全髋关节置换术中假体周围骨折的研究进展

全髋关节置换术是一个较为成熟的手术,术中假体周围骨折是其并发症之一,假体周围骨折分为髋臼假体周围骨折和股骨假体周围骨折,危险因素包括微创技术的使用、压配式非骨水泥假体柄的使用、髋关节翻修术和骨质疏松等。本文就全髋关节置换术中假体周围骨折的分型及治疗进展进行综述。     

全膝关节置换术后股骨假体周围骨折的治疗进展

全膝关节置换(total knee arthroplasty, TKA)术后最常见股骨假体周围骨折。术后股骨假体周围骨折的危险因素包括女性、骨质疏松、类风湿关节炎、骨关节炎、神经肌肉疾病、认知障碍、药物相关(服用皮质类固醇)、肥胖、高龄、感染、假体周围骨溶解、膝关节强直、股骨前皮质切迹等。流行病学研究表明, TKA术后假体周围骨折中股骨假体周围骨折最常见, 发生率为0.3%～2.5%。Lewis和Rorabeck分型是股骨假体周围骨折最常用的分型方法, 该分型提出了假体松动的概念, 并强调了进行翻修手术的必要性。其他还有Su分型、通用分型系统以及Rhee分型, 最新的分型为2022年提出的Kim分型。TKA术后股骨假体周围骨折的治疗策略包括非手术治疗、外固定技术、单钢板固定、双钢板固定、髓内钉固定以及翻修TKA和股骨远端置换术。通过检索并分析TKA术后股骨假体周围骨折的相关文献, 以期更好地指导TKA术后股骨假体周围骨折的预防和治疗。     

全髋关节置换术髋臼假体周围骨折的临床特征及其影响因素分析

目的观察全髋关节置换术髋臼假体周围骨折的临床特征,分析初次全髋关节置换术髋臼假体周围骨折的影响因素。方法回顾性分析自2013-01—2018-06完成的584例初次或翻修全髋关节置换术,17例出现髋臼假体周围骨折,初次手术13例,翻修手术4例。比较初次全髋关节置换术假体周围骨折组与未骨折组在性别、年龄、体重指数、手术侧别、疾病类型、手术入路、骨质疏松状态、假体类型、假体覆盖比例及主刀医师手术量方面的差异。结果全髋关节翻修手术中髋臼假体周围骨折发生率高于初次全髋关节置换术,差异有统计学意义(P<0.05)。多因素Logistic回归分析结果显示疾病类型(髋关节发育不良、类风湿性关节炎)、合并骨质疏松、生物型假体、假体覆盖比例>80%、主刀医师手术量≤80台/年是初次全髋关节置换术髋臼假体周围骨折的危险因素。结论全髋关节翻修手术中髋臼假体周围骨折发生率高于初次手术。对于髋关节发育不良、类风湿性关节炎、合并骨质疏松患者,以及选用生物型假体、假体覆盖比例>80%、主刀医师经验不足时,初次全髋关节置换术中需要警惕髋臼假体周围骨折发生。     

锁定加压钢板合并捆扎带治疗股骨假体周围骨折

目的探讨捆扎带合并锁定加压钢板固定治疗股骨假体周围骨折的临床效果。方法对7例股骨假体周围骨折进行切开复位，锁定加压钢板固定，在含有假体的股骨近折端用锁定螺钉作单侧骨皮质固定，不含假体的股骨远折端作双侧骨皮质螺钉固定，同时在包含假体的骨折端两侧利用捆扎带将股骨及钢板同时捆扎固定，自体骨或异体骨植骨。对假体不稳的患者在骨折复位后行假体翻修术。结果术后患者可早期起床运动：随访5个月～3年，骨折未见移位，7例假体周围骨折均获得愈合，髋关节功能得到恢复。假体未见松动。结论股骨假体周围骨折大多为长螺旋型骨折，捆扎带合并锁定加压钢板治疗股骨假体周围骨折简单有效，固定效果确切，根据骨缺损情况辅以植骨，可获得良好的临床效果。     

股骨假体周围骨折的危险因素

股骨假体周围骨折(PFF)相关危险因素较多,创伤是主要因素,骨质疏松、高龄及女性患者发生PFF的风险较大,骨溶解及继发性假体松动可增加发生PFF的危险,不同疾病患者PFF的发病率有所差异,假体固定方式对PFF发病率也有影响,全髋关节翻修术者发生PFF的风险高于初次全髋关节置换术者,手术技术和假体类型对PFF发病率也有一定的影响。     

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假体周围骨折的治疗方法及临床疗效。方法分别采用非手术治疗、钢缆环扎、锁定钢板内固定、加长柄翻修术结合钢缆环扎或结合记忆合金环抱器内固定等方法治疗10例人工髋关节置换术后并发股骨假体周围骨折。结果 8例获得骨折愈合,1例加长柄翻修结合钢缆环扎内固定的B3型和1例锁定钢板内固定C型骨折未愈合。结论利用Vancouver分类系统,制定手术方法,确定治疗方法治疗假体周围骨折可获得满意疗效。     

膝关节内侧单髁置换术后假体周围骨折的临床诊治进展

单间室膝关节置换术(UKA)是治疗终末期膝关节前内侧骨关节炎的有效方法。UKA围手术期可能发生假体周围胫骨平台及股骨内髁骨折, 其治疗极具挑战性。导致这一并发症的原因包括:技术性原因, 如术中操作导致平台后皮质强度弱化、内侧胫骨关节面切骨量过多导致承载假体的骨量减少、假体对线不良导致骨床应力集中等;假体设计原因, 如非骨水泥假体的压配固定设计、胫骨切骨导向器多钉孔固定等;胫骨平台形态原因, 如亚洲人群胫骨内侧平台窄小及悬凸等。合理选择适应症、正确地把握手术原则及标准化手术技术是预防UKA围手术期假体周围骨折的关键, 治疗方式的选择主要取决于骨折模式及假体的稳定性。     

AO锁定钢板结合线缆系统微创内固定治疗Vancouver B1型股骨假体周围骨折

目的探讨采用AO锁定钢板结合线缆系统微创内固定治疗Vancouver B1型股骨假体周围骨折的临床疗效。方法采用AO锁定钢板结合线缆系统微创内固定治疗6例Vancouver B1型股骨假体周围骨折。结果本组获随访6～36个月,骨折均愈合,无假体松动、钢板拔出及断裂,髋关节功能恢复良好,按照Harris评分标准:优3例,良2例,可1例。结论 AO锁定钢板结合线缆系统微创内固定是一种固定牢靠、可微创治疗Vancouver B1型股骨假体周围骨折的手术方法。     

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治疗进展

全髋关节置换术(THA)后股骨假体周围骨折是临床上颇具挑战性的难题。Vancouver分型涉及股骨假体周围骨折位置及稳定性、假体松动情况、股骨近端骨量等,是临床上应用较多的分型方法。伴有假体松动的Vancouver B2型和B3型骨折占50%以上,因此预防和治疗THA后假体松动和(或)骨溶解很重要。针对股骨假体周围骨折内固定的生物力学研究等已成为热点,伴感染的股骨假体周围骨折、股骨假体周围多次骨折以及内固定失败的防治也见诸报道。该文就股骨假体周围骨折的治疗及预防措施的研究进展作一综述。     

Endosteal substitution with an allograft cortical strut in the treatment of a periprosthetic femur fracture: a case report

The use of allograft cortical struts in the treatment of periprosthetic fractures of the femur has been well described. Allograft struts are used to supplement cerclage wire fixation or may be placed outside the cortex opposite plate and screw fixation to improve screw fixation in osteoporotic bone. This generally requires extensive soft tissue stripping and may lead to delayed bony union. A technique is described wherein an allograft strut was inserted into the medullary canal through the fracture site and used as an endosteal substitution for osteoporotic cortical bone. This technique can improve screw fixation in osteoporotic bone while avoiding devascularization of the fractured femur.     

Periprosthetic fracture of the acetabulum during total hip arthroplasty in a patient with Paget's disease

The case of a patient with Paget's disease of the pelvis (acetabulum) who had an intraoperative posterior wall fracture during the insertion of a noncemented acetabular component into an under-reamed acetabular bed of sclerotic Pagetoid bone is reported. This unusual complication has not, to my knowledge, been previously reported. Patients with sclerotic bone, like those with osteoporotic bone, may also be at risk for periprosthetic acetabular fractures when an under-reaming technique is used.     

Evidence for Success with Locking Plates for Fragility Fractures

Fixation of fragility fractures with plates and screws often results in loss of fixation and need for revision surgery. Locking plates and screw were introduced to improve fixation of fragility fractures and have been in use for a decade. This review was conducted to compile evidence that locking plates and screws improve fixation of fragility fractures. A search of PubMed was performed to identify biomechanical studies as well as clinical series of fragility fractures treated with locking plates. Biomechanics papers had to use models of osteoporotic bone and had to directly compare locking plates with traditional plates. Clinical studies included case series in which locking plates were applied to elderly patients with fractures of the proximal humerus and periprosthetic distal femur fractures. Most studies are retrospective case series. Locking plates lead to greater stability and higher loads to failure than traditional plates. When applied to proximal humerus fractures, uncomplicated healing occurs in 85% of patients. Constant and Dash scores approach normal values. For distal femoral periprosthetic fractures, union rates of 75% are reported with a malunion rate of 10%. Early evidence suggests that locking plates improve results of treatment of proximal humerus fractures and distal femoral periprosthetic fractures in the elderly. Loss of fixation is associated with failure to achieve stability at the fracture site. Principles of fracture fixation in osteoporotic bone defined prior to the introduction of locking plates should still be applied.     

Early postoperative acetabular discontinuity after total hip arthroplasty

Periprosthetic acetabular fracture is a rare complication after total hip arthroplasty (THA). However, we have treated 2 patients with acute postoperative acetabular discontinuity that occurred 2 and 3 weeks after primary THA. Both fractures were in elderly osteoporotic female patients with minimal trauma and may have developed from unrecognized intraoperative fractures. Pelvic stability was restored with acetabular revision using medial morselized bone grafting and a cemented reconstruction cage. This report demonstrates that early postoperative periprosthetic acetabular discontinuity after THA is a risk in elderly patients with severe osteoporosis and that salvage of acetabular fixation can be achieved with cemented cage reconstruction and medial morselized bone grafting.     

Der Prothesennagel—primär belastungsstabiles Implantat bei peri- und subprothetischen Frakturen des Femurs

Increasing numbers of total hip arthroplasties in combination with increasing age and growing daily activities of the elderly lead to increasing numbers of periprosthetic fractures and revision arthroplasties in osteoporotic bone. The prosthesis nail is a hybrid of a hip prosthesis and an intramedullary nail allowing immediate full weight bearing and early rehabilitation. The prosthesis nail consists of three self-locking components: a distally locked intramedullary nail, different lengthening modules, and a hip prosthesis module. From 1992 to 1999, 28 prosthesis nails were implanted in 26 patients (40-88 years, mean age: 71 years). The indications were 21 peri- and subprosthetic fractures caused by trauma, 2 fractures of the proximal femur in combination with a fracture of the femoral head or severe degenerative arthritis, and 4 revision arthroplasties associated with poor bone quality. A combination of the prosthesis nail and bone cement was used in one patient suffering from a pathological fracture of the distal femur. Patients were additionally treated with wire cerclage (six patients) and autogenous bone grafting (ten patients). All patients-except those who received a reconstruction of the acetabulum in the same session (four patients)-were mobilized with full weight bearing on the operated side as soon as wound pain diminished. Bone healing was observed in all periprosthetic fractures. In three patients the prosthesis nail had to be revised: one patient suffered from recurrent dislocations and in one patient weighing 350 pounds limb shortening occurred after the distal locking screw broke. Intramedullary infection was observed once after treatment of a periprosthetic fracture. When bone union was achieved the prosthesis nail was removed and the patient was mobilized with a girdlestone situation. The idea of the prosthesis nail is based on the logical consequence of treating femur fractures with the most efficient procedure, which is intramedullary nailing. The prosthesis nail can be applied according to the requirements of the fracture as a reamed or unreamed nail and immediate full weight bearing is possible. Considering the high average age of the patients, low morbidity, short rehabilitation time, and low costs are the major advantages of this new device. Taking into account the unfavorable preoperative conditions associated with elderly and multimorbid patients, the rate of complications is relatively low.     

Periprosthetic femoral fractures--a comparison between cemented and uncemented hemiarthroplasties

Over a 2-year period, 244 patients underwent hemiarthroplasty for a displaced intracapsular femoral neck fracture. Seventy patients had a cementless Austin-Moore prosthesis (AMP) inserted and 174 patients were treated using a cemented Thompson hemiarthroplasty. All the AMPs were inserted by or under the supervision of an orthopaedic consultant. Five patients (7%) from the AMP group sustained a periprosthetic femoral fracture. Two were iatrogenic and three occurred postoperatively after a simple fall. The fractures occurred proximally around the prosthesis (Johansson type I). Four required revision surgery. There were no periprosthetic femoral fractures in the Thompson group. When compared to the cemented Thompson hemiarthroplasties, the number of periprosthetic femoral fractures was significantly greater with the AMP. Patients in the AMP group were significantly older, although there was no significant difference in ASA grade between the two groups. There was no significant difference in age or gender between those who sustained a periprosthetic fracture and those who did not. These findings suggest that due to the increased risk of periprosthetic femoral fracture, cemented hemiarthroplasty is preferable. Furthermore, with modern cementing techniques, elderly frail patients appear to tolerate bone cement, which may serve to reinforce an osteoporotic proximal femur.     

Winkelstabile Implantate

The biomechanical advantages of fixed angle locking plates resulted in a wide clinical use. The spectrum of indications ranges from complex periarticular fractures to metaphysial and diaphysial comminuted fractures, corrective osteotomies and to the application in periprosthetic fracture situations. The internal fixator principle provides particular advantages in the treatment of osteoporotic bone fractures as well as in the use as a bridging plate in wide multifragmentary diaphysial fractures as a form of elastic fixation with secondary fracture healing. Disadvantages of fixed angle locking plates are secondary screw perforations e.g. in proximal humeral fractures, the fixation of distractions, difficult implant removal (e.g. cold-welded screws) and higher implant costs.     

Locking plate osteosynthesis for Vancouver Type B1 and Type C periprosthetic fractures of femur: a report on 12 patients

Many methods have been described to stabilise periprosthetic fractures around a total hip arthroplasty. Locking plate fixation offers increased angular stability and, theoretically, better fixation in osteoporotic bone. This study presents our results with the use of locking plate fixation for Vancouver Type B1 and Type C periprosthetic fractures following total hip arthroplasty (THA). Twelve patients underwent fixation of periprosthetic fractures with either a locking compression plate (LCP) or a distal femur less invasive stabilisation system (LISS). There were six Type B1 and six Type C fractures. One patient died soon after surgery. The mean follow-up was 13.9 months (range 12-18 months). The fracture healed in 10 of the remaining 11 patients with a median time to union of 4.8 months. There was one implant failure prior to fracture healing and one implant failure after fracture healing. Both were attributed to technical errors. Seven patients returned to their previous level of mobility. Two patients required the use of one walking stick after fracture healing, but had been able to walk unaided before their fall. One patient required two sticks, after previously requiring only a single stick. There were no infections. Our experience encourages us that locking plates have a role to play in managing periprosthetic fractures around a stable femoral stem, especially in patients with poor soft tissue and osteoporosis.     

Vancouver B1型股骨假体周围骨折的手术治疗

目的探讨Vancouver B1型股骨假体周围骨折的理想手术治疗方式。方法2000年3月至2008年1月,12例VancouverB1型股骨假体周围骨折患者行切开复位、内固定治疗。男2例,女10例;年龄62—85岁,平均72岁。内固定方式包括LISS锁定接骨板系统、加压接骨板系统,部分病例结合使用多道钢丝或钢缆捆扎固定,及异体柱状皮质骨和（或）DBM人工骨植骨。对术后骨折延迟愈合患者行自体骨髓灌注等治疗。结果患者均获得随访,随访时间12—96个月,平均32个月。除1例术后发生骨折移位失败外,骨折均愈合,愈合时间3～12个月,平均4．3个月。Harris评分：65—92分,平均79分。结论VancouverB1型股骨假体周围骨折发生率高,处理棘手。目前,LISS系统是治疗此类骨折最有效的方式之一,应尽量使用微创技术以减少骨折处的血供破坏,如需切开整复骨折,应常规植骨,必要时术后可于骨折处定期灌注自体骨髓以促进骨愈合。     

骨质疏松性骨折与骨转移瘤的骨显像鉴别诊断

目的分析骨质疏松性骨折的骨显像特征,评价其用于与转移性骨肿瘤鉴别诊断的价值。方法回顾性研究53例骨质疏松性骨折患者的临床及骨显像资料,提出骨质疏松性骨折的特征性影像表现,并通过对53例骨质疏松性骨折患者和随机抽取的100例骨转移瘤患者的阅片试验,评价骨显像用于骨质疏松性骨折与肿瘤骨转移鉴别诊断的可行性及其临床诊断效能。结果骨质疏松性骨折在骨显像上常表现为多发病灶,其特征性影像表现为与骨骼走形相垂直的点状或短条状浓聚,横行于椎体的线样浓聚,或位于骶骨的“H”形浓聚,这些病灶无膨胀性生长或沿骨骼走形分布特点。依据上述影像特征与肿瘤骨转移进行鉴别,其诊断灵敏度、特异性、准确性分别为96.2%、97.0%和96.7%;且阅片者之间(kappa值:0.80~0.89)及阅片者自身(kappa值:0.82~0.86)的判断结果一致性较好。结论在骨显像中,骨质疏松性骨折具有特征性影像表现,不仅可用于骨质疏松性骨折的诊断,也可用于骨质疏松性骨折与骨转移瘤的鉴别诊断。