVE: To evaluate and compare the biocompatibility and curative effect of dynamic hip screw (DHS), Gamma nail (GN) and proximal femoral nail (PFN) in the treatment of intertrochanteric fractures in the elderly. METHODS: A total of 95 cases of intertrochanteric fracture, 26 males, 69 females, aged 70-88 years, were selected from Department of Orthopaedics, Changhai Hospital of Second Military Medical University of Chinese PLA between June 2006 and March 2008. According to Evans classification system, the patients were randomly divided into 3 groups: DHS (n=30), GN (n=30) and PFN groups (n=35). Postoperative bleeding, hospitalization, surgery duration, postoperative complications, fracture healing, and biocompatibility were recorded. The hip evaluation was evaluated 9 months after surgery using Harris scores. RESULTS: All patients were followed-up. (1)The blood loss o f GN and PFN groups was significantly less than DHS group (P < 0.05); no significant difference was found between any two groups (P > 0.05), but DHS group was the longest while PFN was the shortest. In addition, there was no significant difference in length of stay among groups (P > 0.05). (2) One case of DHS group developed coax vara, and one developed injured extremity crispation. In GN group, one case had fracture of shaft of femur. No complications were found in PFN group, all fracture healed at the primary stage. Wound epidermal infection was found in 4 cases treated with Gamma nail (2 wound liquification, 2 superficial infection), and 6 case treated with dynamic hip screw, including 3 wound liquification, 2 superficial infection and 1 deep infection. Fixation failure such as fixator cutting-out of femoral head or breakage was not found in any case. (3) Harris scores for hip joint showed that there were 23 cases excellent, 4 good, and 3 fine in DHS group, with excellent and good rate of 90.0%; 24 excellent, 4 good, and 2 fine in GN group, with excellent and good rate of 93.3%; 32 excellent, 2 good, and 1 fine in PFN group, with excellent and good rate of 97.1%. There were no significant differences (P > 0.05). CONCLUSION: Application of DHS, GN and PFN in treatment of intertrochanteric fractures in elderly exhibits no significant difference in efficacy. Gamma nail and PFN can shorten the operation time to reduce the amount of blood loss and postoperative complications. For the stable fracture, all three fixtures can be used, and the DHS is the cheaper; for instable fracture, PFN and GN due to the biomechanical advantages are good choices.