摘要目的:探讨髋部骨折内固定治疗失败的原因，并分析行人工髋关节置换术的临床疗效。方法:回顾性研究。纳入2011年3月—2018年7月哈尔滨医科大学附属第一医院收治的股骨颈及股骨粗隆间骨折内固定失败患者45例，其中男16例、女29例，年龄35～80岁，平均47.5岁；股骨颈骨折33例，股骨粗隆间骨折12例。股骨颈骨折依据Garden分型标准，Ⅱ型6例、Ⅲ型20例、Ⅳ型7例；股骨粗隆间骨折依据改良Evan分型标准，Ⅲ型1例、Ⅳ型4例、Ⅴ型7例。45例患者中，采用全髋关节置换术35例，人工股骨头置换术10例。观察患者手术时间、术中出血量、骨折愈合时间及术后并发症发生情况；末次随访时采用Harris评分评定髋关节功能及疗效，并与术前Harris评分进行对比分析；同时分析内固定失败原因。结果:所有患者均顺利完成手术，术中假体周围骨折1例，给予钢丝捆扎固定。手术时间50～150 min，平均72 min。术中失血量150～600 mL，平均260 mL。术后下肢深静脉血栓形成5例、浅表感染4例，予相应处理后治愈，肢体不等长(超过2 cm)2例，未给予特殊处理。45例患者均获随访，随访时间5～30个月，平均10.5个月。随访期间无感染、假体周围骨折、关节脱位、假体松动等并发症发生。假体周围骨折于术后3个月愈合。末次随访时Harris评分82～94(88±6)分，明显高于术前的32～36(34±2)分，差异有统计学意义( t＝49.258, P<0.01)。采用Harris评分评定疗效，优16例、良24例、可4例、差1例，优良率88.9%(40/45)。初次手术失败原因：内固定手术技术原因27例，其中螺钉置入位置或长度不理想12例、内固定物选择不当8例、骨折复位不良10例；股骨颈骨折手术时间>伤后72 h 18例，其中>1周9例；术后负重时间过早(<12周)15例；术后再次跌倒或碰撞伤6例；原因不明7例。 结论:导致髋部骨折内固定失败的原因包括医源性因素与患者源性因素。对于髋部骨折内固定术失败的患者，依据患者年龄及全身状况，采用全髋关节置换术或人工股骨头置换术治疗临床效果良好。

abstractsObjective:To explore the causes of failure of internal fixation of hip fracture and analyze the effect of hip replacement.Methods:From March 2011 to July 2018, the clinical data of 45 patients with failed internal fixation of hip fracture in the First Affiliated Hospital of Harbin Medical University were collected, including 16 males and 29 females, with an average age of 47.5 years (35-80 years). There were 33 femoral neck fractures and 12 intertrochanteric femoral fractures. According to Garden classification, femoral neck fractures were divided into type Ⅱ of 6 cases, type Ⅲ of 20 cases, and type Ⅳ of 7 cases; according to modified Evans classification, intertrochanteric femoral fractures were divided into type Ⅲ of 1 case, type Ⅳ of 4 cases, and type V of 7 cases. The causes of failure were analyzed and summarized. Total hip arthroplasty was performed in 35 cases and hemiarthroplasty in 10 cases. The operation time, intraoperative blood loss and postoperative complications were observed. Harris hip score was used to compare the improvement of hip joint function before and after operation.Results:All patients were successfully operated. The operation time was 50 to 150 minutes (average 72 minutes). Intraoperative blood loss was 150 to 600 mL (average 260 mL). One intraoperative periprosthetic fracture was fixed with steel wire. Postoperatively, 5 cases of deep vein thrombosis and 4 cases of superficial infection were healed after treatment, 2 cases of length discrepancy (more than 2 cm) were found and without special treatment. Forty-five patients were followed up for 5-30 months (average 10.5 months). There were no complications such as infection, periprosthetic fracture, joint dislocation and prosthesis loosening. The periprosthetic fracture healed 3 months after operation. Compared with preoperatively, Harris score was significantly improved, which was 82-94 (88±6) vs 32-36 (34±2) . The difference was statistically significant( t=49.258, P<0.01). In the last follow-up, Harris score was excellent in 16 cases, good in 24 cases, fair in 4 cases and poor in 1 case, with an excellent and good rate of 88.9%(40/45). The cause for the failure were analyzed as: 27 cases were caused by the poor operative technique, including 12 cases with unsatisfactory screw position or length, 8 cases with improper selection of fixation, 10 cases with poor reduction; 18 cases of femoral neck fracture were treated longer than 72 hours after injury, within 9 cases longer than 1 week; 15 cases with excessive early weight-bearing time (less than 12 weeks); postoperative re-hurted in 6 cases and 7 cases without any obvious inducement. Conclusions:The causes of failure of internal fixation of hip fracture include iatrogenic factors and patient factors. According to the age and general condition of patients, total hip arthroplasty or hemiarthroplasty is an effective option for treatment.