難復(fù)位性股骨頸骨折的概念提出與治療李智勇張奇陳偉劉月駒許斌張英澤[摘要]目的提出難復(fù)位性股骨頸骨折的概念，并探討其分型與治療方法。方法對(duì)2006年1月至2008年12月收治的519例移位型股骨頸骨折患者進(jìn)行前瞻性研究，男241例，女278例；年齡21?66歲，平均54.9歲；左側(cè)295例，右側(cè)224例。所有患者首先嘗試牽引閉合復(fù)位，若經(jīng)3次整復(fù)骨折不能達(dá)到理想復(fù)位效果，則認(rèn)為屬于難復(fù)位性股骨頸骨折，改用股骨頭干三維互動(dòng)復(fù)位技術(shù)復(fù)位，并采用3枚空心釘固定。分析難復(fù)位性股骨頸骨折的特點(diǎn)并對(duì)其進(jìn)行分型，評(píng)價(jià)股骨頭干三維互動(dòng)復(fù)位技術(shù)的臨床療效。結(jié)果共有31例(6.0%)難復(fù)位性股骨頸骨折，男20例，女11例；年齡21?58歲，平均39.6歲；均為GardenW型骨折。均采用股骨頭干三維互動(dòng)復(fù)位技術(shù)復(fù)位成功，28例骨折復(fù)位質(zhì)量^Garden指數(shù)I級(jí)，3例達(dá)Garden指數(shù)II級(jí)。根據(jù)X線片及CT影像學(xué)特點(diǎn)，難復(fù)位性股骨頸骨折可分為3型：1型5例(16.1%)：骨折線為斜形，近端骨折片呈“鷹嘴”狀嵌插入骨折遠(yuǎn)端；II型17例(54.8%)：骨折線不規(guī)則，骨折遠(yuǎn)端外旋并嵌插入近端；III型9例(29.0%)：骨折端完全移位，股骨頭和股骨干之間有分離，股骨頭成漂浮狀態(tài)，旋轉(zhuǎn)移位較大。29例患者術(shù)后獲2?4年(平均3.3年)隨訪，骨折均獲骨性愈合，愈合時(shí)間為16?24周(平均20.1周)。3例發(fā)生股骨頭壞死，其中II型l例，I型2例。結(jié)論難復(fù)位性股骨頸骨折可分為3型，采用股骨頭干三維互動(dòng)復(fù)位技術(shù)復(fù)位、3枚空心釘固定可獲得較好的臨床療效。股骨頸骨折；分型；復(fù)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石家莊，河北醫(yī)科大學(xué)第三醫(yī)院骨科研究所-1021"?1022"@@[1]李欣，陳仲，楊洪昌.股骨頸骨折閉合復(fù)位的實(shí)際效果分析.中華創(chuàng)傷骨科雜志，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]張英澤，張奇，李寶俊，等.股骨頭干互動(dòng)三維閉合復(fù)位技術(shù)治療難復(fù)型股骨頸骨折.河北醫(yī)科大學(xué)學(xué)報(bào)，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]劉粵，張長(zhǎng)青，孟煒.閉合復(fù)位空心釘治療中老年股骨頸骨折后股骨頭壞死的多元相關(guān)研究.中華創(chuàng)傷骨科雜志，2006,8：617-621.@@[10]危杰，毛玉江，賈正中.中空加壓螺絲釘治療新鮮股骨頸骨折212例.中華創(chuàng)傷雜志，2000，16:142-144.@@[11]BhandariM,TornettaP3rd,HansonB,etal.Optimalinternalfixationforfemoralneckfractures:multiplescrewsorslidinghipscrews?JOrthopTra