髓外与髓内固定治疗高龄稳定股骨粗隆间骨折围手术期隐性失血的对比研究

目的探讨不同内固定方式对高龄稳定股骨粗隆间骨折围手术期隐性失血的影响。方法分析2010年1月至2015年12月应用髓外固定(dynamic hip screw,DHS)与髓内固定(proximal femoral nail anti-rotation,PFNA)治疗128例股骨粗隆间骨折患者资料,年龄80～95岁,髓外组56例,髓内组72例。比较不同内固定方式对围手术期隐性失血的影响,比较手术时间、骨折愈合时间、髋关节功能评分(FRS)及术后并发症。结果 128例患者随访12～36个月,平均18.2个月。髓外组手术时间(77.8±8.4)min和显性失血量(154.4±45.3) m L大于髓内组(70.5±11.8) min和(123.2±32.1) mL(P0.001);髓外组总失血量(747.3±134.3) mL和隐性失血量(592.9±134.3) mL小于髓内组(906.8±143.6) mL和(783.6±141.3) m L(P0.001)。髓外组术后第1、3、5 d血红蛋白和红细胞压积均高于髓内组(P0.05)。髓外组部分负重时间(9.59±2.04)周、完全负重时间(13.43±1.55)周大于髓内组(8.11±1.39)周和(11.99±1.48)周(P0.001);髓外组骨折愈合时间(14.30±1.53)周、FRS评分为(76.32±8.56)分,髓内组为(13.97±1.73)周和(76.75±8.96)分(P0.05)。髓外组出现8.9%肺部感染,3.6%因心、肺、感染等并发症而死亡,1.8%下肢深静脉血栓,5.4%螺钉切割,7.1%髋内翻;髓内组分别为12.5%、5.6%、1.4%、2.8%、4.2%(P0.05)。结论在治疗高龄稳定股骨粗隆间骨折时,髓外与髓内固定均可获得满意的临床结果,但髓外固定在减少围手术期隐性失血上有优势,若采用髓内固定应尽量避免远端扩髓,术后3 d应严密监测血红蛋白和红细胞压积变化,准确评估隐性失血情况,及时纠正贫血状态,减少高龄患者术后严重贫血带来的并发症。

Study of perioperative hidden blood loss of stable intertrochanteric fractures in the elderly treated with extramedullary and intramedullary fixation

Objective To investigate perioperative hidden blood loss of stable intertrochanteric fractures in the elderly treated with extramedullary and intramedullary fixation. Methods From January 2010 to December 2015, 128 patients with intertrochanteric fractures were treated with extramedullary fixation (DHS) and intramedullary fixation (PFNA). There were 56 cases in the extramedullary and 72 cases in the intramedullary, aged from 80 to 95 years. The perioperative hidden blood loss of stable intertrochanteric fractures in the elderly treated with extramedullary and intramedullary fixation were compared. The operative time, fracture healing time, functional recovery scale (FRS) and complications were also compared. Results The operation time and observed blood loss were (77.8±8.4) min and (154.4±45.3) mL in the extramedullary, and that of the intramedullary were (70.5±11.8) min and (123.2± 32.1) mL; the total blood loss and hidden blood loss were (747.3±134.3) and (592.9 ±134.3) mL in the extramedullary, and that of the intramedullary were (906.8±143.6) and (783.6±141.3) mL (P<0.001). Hemoglobin and hematocrit in the extramedullary were higher than those in the intramedullary group on the 1st, 3rd and 5th day postoperatively (P<0.05). The partial and complete time of weight-bearing in the extramedullary were (9.59±2.04) and (13.43 ±1.55) weeks , and that of the intramedullary were (8.11±1.39) and (11.99±1.48) weeks (P<0.001). The time of fracture healing and FRS score in the extramedullary were (14.30 ±1.53) weeks and (76.32 ±8.56) points, and that of the intramedullary were (13.97±1.73) weeks and (76.75±8.96) points (P>0.05). In the extramedullary, 8.9% of pulmonary infections occurred, 3.6% died of complications such as heart, lung diseases and infection, 1.8% of deep venous thrombosis of lower extremities, 5.4% of screw cutting and 7.1% of coxa vara occurred; while in the intramedullary group, they were 12.5%, 5.6%, 1.4%, 2.8% and 4.2% respectively (P>0.05). Conclusion Satisfactory clinical outcomes could be achieved in both extramedullary and intramedullary fixation in the treatment of stable intertrochanteric fractures in the elderly, but extramedullary fixation is more advantageous in reducing perioperative hidden blood loss. If intramedullary fixation is used, reaming should be avoided as far as possible. Changes of hemoglobin and hematocrit should be strictly monitored three days postoperatively, hidden blood loss should be accurately assessed, anemia should be corrected in time, in order to reduce complications caused by severe anemia in the elderly.