高龄老年不稳定型股骨转子间骨折DHS固定与股骨头置换的临床评估

目的比较DHS内固定与股骨头置换术在治疗高龄老年不稳定型股骨转子间骨折的5项临床指标,评估两种治疗方法的优劣。方法随机抽取2000年6月～2004年12月高龄老年不稳定型股骨转子间骨折行DHS内固定(A组)与股骨头置换术(B组)各20例,对手术时间、术中出血量、术后下床锻炼时间、并发症、疗效优良率5项临床指标进行比较。结果5项临床指标显示B组疗效明显优于A组,两组数据经统计学处理有显著性差异(P<0.01)。结论股骨头置换术的疗效明显优于DHS内固定,其可作为临床治疗高龄老年不稳定型股骨转子间骨折的一种合理的选择。     

人工肱骨头置换与肱骨近端锁定钢板治疗老年复杂肱骨近端骨折的近期临床疗效分析

[摘要] 目的 对比分析人工肱骨头置换术和肱骨近端锁定钢板治疗老年复杂肱骨近端骨折的近期疗效。方法 回顾性分析本院骨科2012年1月~2014年6月采用人工肱骨头置换术和肱骨近端锁定钢板治疗的老年（年龄>65岁）NeerⅢ、Ⅳ部分肱骨近端骨折患者54例，人工肱骨头置换治疗（置换组）30例，肱骨近端锁定钢板内固定治疗（内固定组）24例。比较分析两组手术时间、术中出血量、随访Neer评分及Constant-Murley评分来评定两组临床疗效。结果 两组随访时间相仿，平均随访时间为19.5个月（12~36个月）。内固定组手术时间（101±13）分钟，术中出血量（237.9±32.4）mL，Neer评分（82.5±3.2），Constant-Murley评分（71.7±5.0）；置换组手术时间（98±11）分钟，术中出血量（246.0±39.8）mL，Neer评分（82.9±4.5），Constant-Murley评分（73.5±5.0）。两组手术时间、术中出血量、随访Neer及Constant-Murley评分比较差异均无统计学意义（P＞0.05）。内固定组有1例出现肩关节半脱位，肱骨头置换组有2例出现肩关节半脱位，通过三角巾悬吊后关节脱位均得到纠正。有1例四部分骨折患者，行内固定术后出现内固定松动、肱骨头坏死，改行人工肱骨头置换术。结论 人工肱骨头置换术和肱骨近端锁定钢板治疗老年肱骨近端复杂骨折的近期临床疗效相似，对不可修复的肱骨近端骨折宜行肱骨头置换术。     

Perioperative Mortality and Periprosthetic Fracture: A Single-Center Experience of 857 Uncemented Hemiarthroplasties for Displaced Femoral Neck Fractures

BackgroundUncemented hemiarthroplasty (UHA) for displaced femoral neck fracture (FNF) is favored by some surgeons because of the reduced rate of perioperative mortality and operative time. However higher rates of intraoperative and postoperative periprosthetic fractures (PPFs) have been reported. The aim of the study was to review day-0, day-1, day-2, day-30, and one-year mortality as well as intraoperative and postoperative PPF after UHA for displaced FNF and compare this with cemented hemiarthroplasties (CHAs) performed. Secondary objectives were to assess whether femoral stem geometry and alignment were associated with PPF in UHA.MethodsA retrospective observational study was conducted of patients treated with a hemiarthroplasty for a displaced FNF over an eleven-year period. Radiographic analysis was conducted of femoral geometry and stem alignment.ResultsOver the 11-year study period, 857 UHAs and 247 CHAs were performed. There were no on-table, day-0, day-1, or day-2 deaths in UHA. Intraoperative PPF occurred in 3.6% UHA and 2% CHA and postoperative PPF in 2.4% UHA and 4.8% CHA. Intraoperative PPF was not associated with increased mortality (P = .15), postoperative PPF, or all-cause revision in UHA. Valgus stem alignment was a risk factor for a postoperative PPF and additional surgery in UHA (P = .004).ConclusionUHA was associated with no perioperative deaths and a 30-day mortality rate of 5% in this series. It can be considered in patients with multiple medical comorbidities. Careful surgical planning and technique is important to optimize stem alignment particularly in Dorr C type femurs.     

Cementless Hemiarthroplasty for Intracapsular Femoral Neck Fractures in the Octa- and Nonagenarians

BackgroudCurrent evidence supports the use of cemented hemiarthroplasty for treatment of intracapsular femoral neck fractures since it is associated with a lower risk of implant-related complications. However, many medical centers employ the cementless technique for the frail elderly population because it is faster and has lower cardiovascular risks and perioperative mortality. This observational study reports the outcomes of cementless bipolar hemiarthroplasty for intracapsular femoral neck fractures in patients aged 80 years and older.MethodsA total of 424 patients (female, 77.1%) with a mean age of 86.9 years were operated for intracapsular femoral neck fractures between January 2009 and December 2017. Of those, 66.7% had an American Society of Anaesthesiologists (ASA) score of 3 or more. All operations were performed with the posterolateral surgical approach and all patients received a cementless stem. Intraoperative and perioperative values and in-hospital outcomes were evaluated, and clinical and radiographical follow-up was done at 40 days, 90 days, and when possible between 5 months and 12 months postoperatively. Multivariate analysis was performed to evaluate if there were factors affecting mortality.ResultsThe mean operative time was 50 minutes. There were no deaths intraoperatively. Intraoperative periprosthetic fractures occurred in 2.1% of the cases with 66.7% of them fixed through cerclage wires intraoperatively. The median length of hospitalization was 11 days (interquartile range, 8.75–15) and 2.4% of patients died while in hospital after surgery. Approximately 91.5% of patients presented with perioperative anemia. Only 1.9% of the complications were related to the implant, 62.5% of which were dislocations. More than 90% of patients were ambulatory either autonomously or with support at each follow-up assessment. Age, male sex, and higher ASA score were related to increased mortality.ConclusionsDespite some limitations, this observational study underlines that a cementless femoral stem of modern design can give good clinical outcomes, thus being an appropriate solution especially for the frail elderly.     

Increased infection risk after hip hemiarthroplasty in institutionalized patients with proximal femur fracture

In patients undergoing hip hemiarthroplasty (HHA) secondary to proximal femur fracture, acute periprosthetic joint infection (PJI) is one of the most important complications. We have detected an increased risk of PJI in chronic institutionalized patients (CIPs), and a higher number of early postoperative infections are caused by Gram-negative bacteria (GNB), not covered by the current prophylaxis (cefazolin in noninstitutionalized patients (NIPs) and cotrimoxazole in CIPs). We sought to compare infection characteristics between NIPs and CIPs, analyzing predisposing factors, causative pathogens, and antibiotic prophylaxis-related microbiological characteristics. We performed a retrospective review of our prospective institutional database to identify all patients consecutively admitted for HHA to treat proximal femur fracture at our centre between 2011 and 2013. PJI was diagnosed in 21 of 381 (5.51%) patients, with 10 of 105 (9.52%) in the CIP group and 11 of 276 (3.99%) in the NIP group, and statistical significance was achieved. GNB accounted for PJI in 14 (66.67%) patients. We detected a single case of methicillin-resistant Staphylococcus aureus (MRSA) infection in the NIP group.We confirm a higher risk of acute PJI among institutionalized patients, commonly caused by Gram-negative microorganisms, which are not covered by the current prophylaxis. New prophylactic strategies should be investigated in order to reduce this problem.     

锁定钢板与人工肱骨头置换治疗成人肱骨近端骨折疗效的Meta分析

目的对采取锁定钢板与人工肱骨头置换治疗成人肱骨近端骨折的临床疗效进行Meta分析,探讨两种手术方式的治疗效果。方法通过计算机检索中国生物医学文献数据库(CBM)、中文万方数据库、维普数据库(VIP)、中国知网(CNKI)及外文PubMed、Science Direct等数据库2004年1月至2013年12月期间发表的相关治疗肱骨近端骨折的各种对照研究,进行Meta分析。结果共纳入符合标准的文献9篇,采用Review Manager 5.2软件进行Meta分析,结果显示:锁定钢板与人工肱骨头置换比较Neer评分优良率方面差异无统计学意义(OR=0.84,95%CI:0.33~2.14,P=0.72),在ASES评分优良率方面无显著差异(OR=0.80,95%CI:0.26~2.44,P=0.69)。结论目前认为锁定钢板与人工肱骨头置换对特定骨折类型各有利弊。对于高龄粉碎性的肱骨近端骨折患者,多数倾向于人工肱骨头置换。对于老年粉碎性的肱骨近端骨折的患者,现有文献中没有足够的对照试验证明人工肱骨头置换的优越性。     

术前罗哌卡因联合右美托咪定和地塞米松髂筋膜间隙阻滞在高龄患者半髋关节置换术中的应用及对患者应激反应的影响

目的 探讨术前罗哌卡因联合右美托咪定和地塞米松行髂筋膜间隙阻滞对高龄患者半髋关节置换术后镇痛效果和应激反应的影响。方法 选取2020年01月至2021年10月入住中国人民解放军总医院第六医学中心拟行半髋关节置换术的高龄患者90例并随机分成两组,每组患者均于术前24 h及手术当日麻醉前30 min行骨折侧超声引导下腹股沟韧带上髂筋膜间隙阻滞,对照组患者使用0.375%罗哌卡因30 mL,观察组患者使用0.375%罗哌卡因联合0.5 μg/kg右美托咪定和0.1mg/kg地塞米松共30 mL,术后两组患者均连接静脉自控镇痛泵。比较两组患者入院后即刻（T0）、术前实施神经阻滞后12 h（T1）、入室时（T2）、术后12 h（T3）、24 h（T4）和48 h（T5）的静息视觉模拟评分（visual analogue scores, VAS）及T3~T5时刻的运动VAS评分;并记录两组患者术后镇痛泵的首次按压时间,镇痛药的使用剂量和不良反应的发生率;同时比较两组患者术前和术后1 d血清白细胞介素-6（interleukin-6, IL-6）、C反应蛋白（c reactive protein, CRP）、皮质醇（cortisol, Cor）、去甲肾上腺素（norepinephrine, NE）和肾上腺素（epinephrine, E）水平。结果 与对照组比较,观察组患者T2和T4时刻的静息VAS评分以及T3~T5时刻的运动VAS评分均降低（P<0.05）,且术后镇痛泵的首次使用时间推迟,镇痛药的使用剂量减少（P<0.05）。术后1 d,观察组血清IL-6、CRP、Cor、NE和E的水平明显低于对照组（P<0.05）,但两组患者术后并发症和不良反应的发生率比较,差异无统计学意义（P>0.05）。结论 术前罗哌卡因联合右美托咪定和地塞米松行髂筋膜间隙阻滞可有效减轻高龄患者半髋关节置换术后的疼痛程度、延长镇痛时间、减轻术后炎症和应激反应,且安全可靠。     

加长柄人工股骨头置换治疗高龄不稳定型股骨转子间骨折

目的评价应用加长柄股骨头置换治疗高龄骨质疏松不稳定型转子间骨折的临床疗效。方法对85例高龄不稳定型股骨转子间骨折采用加长柄人工股骨头置换术,根据Harris髋关节评分评价临床疗效。结果患者均获得随访,时间9~18个月。患者髋关节功能均恢复良好,术后3~6个月基本恢复生活能力。术后随访均未出现下肢深静脉血栓、关节脱位、人工假体松动、下沉或断裂、假体周围骨折等并发症。术后9个月根据髋关节Harris评分优良率达90.83%。结论加长柄人工股骨头置换是治疗高龄不稳定型转子间骨折安全、有效的方法,但远期疗效尚需进一步随访观察。