全涂层远端固定长柄假体治疗髋关节置换术后股骨假体周围骨折的临床研究

目的分析全涂层远端固定长柄假体治疗髋关节置换术后假体周围骨折的临床效果。方法回顾性分析35例使用全涂层远端固定长柄假体治疗的髋关节置换术后股骨假体周围骨折病例,根据Vancouver分型,B2型12例,B3型20例,C型3例,通过Harris评分对患髋进行功能评价,X线片观察骨折愈合、股骨柄下沉情况。结果3例行单纯长柄假体翻修,10例行长柄假体翻修＋钢丝环扎固定,22例行长柄假体翻修＋同种异体颗粒骨压配植骨＋同种异体骨板捆绑固定治疗,平均随访4．5年,所有骨折均顺利愈合,平均愈合时间为15．3周,Harris评分平均86．5分,2例股骨柄分别下沉3mm和4mm,均在术后3个月达到稳定,32例假体获得骨长入固定,3例获得稳定的纤维固定,未发现骨溶解、感染以及再发骨折。结论髋关节置换术后假体周围骨折选择全涂层远端固定长柄假体翻修,根据骨缺损严重程度合理选择同种异体颗粒骨打压植骨＋同种异体骨板捆绑固定可以获得良好的临床效果。     

全髋关节置换假体柄周围骨折的治疗

目的 :回顾性研究全髋关节置换假体柄周围骨折的治疗及预防。方法 :将本院近年收治的全髋置换假体柄周围骨折的 8例病例按Vancouver分类方法进行分类 ,其中A1型 3例 ,B1型 3例 ,B2型 1例 ,B3型 1例 ,分别用钢丝环扎固定 ,异体皮质骨板加钢丝环扎 ;骨水泥长柄假体翻修。结果 :术后随访 8～ 18个月 ,骨折愈合 ,假体固定可靠。结论 :全髋关节置换术后假体柄周围骨折用Vancouver分类方法分类 ,简单、适用。采用异体皮质骨板与钢丝环扎固定骨折 ,治疗假体柄周围骨折 ,不仅固定可靠而且能促进骨折愈合、恢复骨量。     

全髋关节置换术后股骨假体周围骨折的治疗

目的 探讨人工全髋关节置换术后股骨假体周围骨折的治疗方法及疗效. 方法 回顾性分析2005年7月至2010年6月收治且获得随访的13例人工全髋关节置换术后股骨假体周围骨折,其中男6例,女7例;年龄51 ～ 80岁,平均67岁;骨折按Vancouver分型:B1型3例,B2型5例,B3型3例,C型2例.分别用钢丝或钢缆环扎固定,异体皮质骨板加钢丝环扎;长柄假体翻修;记忆合金环抱器、锁定加压钢板固定.结果 所有患者术后随访9 ～ 30个月,平均16个月.骨折均愈合,时间4～7个月,平均4.8个月.患者无感染、畸形愈合、假体松动脱位、内固定断裂和深静脉血栓形成.根据Harris髋关节功能评分:优7例,良5例,可1例. 结论 全髋关节置换术后假体周围骨折的治疗方案需结合骨折部位、假体有无松动、局部骨质量、身体状况而制定,原则是移位骨折要进行牢固固定、松动假体要进行翻修、严重骨缺损需要植骨处理.     

全髋关节置换术后股骨假体周围Vancouver B型骨折治疗的随访研究

目的 探讨全髋关节置换术后股骨假体周围Vancouver B型骨折治疗方法的选择,总结同种异体皮质骨板移植重建股骨假体周围骨折的临床效果.方法 22例全髋关节置换术后股骨假体周围骨折患者,男7例,女15例;年龄平均65岁(53～75岁).Vancouver分类B1型5例,B2型4例,B3型13例.B1型骨折采用异体皮质骨板移植加钢丝环扎治疗;B2型骨折选择加长股骨柄翻修;B3型骨折选择骨水泥柄翻修,加同种异体皮质骨板移植和钢丝环扎同定.所有患者均获得随访,随访时间平均67个月(37～95个月).采用Harris髋关节功能评分、X线片、外周血T淋巴细胞亚群、抗体免疫复合物检测 和核素骨显像对治疗结果进行评价.结果 22例患者骨折全部愈合,21例患者能自由行走,1例需要助 行器帮助.末次随访Harris评分平均89分(79～93分).患者未发生免疫排斥反应;术后3个月,骨折愈合,术后12个月,移植骨板与宿主骨骨性愈合,股骨皮质厚度增加3～5mm;核素骨显像骨板移植区放射性核素分布较对侧浓集.3例患者移植骨板出现部分吸收现象.术后2年.骨板与宿主骨融合,移植骨板吸收停止.结论 针对股骨假体周围骨折不同类型分别采取不同方法治疗能够取得较好疗效,同种异体皮质骨板移植在维持骨折稳定性、促进骨折愈合、增加局部骨量和改善骨强度方面有较好疗效.     

人工髋关节股骨假体周围Vancouver B型骨折治疗的临床分析

目的探讨人工髋关节置换术后股骨假体周围Vancouver B型骨折患者,进行假体翻修、内固定治疗的效果。方法 2005年1月至2009年12月间,广州医科大学大学附属第一医院关节外科收治人工髋关节置换术后股骨假体周围B型骨折患者16例,其中11例为全髋,5例为半髋;男4例,女12例;年龄平均69岁(59~81岁);Vancouver分类B1型3例,B2型5例,B3型8例。B1型骨折采用内固定、或加异体皮质骨板移植治疗;B2型骨折选择加长股骨柄翻修、捆扎带环扎;B3型骨折选择加长股骨柄翻修、加同种异体皮质骨板移植和捆扎带环扎固定。所有患者均进行随访,随访时间平均90个月(5~9年)。采用Harris髋关节功能评分、X线片对治疗结果进行评价。结果 12例患者获得随访,骨折全部愈合,患者能自由行走,末次随访髋关节功能评分(Harris评分)平均90分(76~93分)。结论针对人工髋关节置换术后股骨假体周围骨折的不同类型,分别采取切开复位内固定、加长股骨柄假体翻修、异体皮质骨板移植治疗,能取得较好疗效。     

全髋关节置换术后温哥华B型假体周围骨折的治疗

背景:全髋关节置换手术是目前最为成功有效的外科手术之一,与之伴随的是多种术后并发症的出现,假体周围骨折是其中最显著的并发症之一,发病率有上升趋势。目的:回顾性研究全髋关节置换术后温哥华B型股骨假体周围骨折的治疗措施。方法:2006年1月至2011年1月收治全髋关节置换术后股骨假体周围骨折33例,男17例,女16例;年龄38～81岁,平均68.2 岁。33 例均为温哥华 B 型假体周围骨折:B1 型骨折组 11 例,采取切开复位钢丝捆扎固定或接骨板固定+异体皮质骨板植骨;B2型骨折组16例,采用记忆合金环抱器+大量植骨或长柄全涂层假体联合钢丝捆扎+局部异体松质骨植骨;B3型骨折6例,采用长柄生物性假体或组配型假体+同种异体骨板联合钢丝捆扎。结果:全部获得随访,随访时间为0.5～5.5年,平均3.6年。髋关节功能恢复良好,骨折愈合,对位对线良好。骨折愈合时间为3～22个月,平均6.5个月。B1型骨折组中1例术后因跌倒再次骨折,行二次翻修手术,末次随访时Harris评分为82～96 分,平均 91.2 分;B2 型骨折组中 1 例术后 3 年出现假体松动下沉,行二次翻修手术,末次随访时 Harris 评分为 76～92 分,平均 87.0 分;B3 型骨折组中 1 例术后 3 个月出现移植骨排异反应与感染,经治疗无效,再次手术取出同种异体骨板,抗生素药物治疗后症状缓解,末次随访时Harris评分为66～80分,平均71.5分。无一例发生深静脉血栓形成、神经损伤等并发症。结论:股骨柄假体周围骨折中温哥华B型较常见,根据骨折类型选择不同的治疗方法,均可获得满意疗效。     

全髋关节翻修术中股骨假体周围骨折的处理

目的研究全髋关节翻修术中股骨假体周围骨折的治疗方法。方法对2002年10月至2007年2月在全髋关节翻修术中出现股骨假体周围骨折的32例非感染翻修患者进行回顾性分析。采用Vancouver分型方法对骨折进行分类,其中A型11例,B型16例,C型2例,同时发生A、B型骨折的3例。24例采用加长广泛涂层柄翻修联合异体皮质骨板固定,6例采用加长广泛涂层柄加钢丝固定,1例采用骨水泥假体,1例仅采用异体皮质骨板固定。结果28例患者获得随访,平均随访时间23.5个月(3~56个月)。术后12~22周所有患者骨折均愈合(平均17.5周)。1例患者术后患肢疼痛,2例同侧膝关节僵直。术后平均Harris评分为92分。结论绝大多数翻修术中出现股骨假体周围骨折的患者能顺利恢复功能。非骨水泥广泛涂层柄可能是较好的选择。异体皮质骨板移植对骨量较差的患者来说是有用的技术。     

生物型翻修加长柄在人工全髋关节翻修术中的应用

目的探讨生物型翻修加长柄治疗全髋关节置换术后股骨假体松动伴股骨骨缺损的早期疗效。方法对15例(15髋)全髋关节置换术后股骨假体松动伴股骨骨缺损采用生物型翻修加长柄治疗,对于骨缺损采用自体或同种异体颗粒骨植骨,自体大块髂骨结构性植骨,使用钢丝、钢缆固定。结果术后髋关节疼痛消失,关节功能改善。15例获随访6~22个月,平均18个月。末次随访时未发现假体周围骨折及假体远端出现新透亮带,Harris评分平均89.8分。结论人工全髋关节翻修术中使用生物型翻修加长柄治疗股骨假体松动伴股骨骨缺损早期疗效可靠,但远期疗效有待进一步观察。     

人工髋关节置换术后股骨假体周围骨折的治疗

目的 探讨人工髋关节置换术后股骨假体周围骨折的治疗方法及临床效果.方法 采用温哥华术后骨折分型标准,共收治人工髋关节置换术后股骨假体周围骨折13例.结果 13例均获得随访,随访时髋关节功能按Harris评分:优4例,良5例,中3例,差1例.其中1例不愈合,其余12例获骨性愈合.结论 对此类骨折应根据近期影像资料进行周密的术前计划,结合骨折部位、假体稳定性及骨储备情况等因素,选择治疗方案.使用钢丝环扎、非骨水泥型长柄翻修联合应用异体皮质骨板及局部植骨是处理不同类型股骨假体周围骨折的有效治疗方法.     

广泛微孔涂层非骨水泥假体治疗Vancouver B2型假体周围骨折

目的 评价广泛微孔涂层非骨水泥长柄假体治疗Vancouver B2型股骨假体周围骨折的疗效.方法 2002年10月至2007年5月对10例初次全髋置换术后Vancouver B2型假体周围骨折患者采用广泛微孔涂层非骨水泥长柄假体予以翻修,其中初次置换股骨柄为骨水泥固定者4例,非骨水泥固定6例.结果 10例患者均获随访,平均随访时间44个月(12～67个月),Harris评分平均为87.6分.所有患者骨折均愈合,骨折平均愈合时间4.6个月.8例骨长入稳定,2例纤维稳定,无假体松动和下沉,1例出现大腿痛,3例股骨近端出现应力遮挡.结论 广泛微孔涂层长柄非骨水泥假体治疗Vancouver B2型假体周围骨折,很好地控制了骨折端轴向和旋转稳定性,且骨与假体有很好的骨整合,为骨折的愈合提供了良好的环境,骨折愈合率高.     

Dynamic compression plates for Vancouver type B periprosthetic femoral fractures: a 3-year follow-up of 18 cases

Background There is no consensus on the best surgical treatment of periprosthetic femoral fractures. We report our experience with a dynamic compression plate.

Patients and methods We reviewed the results of 18 periprosthetic femoral fractures treated with open reduction and internal fixation using the dynamic compression plate (DCP). There were 7 Vancouver type B1, 2 type B2 and 9 type B3 fractures. 16 cases had previously undergone at least one revision procedure. In addition to a DCP plate, all B2 and B3 fractures were revised to cemented prostheses, and all B3 fractures were revised with impaction grafting. Mean follow-up was 39 months.

Results The mean healing time for those 11 cases that united was 13 months. One B1-type and one B3-type fracture with plate fracture within 8 months of surgery failed to heal. Furthermore, one B1-type fracture and one B2-type fracture failed and developed nonunion. 3 patients died, from causes not related to surgery, within 8 months after surgery without signs of healing.

Interpretation Open reduction and internal fixation using DCPs seems to be a valid method for the treatment of postoperative periprosthetic femoral fractures with stable stem in place. If the stem is unstable, we suggest that DCPs may be used in association with femoral revision using a long stem. In cases with stable stem (B1), we are inclined to agree with other authors that additional fixation using an extramedullary cortical strut graft may be necessary to improve stability and promote final healing.     

Locking compression plate fixation of Vancouver type-B1 periprosthetic femoral fractures

BACKGROUND: Fractures occurring at or near the distal tip of a hip prosthesis with a stable femoral stem (Vancouver type-B fractures) are associated with many complications because of the inherently unstable fracture pattern. Locking compression plates use screws that lock into the plate allowing multiple points of unicortical fixation. Such unicortical fixation may lower the risk of damage to the cement mantle or a stable femoral stem during the treatment of a periprosthetic femoral fracture. The purpose of this study was to analyze clinically and radiographically a group of patients with a Vancouver type-B1 periprosthetic femoral fracture treated with open reduction and internal fixation with use of a locking compression plate. METHODS: Fourteen consecutive patients (fourteen hips) with a Vancouver type-B1 periprosthetic femoral fracture were treated with a locking compression plate. There were five men and nine women with an average age of sixty-eight years at the time of fracture. All of the fractures occurred after a total hip arthroplasty performed with cement, and eleven of the arthroplasties were revisions. In addition to the plate, cortical strut allografts were used to stabilize five fractures. The patients were assessed clinically and radiographically. RESULTS: The average duration of follow-up was twenty months. Eight fractures healed uneventfully at an average of 5.4 months. Three treatment constructs failed with fracture of the plate within twelve months after surgery. An additional three constructs also failed because of plate pullout. All failures except one occurred in constructs in which a cortical strut allograft had not been utilized. CONCLUSIONS: On the basis of the high failure rate in this series of patients, locking compression plates do not appear to offer advantages over other types of plates in the treatment of type-B1 periprosthetic femoral fractures. Despite the potential to preserve the cement mantle, the locked screws did not appear to offer good pullout resistance in this fracture type. We believe that supplementation with strut allografts should be used routinely if this type of locking compression plate is selected to treat these fractures.     

Dynamic compression plates for Vancouver type B periprosthetic femoral fractures

Background There is no consensus on the best surgical treatment of periprosthetic femoral fractures. We report our experience with a dynamic compression plate.

Patients and methods We reviewed the results of 18 periprosthetic femoral fractures treated with open reduction and internal fixation using the dynamic compression plate (DCP). There were 7 Vancouver type B1, 2 type B2 and 9 type B3 fractures. 16 cases had previously undergone at least one revision procedure. In addition to a DCP plate, all B2 and B3 fractures were revised to cemented prostheses, and all B3 fractures were revised with impaction grafting. Mean follow-up was 39 months.

Results The mean healing time for those 11 cases that united was 13 months. One B1-type and one B3-type fracture with plate fracture within 8 months of surgery failed to heal. Furthermore, one B1-type fracture and one B2-type fracture failed and developed nonunion. 3 patients died, from causes not related to surgery, within 8 months after surgery without signs of healing.

Interpretation Open reduction and internal fixation using DCPs seems to be a valid method for the treatment of postoperative periprosthetic femoral fractures with stable stem in place. If the stem is unstable, we suggest that DCPs may be used in association with femoral revision using a long stem. In cases with stable stem (B1), we are inclined to agree with other authors that additional fixation using an extramedullary cortical strut graft may be necessary to improve stability and promote final healing.     

Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate

BACKGROUND: Periprosthetic femoral fractures around hip replacements are increasingly common. When the femoral component is stable, open reduction and internal fixation is recommended in all but exceptional cases. The purpose of this study was to evaluate the outcome of treatment of fractures around stable implants with cortical onlay strut allografts with or without a plate. METHODS: A survey of our four centers identified forty patients with a fracture around a well-fixed femoral stem treated with cortical onlay strut allografts without revision of the femoral component. There were fourteen men and twenty-six women, with an average age of sixty-nine years. Nineteen patients were treated with cortical onlay strut allografts alone, and twenty-one were managed with a plate and one or two cortical struts. All of the patients were followed until fracture union or until a reoperation was done. The mean duration of follow-up was twenty-eight months for thirty-nine patients. One patient, who was noncompliant with treatment recommendations, had a failure at two months because of a fracture of the plate and graft. The primary end point of the evaluation was fracture union; secondary end points included strut-to-host bone union, the amount of final bone stock, and postoperative function. RESULTS: Thirty-nine (98%) of the forty fractures united, and strut-to-host bone union was typically seen within the first year. There were four malunions, all of which had <10 degrees of malalignment, and one deep infection. There was no evidence of femoral loosening in any patient. All but one of the surviving patients returned to their preoperative functional level within one year. CONCLUSIONS: Cortical onlay strut allografts act as biological bone plates, serving both a mechanical and a biological function. The use of cortical struts, either alone or in conjunction with a plate, led to a very high rate of fracture union, satisfactory alignment, and an increase in femoral bone stock at the time of short-term follow-up. Although this study did not address the potential for later allograft remodeling, our findings suggest that cortical strut grafts should be used routinely to augment fixation and healing of a periprosthetic femoral fracture.     

High union rates of locking compression plating with cortical strut allograft for type B1 periprosthetic femoral fractures

Purpose

Unified classification system (UCS) type B1 periprosthetic femoral fractures are associated with many complications, and management decisions continue to be controversial. The purpose of this study was to evaluate outcomes of UCS type B1 periprosthetic femoral fractures treated by locking compression plating with strut allograft augmentation.

Materials and methods

We retrospectively reviewed 17 consecutive UCS type B1 periprosthetic femoral fractures treated by open reduction and internal fixation using a lateral locking compression plate supplemented with an anterior cortical strut allograft. There was one man and 16 women with an average age of 74 years (range, 57–92 years). All had a cementless hip arthroplasty, and eight of the arthroplasties were revisions.

Results

The mean duration of follow-up was 28 months (range, 12–74 months). All 17 fractures healed successfully at a mean of 20 weeks (range, 12–30 weeks). The mean post-operative Harris hip score was 86 points (range, 77–95 points). No mechanical complications such as failure of plate or screws and malalignment were noted. According to the graft-remodeling classification of Emerson et al., a partial bridging was observed in nine and a complete bridging in eight. Two patients required a removal of the plate due to irritation of the iliotibial band. No femoral stem loosening or deep infection was observed.

Conclusion

Our findings indicate that open reduction and internal fixation of UCS type B1 periprosthetic femoral fractures using a lateral locking compression plate supplemented with anterior cortical strut allograft provides adequate mechanical stability of fracture fixation and enhances the fracture healing.

     

Superior outcome of strut allograft-augmented plate fixation for the treatment of periprosthetic fractures around a stable femoral stem

Purpose

This study was designed to compare the outcome of two surgical approaches for treating femoral periprosthetic fractures around a stable femoral stem. The hypothesis was that plate fixation alone might be associated with a higher complication rate due to insufficient mechanical stability. We also considered that the addition of a strut allograft would contribute to fracture healing by means of osteoconduction.

Methods

We retrospectively assessed the outcome of 21 patients who sustained periprosthetic fractures around a total hip replacement system (Vancouver type B1 and type C fractures) and who were treated in our department (January 2006 and August 2011) either by plate fixation alone or by plate fixation and a strut allograft. The mean postoperative follow-up was 23 months (range 9–69 months). Eleven patients were treated by plate fixation alone (Plate Group), and 10 patients were treated by plate fixation and a deep frozen cortical strut allograft (AG Group). Functional outcome was rated by the Harris Hip scoring system. Postoperative radiographs were assessed for evidence of fracture union. Surgical failure was defined as any complication requiring surgical revision.

Results

The 21 patients included 17 females and 4 males. The average age was 79 years (range, 73–88) for the Plate Group and 82 years (range, 53–94) for the AG Group, and the average time to fracture union was 12 weeks (range, 2.5–6 months) and 12.95 weeks (range, 1.5–3) respectively. The overall failure rate was significantly higher in the Plate Group: 5 of them required revision surgery compared to none in the AG Group (p = 0.014).

Conclusion

The results of this analysis indicate that a strut allograft augmentation approach to Vancouver type B1 and type C periprosthetic fractures results in a better outcome than plate fixation alone by apparently adding mechanical stability and enhancing the biological healing process.     

Periprosthetic fracture of the femur after hip arthroplasty: The clinical outcome using cortical strut allografts

Between 1993 and 1998, 15 patients with periprosthetic fractures of the femur after hip arthroplasty were treated using deep-frozen cortical strut allografts as an adjunct support after internal fixation or revision arthroplasty. According to the Vancouver classification system, there were 7 type B1, 2 type B2, 4 type B3 and 2 type C fractures. Seven patients had severe osteopenia, 10 patients had bone defects between 2 to 7 cm and 2 were associated with infection. Nine patients had internal fixation of the fracture using a compression plate, and 6 had revision arthroplasty using a long-stemmed femoral prosthesis. The average length of the allograft was 13.9 cm. At an average follow-up of 31 months, all the patients had a satisfactory functional result except one who had a leg length discrepancy of 4 cm due to multiple operations. There were no non-unions, malunions or infections. The fractures healed between 10 to 24 weeks (average, 15.6 weeks). In conclusion, a cortical strut allograft associated with internal fixation can be an effective method of treating periprosthetic fractures of the femur after hip arthroplasty.     

Cement-in-cement stem revision for Vancouver type B periprosthetic femoral fractures after total hip arthroplasty: A 3-year follow-up of 23 cases

Background and purpose Revision surgery for periprosthetic femoral fractures around an unstable cemented femoral stem traditionally requires removal of existing cement. We propose a new technique whereby a well-fixed cement mantle can be retained in cases with simple fractures that can be reduced anatomically when a cemented revision is planned. This technique is well established in femoral stem revision, but not in association with a fracture.Patients and methods We treated 23 Vancouver type B periprosthetic femoral fractures by reducing the fracture and cementing a revision stem into the pre-existing cement mantle, with or without supplementary fixation.Results 3 patients died in the first 6 months for reasons unrelated to surgery. In addition, 1 was too frail to attend follow-up and was therefore excluded from the study, and 1 patient underwent revision surgery for a nonunion. The remaining 18 cases all healed with radiographic union after an average time of 4.4 (2–11) months. There was no sign of loosening or subsidence of the revision stems within the old cement mantle in any of these cases at the most recent follow-up after an average of 3 (0.3–9) years.Interpretation Our results support the use of the cement-in-cement revision in anatomically reducible periprosthetic fractures with a well-preserved pre-existing cement mantle. This technique is particularly useful for the elderly patient and for those who are not fit for prolonged surgical procedures.