【关键词】  ,髋骨折

    Complications and highrisk factors of internal fixation in elderly patients with  intertrochanteric femoral fracture

　　【Abstract】 AIM: To compare the postoperative functional restoration and complication incidence of different therapies in elderly patients with  intertrochanteric femoral fracture and to predict the highrisk factors of the operation. METHODS:  One hundred and sixtyeight cases of elderly patients with  intertrochanteric femoral fractures, who were treated from March, 1995 to June, 2001 were enrolled in the study. Of all the cases, 136 cases received internal fixation therapy and 83 cases were followed up for an average of 37.8 months. According to operative approach, types of fractures and age, the patients were divided into several  groups and the therapeutic effects and complications were compared. By calculating  composite exponent W of operation risks and mean ages of patients with complications (especially at early stage after operation), the prediction of the operation risk was made. RESULTS:  Of the 83 cases, 67 (80.7%) had good functional restoration. Of the 10 (12.0%) cases with complications after operation, 3 cases suffered complications at early stage after operation. The duration  and bleeding volume of operation in dynamic hip screw (DHS) internal fixation group were more than those in the other groups (P＜0.05). Hospitalization time in intramedullary pin internal fixation group was shorter than that in the other groups. Patients in the group of ages above 70 years had a bad functional restoration. Complication incidence between every two groups had no statistical significance. The average age in the 10 cases with complications was 82  years old. The mean age of 3 cases with early complications was 92 years old, whose exponent W was 6, 7 and 8 respectively. CONCLUSION:  Suitable internal fixation materials should be chosen in the therapy of elderly patients with  intertrochanteric femoral fractures. DHS, multipin, especially intramedullary pin, can satisfy the needs of fractures of various types for all ages. Age may be a  high risk factor in the therapy of elderly patients with  intertrochanteric femoral fracture.

　　【Keywords】 hip fractures; aged; internal fixation; postoperative complication; risk factors

　　【摘要】 目的： 比较不同内固定方法治疗老年股骨粗隆间骨折的疗效,并发症发生原因并预测手术危险的高危因素. 方法： 199503/200106收治60岁以上老年股骨粗隆间骨折患者168例. 行手术内固定治疗136例，83例获得12~75（平均37.8） mo的随访，通过病历分析获得年龄、性别、骨折类型、手术方式、手术时间、住院天数、术中出血量、是否输血以及输血量、伤前生活自理能力、伤前身体状况、术前血红蛋白（Hb）水平、功能恢复及并发症发生情况，分别按手术方式、骨折类型以及年龄分组比较其疗效和并发症发生情况，通过计算发生并发症（尤其是术后早期并发症）患者的平均年龄和手术危险性预测综合指数W值，预测手术危险的高危因素. 结果： 本组83例，术后功能恢复优良67例，可9例，差7例；优良率80.7%. 术后发生并发症10例，平均年龄为82岁，发生率12.0%，术后早期诱发原有合并症3例,平均年龄为92岁.  动力髋内固定组的手术时间比其他两组明显延长（P＜0.05）；术中出血以及输血量比其他两组明显增多；髓内钉内固定组住院天数比其他两组明显缩短；年龄大于70岁组功能恢复较差；以上比较均有统计学意义. 各组并发症发生比较无显著性差异. 早期诱发原有合并症的3例患者，手术危险性预测综合指数W值分别为6, 7和8.  结论：  老年股骨粗隆间骨折应合理选择内固定方式，DHS、髓内钉、多枚钉可满足各种不同类型和年龄的骨折，尤其是髓内钉适用范围较广；年龄可能是老年股骨粗隆间骨折手术危险的高危因素.

　　【关键词】  髋骨折；老年人；内固定；手术后并发症；危险因素

　　0引言

　　股骨粗隆间骨折是老年人常见的骨折之一，占全身骨折的1.4%［1，2］，随着社会的老龄化，其发病数量逐渐增加，信捷职称论文写作发表网，手术治疗已成为国内外公认的首选治疗方法［3］. 如何选择内固定方式及预测手术危险，是临床医生所关心的问题. 我们对60岁以上老年股骨粗隆间骨折患者采用手术内固定治疗, 观察了其疗效和并发症发生情况. 并对手术危险性进行了预测.

　　1对象和方法

　　1.1对象

　　199503/200106共收治60岁以上老年股骨粗隆间骨折患者168例，所有病例均来自第四军医大学西京医院. 行手术内固定治疗136例，其中83例获得12~75（平均37.8） mo的随访. 本组83(男40，女43)例；左侧45例，右侧38例；年龄60~96（平均74）岁. 致伤原因均为平地摔伤,非病理性骨折. 骨折类型稳定型33例，不稳定型50例. 伤前身体状况相对健康47例，健康状况较差 36例. 手术方式动力髋组29例，髓内钉组25例，多枚钉组29例.

　　1.2方法

　　采用回顾性研究，通过复习病例及随访获得以下资料： 年龄、性别、骨折类型、手术方式、手术时间、住院天数、术中出血量、是否输血以及输血量、伤前生活自理能力、伤前身体状况和功能恢复及并发症发生情况，然后分别按手术方式、骨折类型以及年龄分组比较其疗效和并发症发生例数. 通过计算发生并发症（尤其是术后早期并发症）患者的平均年龄和综合指数W值，对手术危险性进行预测. 其中骨折类型参照EvansJenson 以及AO分类法［4，5］分为稳定型和不稳定型. 手术方式分别采用动力髋、髓内钉和多枚钉内固定，髓内钉包括股骨近端交锁髓内钉（PFN）和改良型Gamma钉；多枚钉包括多枚斯氏钉和空心螺纹钉. 伤前身体状况分级根据美国麻醉学会的疾病严重度分级法［6］分为相对健康和健康状况较差两组. 功能恢复评估方法我们采用李强等［7］报道的分项百分制髋评分法，分为优良（优或良）、可和差. 术后并发症主要包括：术后诱发心脑血管、肺、肾等系统疾病；髋部疼痛；髋内翻畸形；内固定弯曲、断裂；钉头切出股骨头；感染；继发骨折；肢体短缩以及骨不连等. 伤前生活自理能力分级及手术危险性预测综合指数W值的计算根据王福权等［8］报道的分级及计算方法.

　　统计学处理： 所有数据采用SPSS10.0统计软件，不同手术方式组，不同骨折类型及年龄组的功能恢复状况比较用非参数秩和检验，性别、伤前身体状况、骨折类型、输血例数和并发症发生组间比较采用χ2检验；不同手术方式组的年龄、手术时间、住院天数、术中出血和输血量比较采用多组均数比较的方差分析及LSDt检验，方差不齐时，用非参数秩和检验. 并发症发生率比较采用χ2检验.

　　2结果

　　本组83例均行手术内固定治疗，术后随访时间12~75（平均37.8） mo. 术后功能恢复优良67例，可9例，差7例；优良率80.7%. 术后发生并发症10例，发生率12.0%. 其中髋内翻畸形3例，未做处理；术后诱发原有合并症3例，给予对症处理后好转；术后发生泌尿系感染1例，经治疗后好转；术后内固定断裂+再骨折+髋内