【作者】 张军；

【导师】 尹宗生；

【作者基本信息】 安徽医科大学 ， 外科学， 2008， 硕士

【摘要】 目的探讨股骨转子间骨折（intertrochanteric femur fractures,IFF）采用动力髋螺钉（dynamic hip screw,DHS）内固定,术后发生股骨颈干角（angle ofinclination,AI）角度的改变与术前骨折分型、术中相关处理及术后骨量丢失的相关性,对此进行综合性随访分析,得到患侧AI角度丢失的可能原因,并据此提出预防或减少其发生的干预措施,为临床工作提供一定的参考。方法对我院2004年1月至2005年6月间门、急诊收治的IFF（按Evans分型为其中的Ic型）患者60例,按入院顺序,采用随机数字表将60位患者逐一编号分为A、B、C、D四组,四组均采用DHS内固定治疗。A组不苛意重建股骨近端内侧结构;B组在术中重建内侧结构;C组在A组的基础上加用钙剂和维生素D₃治疗;D组在B组的基础上加用钙剂和维生素D₃治疗。对术后股骨转子区骨密度（bonemineral density,BMD）、AI、骨折愈合时间及术后患肢功能恢复情况作比较分析。结果60例患者术后随访1年,60例全部获得一期临床愈合,平均临床愈合时间为18.2周,其中A组为20.2周,B组为19.3周,C组为17.8周,D组为15.8周,四组比较A、B组无明显差异（P＞0.05）,C组较A、B组愈合时间有所缩短（P＜0.05）,D组较A、B组愈合时间有明显缩短（P＜0.01）,提示C、D组在骨折临床愈合上优于A、B组,D组为最优;四组股骨转子区BMD动态比较结果提示,术后1月四组BMD均较术前有所下降,A、B组BMD较C、D组BMD下降显著（P＜0.05）;术后3月时,四组BMD较术后1月时均有所增加,C、D组术后3月BMD已基本恢复至术前水平,较A、B组BMD增加快;术后6月时,A、B组BMD仍低于术前水平,C、D组BMD已超出术后2天水平,达到或接近正常水平,且术后3-6月期间C、D组BMD较A、B组BMD增加快。术后患肢AI测量结果显示,术后1月时,四组AI均值较术后2天比较均未见明显改变（P＞0.05）;术后3月时,B、D组AI均值与A、C组比较有显著差异（P＜0.01）,结合具体数据说明A、C组AI的改变明显多于B、D组;术后6月时,四组AI均值均较术后3月时无明显改变,患肢AI基本固定。术后髋关节功能按Harris评分,优良率平均为85.0%,其中A组80.0%,B组86.7%,C组80.0%,D组93.3%,总体疗效满意,其中B、D组较A、C组优良率高,D组为最高（P＜0.01）。结论在IFF治疗中,DHS内固定系统具有较可靠的力学稳定性能,应为髓外内固定系统的首选;DHS内固定术后早期股骨转子区骨量丢失严重,可能发生局部骨质疏松;术中重建股骨内侧结构可有效恢复股骨近端的解剖,术后应用钙剂和维生素D₃可明显改善骨骼质量,将两者结合可减少DHS术后AI改变的发生机率,缩短骨折愈合时间,患侧髋关节功能恢复满意。更多还原

【Abstract】 Objective:To discuss the relationship among the postoperative change of the angle of inclination（AI） and preoperative fracture type,the relevant management,postoperative bone loss after treating intertrochanteric femur fractures（IFF） with Dynamic Hip Screw（DHS）.After following up, the possible AIuses of AI loss have been demonstrated,and according to them the intervention measures to prevent or reduce the occurrence have been proposed for clinical reference.Methods:Sixty IFF（Evans type Ic） cases of our hospital from January 2004 to June 2005 were randomized to group A,B,C or D,all of which were treated with DHS.The medial proximate of the femur were not reconstructed in Group A and reconstructed in Group B.On the basis of group A,the calcium and vitamin D₃ were added into the treatment in group C.In group D,the calcium and vitamin D₃ were also used on the basis of group B.The postoperative bone mineral density（BMD）,AI,the healing time and the function of the affected limbs were compared and analyzed.Resluts:Sixty cases of patients were followed up for one year,and the average healing time is 18.2 weeks（group A 20.2 weeks,group B 19.3 weeks, group C 17.8 weeks and group D 15.8 weeks）.There was no significant difference between group A and B（P＞0.05）.The healing time of group C and D were shorter than that of group A and B（group A and B vs.group C P＜0.05;group A and B vs.group D P＜0.01）.It showed that group C and D were better than group A and B,and group D was the best.Determining the BMD of all groups,the values of one month after operation descended, and group A and B were significantly lower than group C and D（P＜0.05）. The BMD of three months after operation have been improved,and group C and D have been almost recovered to the level of pre-operation,faster than group A and B.After six months the BMD of group A and B were still lower than the level of pre-operation,but the BMD of group C and D have reached or got close to the normal level.Compared with group A and B, the BMD of group C and D increased rapidly.The measurements of AI of the affected limbs shown that the average AI of the four groups didn’t change one month after operation（P＞0.05）.After three months,the AI of group A and C changed significantly greater than that of group B and D（P＜0.01）.After 6 months,the AI of all groups were unchanged,and equal to that of three months after operation.Assessing the function of the affected hip according to the Harris score,the average rate of excellent and good results was 85.0%,80.0%in group A,86.7%in group B,80.0%in group C and 93.3%in group D.The total curative effect was satisfied. The rate of excellent and good results of group B and D was higher than that of group A and C,and group D was the best.Conclusion:In treating IFF,DHS is one of the best choices of the extramedullary fixation system because of the reliable mechanical stability properties.After DHS fixation,bone loss in the region trochanterica is serious,and may result in osteoporosis.So reconstructing the medial structure of the femur can be effectively restored the anatomy of the proximal femur,and using the calcium and vitamin D3 can improve bone quality.The combination of these two methods can reduce occurrence of AI changing after operation,shorten the healing time of the fracture,and regain satisfyingly the function of the hip.更多还原