难复型股骨颈骨折

难复位性股骨颈骨折的概念提出与治疗李智勇张奇陈伟刘月驹许斌张英泽[摘要]目的提出难复位性股骨颈骨折的概念，并探讨其分型与治疗方法。方法对2006年1月至2008年12月收治的519例移位型股骨颈骨折患者进行前瞻性研究，男241例，女278例；年龄21〜66岁，平均54.9岁；左侧295例，右侧224例。所有患者首先尝试牵引闭合复位，若经3次整复骨折不能达到理想复位效果，则认为属于难复位性股骨颈骨折，改用股骨头干三维互动复位技术复位，并采用3枚空心钉固定。分析难复位性股骨颈骨折的特点并对其进行分型，评价股骨头干三维互动复位技术的临床疗效。结果共有31例(6.0%)难复位性股骨颈骨折，男20例，女11例；年龄21〜58岁，平均39.6岁；均为GardenW型骨折。均采用股骨头干三维互动复位技术复位成功，28例骨折复位质量^Garden指数I级，3例达Garden指数II级。根据X线片及CT影像学特点，难复位性股骨颈骨折可分为3型：1型5例(16.1%)：骨折线为斜形，近端骨折片呈“鹰嘴”状嵌插入骨折远端；II型17例(54.8%)：骨折线不规则，骨折远端外旋并嵌插入近端；III型9例(29.0%)：骨折端完全移位，股骨头和股骨干之间有分离，股骨头成漂浮状态，旋转移位较大。29例患者术后获2〜4年(平均3.3年)随访，骨折均获骨性愈合，愈合时间为16〜24周(平均20.1周)。3例发生股骨头坏死，其中II型l例，I型2例。结论难复位性股骨颈骨折可分为3型，采用股骨头干三维互动复位技术复位、3枚空心钉固定可获得较好的临床疗效。股骨颈骨折；分型；复位ClassificationandtreatmentofirreduciblefemoralneckfracturesLIZhi-yongZHANGQiCHENWeiTheInstituteofOrthopaedics,TheThirdAffiliatedHospital,HebeiMedicalUniversity,Shijiazhuang050051,China[Abstract]ObjectiveToexploretheclassificationandtreatmentmethodsoffemoralneckfractureswhicharedifficulttoreduce.MethodsThepresentstudyenrolled519patientswithdisplacedfemoralneckfractureswhohadbeentreatedfromJanuary2006toDecember2008inourinstitute.Theywere241menand278women,withameanageof54.9years(from21to66years).Thelefthipjointwasinvolvedin295casesandtherightin224cases.Ifafracturefailedtoobtainsatisfactoryrepositionafterwetriedclosedreductionfor3times,itwasdefinedasanirreduciblefemoralneckfracturewhichwasnextreducedbyourself-designedtechniquecalled"3-Dinterreactionreduction"beforeitwasfixedby3cannulatedscrews.Theirreduciblefemoralneckfractureswerecharacterizedandtheclinicalefficacyof"3-Dinterreactionreduction"wasevaluated.ResultsInthisgroup,31casesofirreduciblefemoralneckfractureweredefinedandsuccessfullyreducedbythe"3-Dinterreactionreduction"technique.Ofthem,28casesobtainedreductionofGardenGradeIand3casesofGardenGradeII.Theirreduciblefemoralneckfractureswereclassifiedinto3typesaccordingtotheirradiologicalfeatures.IntypeI(5cases,16.I%),thefracturelinewasobliqueandanolecranon-shapedproximalfragmentintrudedintothedistantfractureend.IntypeII(17cases,54.8%),thefracturelinewasirregularandtheoutward-rotateddistantfractureendintrudedintotheproximalfractureend.IntypeIII(9cases,29.0%),thefractureendswerecompletelydisplacedandthefloatingfemoralheadwasdisconnectedwiththeshaft.Ofthepatientswithirreduciblefemoralneckfracture,29werefollowedupfor2to4years(average,3.3years).Boneunionwasachievedinallthe29casesafteranaverageof20.1weeks(from16to24weeks).Ofthem,3casesdevelopednecrosisoffemoralhead,oneoftypeIIand2oftypeIIIbyourclassification.ConclusionsIrreduciblefemoralneckfracturescanbeclassifiedinto3types."3-Dinterreactionreduction"andfixationwith3cannulatedscrewscanbeafinestrategytotreatthem.Femoralneckfractures;Classification;Reduction10.3760/cma.j.issn.1671-7600.2011.11.005050051石家庄，河北医科大学第三医院骨科研究所-1021"•1022"@@[1]李欣，陈仲，杨洪昌.股骨颈骨折闭合复位的实际效果分析.中华创伤骨科杂志，2011,13:25-28.@@[2]ParkerMJ,RaghavanR,GurusamyK.Incidenceoffracture-healingcomplicationsafterfemoralneckfractures.ClinOrthopRelatRes,2007(458):175-179.@@[3]GardenRS.Malreductionandavascularnecrosisinsubcapitalfracturesofthefemur.JBoneJointSurgBr,1971,53:183-197.@@[4]DavidovitchRI,JordanCJ,EgolKA,etal.Challengesinthetreatmentoffemoralneckfracturesinthenonelderlyadult.JTrauma,2010,68:236-242.@@[5]BarnesB,DunovanK.Functionaloutcomesafterhipfracture.PhysTher,1987,67:1675-1679.@@[6]张英泽，张奇，李宝俊，等.股骨头干互动三维闭合复位技术治疗难复型股骨颈骨折.河北医科大学学报，2009,30:70-71，插5.@@[7]SchepNW,HeintjesRJ,MartensEP,etal.Retrospectiveanalysisoffactorsinfluencingtheoperativeresultafterpercutaneousosteosynthesisofintracapsularfemoralneckfractures.Injury,2004,35:1003-1009.@@[8]RehnbergL,OlerudC.Thestabilityoffemoralneckfracturesanditsinfluenceonhealing.JBoneJointSurgBr,1989,71:173-177.@@[9]刘粤，张长青，孟炜.闭合复位空心钉治疗中老年股骨颈骨折后股骨头坏死的多元相关研究.中华创伤骨科杂志，2006,8：617-621.@@[10]危杰，毛玉江，贾正中.中空加压螺丝钉治疗新鲜股骨颈骨折212例.中华创伤杂志，2000，16:142-144.@@[11]BhandariM,TornettaP3rd,HansonB,etal.Optimalinternalfixationforfemoralneckfractures:multiplescrewsorslidinghipscrews?JOrthopTra