颈基底型股骨转子间骨折楔效应的影像学研究及治疗分析

doi:10.3877/cma.j.issn.2096-0263.2021.05.004

目的

探讨股骨近端防旋髓内钉（PFNA）治疗颈基底型股骨转子间骨折时楔效应的影像学特点及处理措施。

方法

回顾性分析了我院2013年至2018年手术治疗的386例股骨转子间骨折病例，选取采用PFNA治疗的颈基底型股骨转子间骨折病例。依据术后髋关节影像学资料，统计出现楔效应的发生率，测量患者双侧颈干角和股骨头中心到股骨外侧皮质的距离。该组病例中出现楔效应的患髋作为试验组，健髋作为自身对照组，分析楔效应组骨折影像学特点和对PFNA固定复位质量的影响。

结果

共有39例PFNA治疗的颈基底型股骨转子间骨折病例，男13例，女26例，平均年龄（72±5）岁。其中有21例术后出现楔效应而纳入研究，男10例，女11例，平均年龄（74±6）岁。术后影像测量发现，楔效应组股骨颈干角平均为（129.4±3.7）°，小于自身对照组（P<0.05）；楔效应组股骨头到股骨外侧皮质距离平均为（63.2±6.8）mm，高于自身对照组（P<0.05）；楔效应组后外侧骨折块的解剖影像学特点可分为4个亚型。术后随访发现，楔效应组患者治疗1年后的Harris评分明显低于未发生楔效应的PFNA治疗的颈基底型股骨转子间骨折组（P<0.05）。

结论

揭示了PFNA治疗颈基底型股骨转子间骨折时存在的楔效应的影像学特点及形成原因，正确认识楔效应有助于提高髓内固定转子间骨折的复位质量，减少内置物相关并发症。

关键词: 髓内钉, 内固定, 髋骨折

Objective

To investigate the imaging characteristics and treatment of the wedge effect of basicervical intertrochanteric fracture with proximal femoral nail anti-rotation (PFNA).

Methods

In this study, 386 cases of intertrochanteric fracture treated by surgery from 2013 to 2018 were analyzed retrospectively, including 39 cases of basicervical intertrochanteric fracture treated by PFNA. According to the imaging data of the hip joint after surgery, the wedge effect was seen in some cases. Distances from the bilateral neck-shaft angle and the femoral head to the lateral femoral cortex were measured, respectively. The affected side was treated as the wedge effect group and the healthy side was seen as the control group. Then the imaging characteristics of fractures in the wedge effect group and the efficacy of PFNA were analyzed.

Results

There were 39 cases (13 males and 26 females) of basicervical intertrochanteric fracture treated with PFNA, with an average age of (72±5). The wedge effect was found in 21 cases, including 10 males and 11 females, with an average age of (74±6). The average femoral neck-shaft angle in the wedge effect group was (129.4±3.7)°, which was significantly smaller than that in the control group (P<0.05). The average distance from the femoral head to the lateral cortex in the wedge effect group was (63.2±6.8) mm, which was also significantly longer than that in the control group (P<0.05). The features of radiographic anatomy for posterior-lateral fractures in the wedge effect group can be divided into 4 subtypes. One year after surgery, the Harris Hip Score in the wedge effect group was significantly less than that in the PFNA group without wedge effect (P<0.05).

Conclusion

The imaging characteristics and the cause of wedge effect in the treatment of basicervical intertrochanteric fracture with PFNA are identified. Developed a better understanding of the wedge effect, that will help to improve the restoration of intertrochanteric fractures with intramedullary fixation and reduce the complications associated with implants.

Key words: Intramedullary nailing, Internal fracture fixation, Hip fractures

图1~3 女，65岁，颈基底型股骨转子间骨折。图1~2　PFNA术后髋关节正位片显示楔效应；图3　股骨转子间骨折楔效应影像学测量方法，线段B代表从股骨头的中心点（C）到股骨干外侧（A）的距离

图4~11 颈基底型股骨转子间骨折后外侧骨折块（PLF）的解剖影像学特点分型。图4~5 I型指头颈部骨块和股骨干骨骨块伴有体积较小的PLF；图6~7 Ⅱ型指中等大小PLF合并头颈部骨块和股骨干骨块，此型次要骨折线更加居中，位于完整的小转子外侧缘；图8~9 Ⅲ型指PLF与小转子相连共同构成"香蕉"样骨块；图10~11 Ⅳ型指小转子出现骨折时，出现了4个骨折块，即头颈部骨折块、股骨干骨折块，PLF和小转子骨折块

表1 股骨转子间骨折楔效应影像学特点（±s）

组别	颈干角（°）	股骨头中心到股骨外侧皮质的距离（mm）
楔效应组	129±4	63±7
自身对照组	136±8	56±8
t值	3.477	3.076
P值	0.008	0.026

表1 股骨转子间骨折楔效应影像学特点（±s）

组别	颈干角（°）	股骨头中心到股骨外侧皮质的距离（mm）
楔效应组	129±4	63±7
自身对照组	136±8	56±8
t值	3.477	3.076
P值	0.008	0.026

图17 可避免钉-骨撞击时发生近端骨折段的旋转，还可以在复位骨折后预先紧贴前方皮质深部置入一枚3.5 mm克氏针稳定骨折断端，在扩髓时将髓腔锉压向内侧挤压充分磨削头颈骨折段外上方的皮质，避免插入PFNA主钉时发生钉-骨撞击产生楔效应

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Radiological and therapeutic study of the wedge effect of basicervical femoral trochanter fractures

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Radiological and therapeutic study of the wedge effect of basicervical femoral trochanter fractures