股骨转子间杵臼状外展截骨术治疗儿童髋内翻

本文报告采用股骨转子间杵臼状外展截骨术治疗儿童髋内翻１０例（１４髋）。年龄为６～１２岁。截骨处均在８周愈合。８例（１２髋）随访３～１０年（平均４年２月），均取得满意疗效。作者认为，本术式方法简单，截骨处接触面大，截骨后稳定，愈合快，畸形矫正满意，疗效好。对股骨颈干角小于１１０°者均可采用本法矫正，较大儿童颈干角应矫正至１３５°～１４５°。截骨后应以钢板螺丝钉内固定，并用髋人字石膏固定６～８周。     

Nonunion of Stress Fracture of Femoral Neck in a Child Managed with Valgus Osteotomy

Stress fracture of the femoral neck is very rare in children with an open upper femoral physis. There are only a few cases reported in the literature with most of these fatigue fractures of femoral neck managed conservatively. Some fractures require internal fixation either for displacement or for nonunion. A 7-year-old girl with a fatigue fracture of the femoral neck is presented, which resulted in coxa vara and functional disability. She was managed with valgus osteotomy and internal fixation using a dynamic hip screw. This resulted in union of the fracture site with good functional outcome.     

Subtrochanteric valgus osteotomy in developmental coxa vara

Background:

Valgus subtrochanteric osteotomy is the gold standard surgical treatment of developmental coxa vara. Nevertheless, there has been no consensus on the method of fixation and osteotomy details. In the literature, there are few reports on employing rigid internal fixation methods that preclude the need of postoperative immobilization. We present early radiologic and clinical outcome of a modified Y shaped subtrochanteric valgus osteotomy fixed with precontoured DCP.

Patients and Methods:

Ten patients with 10 hips of developmental coxa vara were subjected to a corrective Y-shaped subtrochanteric valgus femoral osteotomy. All the cases were fixed by a precontoured small dynamic compression plate (DCP). There were six males and four females. The right hip was affected in four patients and the left hip in six. The average age at the presentation time was 5.1 years (range 4–9 years). Clinical evaluation was done by IOWA hip score.

Results:

Clinically, the IOWA hip score improved postoperatively significantly (P<.05). The average preoperative head shaft angle was 94° (range 85°-100°) and the average post-operative head shaft angle was 120° (range 115°-125°). Postoperatively, the average epiphyseal-Hilgenreiner angle and the head-shaft angle fell into the normal values. No recurrence of deformity was reported.

Conclusion:

The Y-shaped subtrochanteric valgus osteotomy with rigid internal fixation precludes the use of external immobilization attained satisfactory clinical and radiologic results with no evidence of deformity recurrence on the short-term follow-up.     

Pseudarthrosis of femoral neck stress fracture treated with open reduction, sliding hip screw and bone morphogenic protein

INTRODUCTIONPseudarthrosis of femoral neck stress fractures in young adults are associated with a high incidence of complications and revision surgery. The majority are treated urgently with closed reduction and internal fixation.PRESENTATION OF CASEWe describe a displaced tension-type femoral neck fatigue fracture presenting late. Pseudarthrosis formation prior to surgery resulted in resorption and shortening of the femoral neck. Open reduction and internal fixation was performed, with adjuvant recombinant human bone morphogenic protein-7 therapy. Radiological union was achieved by twelve weeks and by one year the patient was asymptomatic.DISCUSSIONReports of successful management of femoral neck fatigue fracture non-unions are rare. Meyer's muscle pedicle graft, valgus subtrochanteric osteotomy, and cannulated screw fixation with autologous iliac crest bone graftare alternative procedures.CONCLUSIONThis extremely rare fracture type merits open reduction to enable accurate fracture reduction. Supplementing sliding hip screw fixation with an orthobiological agent was successful in this challenging situation.     

Salvage of a failed valgus osteotomy for non-union of an unstable pertrochanteric fracture

Salvage of a failed valgus osteotomy for nonunion of an unstable pertrochanteric fracture is reported. A valgus intertrochanteric osteotomy was performed for a failed sliding hip screw fixation of an unstable pertrochanteric fracture at another institution. Four months following osteotomy, the fracture was still un-united with two distal screws of the hip plate broken and a coxa vara deformity. Reconstruction was performed with a nine-hole 95° angle blade plate and cancellous bone graft, because the insufficient fixation of the distal fragment was considered to be the main reason for failure. The osteotomy was healed at six months post-surgery and the patient reported complete resolution of symptoms. Intertrochanteric valgus osteotomy is an effective procedure for mal-union and non-union of pertrochanteric fracture but stable fixation is required for a good result. The blade of the angle plate offers good purchase of the proximal fragment and secures it under rotational and bending stresses. We recommend that distal fragments should be fixed with at least seven cortices for this type of osteotomy.     

Treatment of cutout of a lag screw of a dynamic hip screw in an intertrochanteric fracture

Sixteen consecutive patients with cutout of a lag screw of a dynamic hip screw fixation in an intertrochanteric fracture were treated with reinsertion of a lag screw, bone cement supplementation in the neck-trochanter, and subtrochanteric valgus osteotomy. Postoperatively, patients were permitted to ambulate with protected weight-bearing. Fourteen patients were followed-up for at least 1 year (median 2 years; range 1–3 years), and all had a solid union. The union period took a median of 5 months, with a range of 3–7 months. Usually, union of an intertrochanteric fracture was faster than that of subtrochanteric osteotomy (P < 0.01). There were no complications of wound infection, loss of reduction, cutout of a lag screw, or osteonecrosis of the femoral head. From clinical and theoretical considerations, we conclude that despite cutout of a lag screw of a dynamic hip screw fixation being difficult to treat, out technique still can provide an excellent outcome. Therefore, we strongly recommend its wide use. Received: 7 February 1997     

Bent plate fixation in combined intertrochanteric and subtrochanteric fractures of the femur

Twenty-five combined intertrochanteric and subtrochanteric fractures of the femur (Type IV of Kyle's or Type V of Seinsheimer's classification) were treated with a bent plate and followed up through union (average: 2 years). All of the patients received immediate supplementary bone grafting and additional external supports. All but one of the fractures united between 3 and 6 months. Complications were: delayed union (1 case), which was treated by bone graft, trochanteric bursitis (3), and mild coxa vara (2). Anatomical reduction of scattered fragments and its maintenance through bony union were achieved in all cases. The bent plate provided excellent fixation in combined intertrochanteric and subtrochanteric fracture of the femur, and could be a successful alternative for these combined fractures.     

Valgus intertrochanteric osteotomy for coxa vara of Bucholz–Ogden Types II and III in patients older than 30 years

Background  

Ischemic necrosis of the proximal femur resulting in coxa vara is a severe iatrogenous complication of the treatment of developmental dysplasia of the hip (DDH). Severe relative overgrowth of the greater trochanter and reduction of the neck result in insufficiency of hip abductors. Unequal limb length causes obliquity of the pelvis, compensatory scoliosis of the lumbar spine and valgus deformity of the ipsilateral knee. The purpose of this study was to investigate the effect of valgus intertrochanteric osteotomy in patients with coxa vara older than 30 years.     

Technical aspects of the use of dynamic condylar screw in biological fixation of comminuted subtrochanteric fractures

Background  Indirect reduction and biological internal fixation using dynamic condylar screw (DCS) yield acceptable results in comminuted subtrochanteric fractures. An analysis of the technical difficulties of the procedure with the tricks to prevent these is presented. Materials and methods  Forty-eight consecutive patients with the mean age of 44.5 years with comminuted subtrochanteric fractures were treated with a DCS and biological reduction methods. Results  All fractures united without bone grafting at average union time of 16.16 weeks. Average Harris hip score was 87.97 points. We observed technical difficulties in six patients like inaccurate placement of guide pin in two; difficulty in sliding the plate due to obesity in one; difficulty in gliding barrel plate over condylar screw in one; and technical failure in two patients. Malunion (coxa vara) leading to limp occurred in one patient. A mean limb length discrepancy of 1.46 cm was detected in 5 patients at last follow up. We improvised the technique to overcome these difficulties. Conclusions  Accurate placement of the guide pin is the key to avoid technical difficulties during the procedure. Surgeon should not proceed further until completely satisfied with the position of the guide pin. Few tricks in the technique make use of dynamic condylar screw in biological fixation of comminuted subtrochanteric fractures easier.     

长Gamma 3型髓内钉内固定治疗股骨粗隆下骨折临床疗效分析

目的探讨长Gamma 3型髓内钉内固定治疗股骨粗隆下骨折的疗效。方法对60例股骨粗隆下骨折采用闭合复位或有限切开复位长Gamma 3型髓内钉内固定治疗。结果 60例均获随访10-24个月,平均18个月。骨折愈合时间9-15个月,平均10个月。末次随访时髋关节功能Harris评分：优16例,良35例,可9例,优良率85%。未发生拉力螺钉切割出股骨头、股骨干骨折、髋内翻畸形等严重并发症。结论采用长Gamma 3型髓内钉内固定治疗股骨粗隆下骨折创伤小,疗效好,便于术后早期功能锻炼,并发症发生率低。     

Transfixing Kirshner wires for fixation of intertrochanteric valgus osteotomies in management of pediatric coxa vara

Background

Coxa vara is a radiological term describing a decrease in the neck–shaft angle to 120° or less. Coxa vara is associated with pathomechanical changes that can manifest clinically. If left untreated, coxa vara can affect the normal development of the pediatric hip. Valgus osteotomy is the standard surgical treatment for coxa vara, but there is no consensus regarding the optimal osteotomy technique and fixation method. The work reported here aimed to highlight transfixing wires as a fixation method for valgus osteotomy applied as treatment for various types of pediatric coxa vara.

Materials and methods

This study included 16 cases of pediatric coxa vara with different etiologies in 9 patients with a mean age of 39.9 ± 15.2 months. Radiological and clinical evaluations and scoring of the condition of each patient according to the Iowa Hip Score were performed pre- and postoperatively. Transfixing wires and a protective spica were used for the fixation of a V-shaped, laterally based, closing-wedge valgus osteotomy in all cases. The postoperative follow-up period ranged from 14 to 102 months, with a mean duration of 33.3 ± 27.7 months.

Results

The mean Hilgenreiner epiphyseal angle (HEA) was corrected from 81.7 ± 2.2° to 24.3 ± 3.5° and the mean femoral neck–shaft angle (FNSA) was improved from 86.9 ± 4.2° to 138.6 ± 3.5°. No recurrence of the deformity was observed during the follow-up periods considered here. The osteotomy site united after an average of 11.7 ± 2.2 weeks with no secondary displacement, and in cases of developmental coxa vara there was progressive ossification of the neck defect with no surgery-related complications. Clinical results were markedly improved by the osteotomy, with a mean postoperative Iowa Hip Score at last follow-up of 95.06 ± 2.6, compared to a mean preoperative score of 57.4 ± 3.6.

Conclusions

Transfixing wires protected in a hip spica cast represent a simple, easy, and reliable fixation method for valgus osteotomies performed to correct pediatic coxa vara. It assures stable fixation and rapid healing of the osteotomy without loss of the achieved correction, it completely avoids the femoral neck affording marked protection to the growth plate.

Level of evidence

IV.

     

Mini-incision dynamic condylar screw fixation for comminuted subtrochanteric hip fractures

PURPOSE. To review the results of indirect reduction and mini-incision dynamic condylar screw (DCS) fixation for comminuted subtrochanteric femoral fractures. METHODS. 29 men and 14 women aged 25 to 65 (mean, 44) years with comminuted subtrochanteric femoral fractures underwent indirect reduction and mini-incision DCS fixation. Fractures were classified according to the AO classification (10 type 32B and 33 type 32C) and Seinsheimer classification (6 type III, 15 type IV, and 22 type V). Functional outcomes were assessed using the Harris hip score and Merle d'Aubigne score. RESULTS. The mean time to full weight bearing was 11 (range, 8-19) weeks. The mean time to union was 16 (range, 13-22) weeks. There were no cases of non-union or implant failure after a mean follow-up period of 25 (range, 18-30) months. Seven patients had a mean limb length discrepancy of 1.5 (range, 1-2) cm. Two patients had coxa vara and persistent limp. According to the Harris hip score, functional results were excellent in 12 and good in 31 patients. The mean Harris hip score was 88 (range, 80-99) and the mean Merle d'Aubigne score was 17 (range, 14-18). There was no deep infection or avascular necrosis of the femoral head. Restriction of knee flexion beyond 90 degrees was noted in 2 patients. CONCLUSION. Results of indirect reduction and mini-incision DCS fixation for comminuted subtrochanteric femoral fractures are favourable. Proper planning and execution of the technique is required to achieve good functional outcomes and avoid complications. Preservation of vascularity of the medial fragments leads to rapid callus formation and early union and hence avoids implant failure and secondary bone grafting.     

Evaluation of results of intertrochanteric valgus osteotomy in ununited fracture neck femur

The aim of this study was to evaluate the results of valgus osteotomy in patients with neglected or failed internal fixation of intracapsular fracture neck femur.Thirty patients in the age group from 17 years to 55 years were treated with valgus osteotomy and fixation with double angled blade plate. One additional 6.5 mm cannulated cancellous screw was also used.The average duration between injury and surgery was 11.3 weeks. The union at fracture site was achieved in 26 patients at an average period of 22 weeks. The union at osteotomy site was achieved at 8.6 weeks. The osteotomy site united in all cases. The complications of surgical procedure included 2 cases of blade cut through, 2 cases of joint penetration, 4 cases of avascular necrosis and 2 cases of nonunion. There was one case of superficial infection which was controlled by antibiotics. The results were clinically graded using and Harris hip score which was good to excellent in 80% of cases, fair in 7%, and poor in 13% of cases.Valgus intertrochanteric osteotomy for neglected or ununited intracapsular fracture of neck of femur and its fixation with double angled blade plate gives satisfactory results in most cases.     

Role of valgus osteotomy and fixation with dynamic hip screw and 120° double angle barrel plate in the management of neglected and ununited femoral neck fracture in young patients

Background  Head preservation is the mainstay of management in younger patients with neglected or ununited intracapsular fracture neck of femur. Very few reports have dealt with the results of valgus intertrochanteric osteotomy and fixation with dynamic hip screw in such cases. In this prospective study, we have tried to evaluate the role of valgus osteotomy and fixation with dynamic hip screw and 120° double angle barrel plate in neglected or ununited intracapsular fracture neck of femur in patients below 60 years of age and whose time since injury is equal to or more than 3 weeks. Materials and methods  We treated 16 such cases with valgus intertrochanteric osteotomy and fixation achieved with dynamic hip screw and 120° double angle barrel plate, with mean age of 36.4 years. The cases were evaluated radiologically and clinically at a mean of 19 months. Results  In 14 of the 16 patients, the fracture went on to satisfactory union after an average of 14.7 weeks (10–26.7 weeks). The average Harris hip score increased from 66.6 points (range 55–75 points) before surgery to 88 points (range 75–95 points). All the patients with united fractures were able to sit cross-legged, squat and do one-leg stance. Pain and limitation of motion improved remarkably. Two patients had unfavourable outcome; both had cut-through of the implant, out of the head. Conclusions  Valgus intertrochanteric osteotomy is a very cheap and effective procedure to achieve union in neglected and ununited fracture neck femur in young patients. We propose fixation with dynamic hip screw and 120° double angle barrel plate as it provides additional compression and, with valgus osteotomy, improved stability of internal fixation, with few complications.     

动力髋螺钉治疗股骨粗隆间骨折并发症分析

目的：分析动力髋螺钉钢板系统（dynamic hip screw,DHS）治疗股骨粗隆间骨折的并发症及其原因。方法：2002年1月至2007年12月69例股骨粗隆间骨折采用DHS治疗,男27例,女42例;年龄53-96岁,平均72．9岁;按照Evans骨折分型：Ⅰ型10例,Ⅱ型21例,Ⅲ型22例,Ⅳ型16例。术前已明确诊断的各种内科系统伴随症的51例（73．9％）,观察分析其并发症的发生情况。结果：57例出院后通过门诊及电话获得随访,随访时间8-70个月,平均41个月。围手术期发生全身系统并发症17例,死亡4例;手术局部相关并发症12人18例次。其中包括滑动髋螺钉松动后退4例、拉力螺钉穿破股骨头3例、钢板断裂1例;髋内翻5例;深部组织感染再次手术取出内固定1例;伤口愈合不良2例,骨折延迟愈合2例。结论：不稳定性粗隆间骨折应用DHS内固定失败的发生率较高,不应作为治疗首选。应根据骨折分型,结合老年患者骨质疏松情况,选择适当的术式,充分重视高龄患者系统性疾病的预防和监护,可以提高股骨粗隆间骨折的疗效并减少术后并发症。     

转子下外展截骨治疗先天性髋内翻长期疗效观察

[目的]分析股骨转子下外展截骨治疗先天性髋内翻的长期疗效。[方法]对17例（2l髋）先天性髋内翻行股骨转子下外展截骨术，术后平均随访13．6a。[结果]所有股骨头骺板早期闭合，平均10．6（5～13）岁；股骨颈部三角骨块于术后5（3～10）个月闭合；14髋股骨大转子过度增长，所有患者均有不同程度股骨颈短缩；1例术后6a发生膝外翻。[结论]手术促进股骨近端骺板和三角骨块早期闭合，稳定髋关节，但引发髋关节周围形态的畸形。截骨同时行股骨大转子骺阻滞是防止股骨大转子过度增长的方法之一。     

截骨矫形钢板固定治疗股骨近段纤维结构不良伴髋内翻畸形

目的 探讨股骨转子下截骨矫形、动力髋或髁螺钉系统固定治疗股骨近段纤维结构不良(fibrous dysplasia,FD)伴髋内翻畸形的临床疗效.方法 回顾性分析2001年4月至2010年5月收治的26例股骨FD伴髋内翻畸形患者的临床资料,男9例,女17例;年龄10～53岁,中位年龄19岁.单骨型14例,多骨型12例.病灶长度为多骨型9～36 cm(平均19 cm),单骨型7～15 cm(平均9 cm);17例合并病理性骨折;术前颈干角65°～110°(平均92°),患肢短缩1.5～4.5cm(平均2.8 cm).21例病灶累及股骨颈者采用髋螺钉固定,5例未累及股骨颈者采用髁螺钉固定.结果 手术时间80～170 min(平均120min),出血量280～1650ml(平均960ml).术后颈干角为119°～140°(平均127°);患肢平均延长2.3 cm(1.5～3.6 cm).随访9～118个月(平均39个月),截骨面均愈合.除1例颈干角从术后126°减小到术后56个月的115°,其余患者无髋内翻畸形复发,无内固定断裂或松动.1例股骨颈变短、髋螺钉沿滑槽滑动,但螺钉未切割股骨头;1例术后7年外伤后钢板远端处股骨干骨折.根据Guille的功能评价标准,24例满意、2例不满意.结论 转子下截骨矫形、动力髋或髁螺钉系统内固定能有效地纠正股骨上段FD伴髋内翻畸形,改善患肢功能.

Abstract：

Objective To investigate the clinical effect of subtrochanteric osteotomy plus dynamic hip/condyle screw (DHS/DCS)fixation to treat the fibrous dysplasia of the proximal femur with coxa vara.Methods Twenty-six clinical cases of femoral fibrous dysplasia with coxa vara were retrospectively analysed from April 2001 to May 2010.There were 9 males and 17 females,with a median age of 19(10 to 53).Forteen patients presented with monostotic disease,and 12 with polyostotic disease.The length of the lesion for polyostotic disease was from 9 cm to 36 cm,while for monostotic disease was from 7 cm to 15 cm.Seventeen cases were merged with pathologic fracture.The neck shaft angles were from 65 to 110 degree preoperation.The shortage of limbs was from 1.5 cm to 4.5 cm.Twenty-one patients involved in femoral neck were fixed with DHS and the other 5 cases with DCS.Results The duration of operation was from 80 to 170 min.The amout of bleeding was from 280 to 1650 ml with the average of 960 ml.The average postoperative neck shaft angles were 127 degree(119 to 140).The shortened limbs were extended 2.3 cm for average (1.5 to 3.6 cm).The follow-up time was from 9 to 118 months with the average of 39 months.All patients with osteotomy were healed.The neck shaft angle of 1 case decreased from post-operative 126°to 115°56months post-operatively,no coxa adducta recurrented and all internal fixations were in position.Hip screw backed out through the barrel in one case with the shortage of femoral neck.One case had femoral fracture after an injury.According to Guille function standard,24 cases were regarded as satisfied and 2 cases as unsatisfied.Conclusion Subtroehanteric osteotomy plus DHS/DCS fixation can effectively correct the fibrous dysplasia of the proximal femur with coxa vara,and significantly improve the function.     

Indications and results of intertrochanteric reconstructive osteotomy in coxa profunda and protrusio coxae

Coxa profunda often connected with coxa vara lead to an increasing stress on the medial part of the acetabulum. Secondary degenerative alterations with painful limited motion are the result. In 20 hip joints with coxa profunda a valgus intertrochanteric osteotomy was carried out in order to modify the direction of the resulting force from the depth to the roof of the acetabulum. A relief of pain was achieved in 18 of 20 cases. Therefore the valgus intertrochanteric osteotomy has to be considered an effective method in the treatment of coxarthrosis in coxa profunda.     

Malunion in displaced intracapsular fracture of femoral neck: A rare case

Intracapsular fracture of femoral neck is treated by anatomical reduction (preferably closed) and cannulated cancellous lag screw fixation. Malunion of these fractures have been described in the coronal plane (coxa valga or coxa vara). We reported a case of young adult patient with displaced intracapsular fracture of femoral neck that had malunited in sagittal plane with callus formation with excellent functional outcome. The radiographs revealed intracapsular fracture of femoral neck right side (Garden type 4 and Pauwel type 3). The patient was operated and closed reduction and internal fixation with three cannulated cancellous screws was performed. The postoperative radiograph revealed a loss of reduction in the lateral view. Due to this technical error, the patient was counselled for revision fixation for which he refused. At 9 months we observed union of the fracture in the displaced position by callus formation. Harris hip score at 2 years was 96 that indicate excellent functional outcome and the radiographs did not reveal any evidence of avascular necrosis of femoral head. We advised revision surgery to our patient as he had increased chances of implant failure and nonunion. However he refused the revision surgery and was continued with the suboptimal reduction. However, the fracture united and that too with callus formation, which is not a described phenomenon in neck of femur fracture.