多学科协作诊疗在髋部骨折围手术期应用效果观察

目的观察多学科协作诊疗(MDT)在老年髋部骨折围手术期应用的效果。方法对照组纳入自2013-01—2014-06常规围手术期处理的42例老年髋部骨折(股骨颈骨折15例,股骨粗隆间骨折20例,股骨粗隆下骨折7例),观察组纳入自2014-07—2016-12行MDT围手术期管理的39例老年髋部骨折(股骨颈骨折11例,股骨粗隆间骨折23例,股骨粗隆下骨折5例)。结果 81例均获得随访,随访时间平均16(10~32)个月。与对照组比,观察组术后并发症发生率更低,末次随访髋关节功能Harris评分更高,患者满意度更高,差异有统计学意义(P0.05)。结论多学科协作诊疗在老年髋部骨折围手术期中应用可降低术后并发症发生率,促进患者髋关节功能恢复,提高患者满意度。     

老年髋部骨折患者术后死亡原因分析

目的调查老年髋部骨折患者术后死亡原因,分析死亡率是否与骨折类型、患者年龄有关。方法回顾性分析自2012-01—2016-12诊治的1 004例老年髋部骨折,股骨颈骨折420例,股骨粗隆间骨折584例。髓内钉内固定505例,空心钉内固定268例,动力髋螺钉内固定76例,髋关节置换术155例。随访时记录患者存活状态,包括死亡率及活动能力。结果中位随访时间39(27,48)个月。总体生存期为0～66个月,中位生存期为26(13,51)个月。老年髋部骨折患者术后1个月、6个月、1年死亡率以及总体死亡率分别为4.3%、9.8%、15.7%、31.9%,死亡高峰期主要集中在术后6个月内。122例股骨颈骨折患者死亡,198例股骨粗隆间骨折患者死亡。320例髋部骨折患者死亡原因:肺部感染122例,心源性疾病90例,脑血管疾病34例,肿瘤28例,感染性疾病19例,肺栓塞9例,消化道出血9例,肾功能衰竭9例。老年髋部骨折患者年龄越大其术后存活时间越短,而术后死亡率与骨折类型无关。结论老年髋部骨折患者术后死亡高峰期集中在手术后6个月内,肺部感染、心血管疾病、脑血管疾病、肿瘤是导致死亡的主要原因,骨折类型对死亡率没有影响,但患者年龄越大其死亡风险越高。     

合并脑梗塞后遗症的老年股骨粗隆间骨折的治疗策略

目的探讨合并脑梗塞后遗症的老年股骨粗隆间骨折围手术期治疗策略。方法回顾性分析采用股骨近端防旋髓内钉及人工股骨头置换的36例股骨粗隆间骨折合并脑梗塞后遗症,探讨围手术期术前准备、麻醉方式、手术方法及术后处理对预后的影响。结果 36例均获随访,随访时间6~12个月,平均9个月,切口均一期愈合,无感染、骨不连、神经损伤发生,髋关节功能按照Harris评分标准[2]评分,平均为(90.9±4.1)分。36例患者均安全度过围手术期,髋关节功能良好,仅2例发生轻度髋内翻畸形。结论合并脑梗塞后遗症的老年股骨粗隆间骨折患者通过充分术前准备、采用合理的麻醉方式、手术方法、准确的术后治疗和康复锻炼,可帮助患者安全的度过围手术期。     

老年髋部骨折患者围手术期死亡原因分析

目的分析老年髋部骨折患者围手术期死亡的原因。方法回顾性分析378例60岁以上老年髋部骨折的临床资料。结果围手术期死亡28例,其中3例术前死亡,25例术后1个月内死亡。死亡原因以心肺疾病为主,占60.7%。股骨颈骨折与股骨粗隆间骨折患者病死率差异无统计学意义(P%=0.836),内固定术治疗与关节置换术治疗术后患者病死率差异有统计学意义(P=0.020),年龄<75岁与≥75岁患者病死率差异有统计学意义(P=0.042)。结论老年髋部骨折患者围手术期病死率较高,死亡原因主要为心肺疾患、高龄,采用关节置换术治疗的患者死亡风险更大。     

PFNA内固定治疗老年脑梗死患者股骨粗隆间骨折围手术期脑卒中风险控制的研究

目的探讨股骨近端防旋髓内钉(PFNA)内固定治疗老年脑梗死患者股骨粗隆间骨折脑卒中风险控制方法。方法笔者自2011-10—2014-11采用PFNA内固定治疗合并脑梗死的老年股骨粗隆间骨折28例,进行围手术期脑卒中风险控制,包括术前脑卒中危险因素控制、术中监测、术后处理,观察围手术期脑卒中发生情况。结果 28例中1例术前出现脑梗死,2例术后出现脑梗死。结论围手术期综合防治可有效控制老年脑梗死患者股骨粗隆间骨折脑卒中发生率。     

锁定钢板治疗股骨粗隆间骨折21例疗效观察

目的探讨应用股骨近端解剖锁定钢板治疗老年粗隆间骨折的疗效。方法对21例老年股骨粗隆间骨折患者行股骨近端解剖锁定钢板固定治疗的临床效果进行观察。并进行术后随访。结果 21例伤口均I期愈合,平均住院时间4周。随访19例,失访2例,随访率90.5%。术后6个月骨折愈合良好17例,占81%,2例术后9个月骨折线愈合。功能恢复良好,无髋内翻、关节僵直、断钉、脱钉、钢板松动、断板等并发症的出现。结论老年粗隆间骨折常合并骨质疏松,应用股骨近端解剖锁定钢板内固定治疗此类疾病,手术操作简单,术后疗效可靠,有利于骨折愈合,并能减少老年患者的并发症,具有良好的临床应用价值。     

股骨大粗隆骨折与人工股骨头置换术后脱位关联的初步研究

目的探讨股骨大粗隆骨折与人工股骨头置换术后髋关节脱位的关联,分析原因及治疗方式。方法回顾性研究自2008-01—2015-12采用人工股骨头置换术治疗397例老年股骨颈骨折及不稳定型股骨粗隆间骨折。所有患者分为3组,A组(股骨颈骨折125例);B组(Evans-JensenⅡB型股骨粗隆间骨折74例);C组(Evans-JensenⅡA、Ⅲ型股骨粗隆间骨折198例)。通过对比各组术后髋关节脱位率,探讨股骨大粗隆骨折与人工股骨头置换术后脱位的关联。结果所有患者获得随访12~90个月,平均37个月。6例术后发生髋关节脱位。A组脱位1例,B组脱位1例,C组脱位4例,C组术后脱位率明显高于A、B 2组,差异有统计学意义(P0.05)。结论术前存在股骨大粗隆骨折患者行人工股骨头置换术后发生脱位的风险明显大于无股骨大粗隆骨折患者,股骨大粗隆骨折造成髋部外展肌力减弱,髋部肌力不平衡是人工股骨头置换术后髋关节脱位的重要影响因素。     

老年髋部骨折围手术期并发谵妄的临床特点及治疗

目的探讨老年髋部骨折围手术期并发谵妄的原因及处理措施。方法对2006年6月至2010年12月收住的102例股骨粗隆间骨折和股骨颈骨折围手术期发生谵妄的11例患者的临床资料进行回顾分析,了解发病特点、影响因素;给予心理沟通、治疗基础疾病、去除发病因素及支持对症处理,观察治疗效果。结果本组11例,活跃型10例,安静型1例;入院后手术前病例3例,术后8例,综合处理后出院前症状改善,恢复良好。结论围手术期谵妄是老年髋部骨折常见并发症,心理沟通、基础疾病治疗、去除发病因素及支持对症的综合处理是预防和治疗髋部骨折合并谵妄的有效措施。     

老年髋部骨折手术疗效及失败原因分析

目的分析老年髋部骨折手术疗效及内固定失败的原因。方法手术治疗207例老年髋部骨折,股骨颈骨折139例,股骨粗隆间骨折68例,探讨手术方式的选择以及失效情况。结果 205例获得随访,随访时间6～18个月。术后发生股骨头坏死15例,髋内翻8例,内固定松动6例,骨折不愈合5例,术后假体脱位2例,再骨折1例,手术失效率17.9%。结论影响老年髋部骨折手术成败的主要因素有:患者全身情况、骨折类型、复位情况、内固定选择及手术操作等。     

苏中地区3所中医院老年股骨颈与股骨粗隆间骨折的流行病学分析

目的分析苏中地区3所中医院老年股骨颈与股骨粗隆间骨折的流行病学特点。方法纳入自2010-09—2015-08靖江市中医院、扬州市中医院及江苏省中医院住院治疗的1 258例60~90岁老年股骨颈与股骨粗隆间骨折。检索各医院病例系统,记录患者年龄、性别、骨折类型、合并症、致伤原因、治疗方案、并发症、病死率等。结果 3所医院5年共诊治股骨颈骨折813例,股骨粗隆间骨折445例。股骨颈骨折中男387例,女426例;股骨粗隆间骨折中男228例,女217例;性别差异无统计学意义(P0.05)。股骨粗隆间骨折患者年龄小于股骨颈骨折患者,差异有统计学意义(P0.05)。3所医院5年内老年股骨颈与股骨粗隆间骨折发病率逐年增高,年均上升3.68%;其中股骨颈骨折发病率年均上升3.15%,股骨粗隆间骨折发病率年均上升4.48%。结论苏中地区3所中医院老年股骨颈与股骨粗隆间骨折发生率逐年上升,骨质疏松是高危因素,而正确的手术方式及围手术期处理可降低患者并发症发生率及死亡率。     

Analysis of outcomes for surgically treated hip fractures in patients undergoing chronic hemodialysis

BACKGROUND: Hip fractures in patients with end-stage renal disease are associated with frequent complications. This study analyzed clinical outcomes for patients on chronic hemodialysis who sustained hip fractures and were treated with a variety of fracture repair methods. METHODS: Twenty-nine patients with thirty-two hip fractures were analyzed in three groups. Group 1 consisted of eleven hips in eleven patients with an intertrochanteric fracture that was treated with internal fixation; Group 2, thirteen hips in ten patients with a femoral neck fracture that was treated with screw fixation; and Group 3, eight hips in eight patients with a femoral neck fracture that was treated with hemiarthroplasty. The outcomes and early and late complications were recorded for each group. Survivorship analysis was performed, and the mortality and complication rates for the groups were compared. RESULTS: In Group 1, eight complications occurred in six hips and nonunion developed in five hips. In Group 2, sixteen complications developed in eleven hips. Union was achieved in two of the thirteen hips, nine hips had nonunion, and two hips had osteonecrosis develop. In Group 3, only one hip had early complications, there were no late complications, and three patients died. The mean duration of follow-up was twenty-three months, and the overall mortality rate was 45%. There were no significant differences among the groups with respect to the cumulative survival proportions. Regression analysis of age, sex, and total hemodialysis duration in relation to mortality risk revealed that only age had a significant influence on mortality (p = 0.019). CONCLUSIONS: Surgical treatment of hip fractures in patients with end-stage renal disease who are on chronic hemodialysis is associated with frequent complications and a high mortality rate. Osteosynthesis is an acceptable option for treating intertrochanteric fractures and nondisplaced femoral neck fractures, but displaced femoral neck fractures should be treated with hemiarthroplasty.     

Operative treatment of hip fractures in patients receiving hemodialysis

Fifteen hips in 13 patients with hip fracture were treated in patients receiving hemodialysis for chronic renal failure. There were four intertrochanteric and 11 femoral neck fractures. 10 of the 11 femoral neck fractures and one of the four intertrochanteric fractures were treated with cemented bipolar hemiarthroplasty. Two intertrochanteric fractures fixed with sliding compression screws. External fixation was used for stabilization in two patients who had femoral neck and intertrochanteric fractures. Two intertrochanteric fractures that were treated with sliding hip screw showed radiological union postoperatively at the 6th month. Of the 11 hemiarthroplasty, four hips developed aseptic loosening (36%). According to Harris hip score grading system, three (37.5%) poor, two (25%) fair, two (25%) good and one (12.5%) case had excellent outcome in the hemiarthroplasty group. The survival of dialysis patients with a hip fracture is markedly reduced. Initial treatment of hemiarthroplasty allows early mobilization and prevents revision surgery.     

髋关节成形术治疗血液透析患者髋部骨折的短期疗效

目的探讨髋关节成形术治疗血液透析患者髋部骨折的短期疗效.方法 回顾性总结采用全髋或者半髋置换术治疗血液透析后髋部骨折的患者18例,男11例,女7例;平均年龄74岁（47～90岁）.所有患者均为诊断为慢性肾衰竭、慢性肾脏病（CKD）Ⅴ期,术前平均接受血液透析治疗的时间为4.2年（6个月～8年）.其中股骨颈骨折患者13例,股骨转子间骨折5例.根据骨折类型及采用的手术方式,将患者分为3组：A组6例股骨颈骨折患者,采用全髋关节置换术;B组7例股骨颈骨折患者,采用人工股骨头置换术;C组5例股骨转子间骨折患者,采用股骨头置换术.结果 13例患者获得随访,平均随访时间4年（1～7.3年）,术后Harris评分平均（81.0±8.4）分,优3髋、良4髋,疼痛评分平均（42.0±1.8）分.术后出现的并发症有：4例术后血肿;1例皮肤浅部感染;泌尿系感染3例,肺部感染4例;4例患者在围手术期死亡.患者的Harris评分与年龄有关.结论 采用髋关节成形术治疗血液透析患者髋部骨折能尽早让患者下地活动,避免长期卧床或者坐轮椅带来的各种并发症,有效的提高了患者的生活质量.     

Bilateral intertrochanteric fractures after surgical treatment of bilateral femoral neck fractures secondary to hypocalcemic convulsions with chronic renal failure: a case report and review of the literature

There have been no reports of bilateral femoral neck fractures followed by bilateral femoral intertrochanteric fractures. A 28-year-old man presenting with bilateral femoral neck fractures due to generalized convulsions was diagnosed with chronic renal failure and treated with percutaneous screw osteosynthesis and hemodialysis. During rehabilitation, the patient again had convulsions resulting in bilateral femoral intertrochanteric fractures 2 months after the operation. He was treated with a compression hip screw on the right side and conservatively on the left side. This is the first well-documented report on bilateral femoral neck fractures followed by bilateral femoral intertrochanteric fractures.     

Gamma3型髓内钉内固定治疗老年股骨粗隆间骨折76例分析

目的评估Gamma3型髓内钉内固定治疗老年股骨粗隆间骨折的临床效果。方法自2010—01—2012—12采用Gamma3型髓内钉内固定治疗老年（年龄〉65岁）St骨粗隆间骨折76例,并进行随访分析。结果1例于术后40d因呼吸衰竭死亡,余75例均获得随访6—24个月,平均15个月。随访患者骨折均愈合,愈合时间10-18周,平均14周。其中2例分别出现8°、10°髋内翻畸形,1例术后1年因内科疾病死亡。术后疗效根据髋关节功能Harris评分标准评定：优37例,良31例,可5例,差2例,优良率90．7％。结论Gamma3型髓内钉内固定治疗老年股骨粗隆间骨折具有手术创伤小、手术时间短、固定牢固、术后并发症少等优点,是治疗股骨粗隆间骨折的理想内固定物。     

PFNA治疗高龄骨质疏松性股骨粗隆间骨折体会

目的探讨股骨近端抗旋髓内钉(proximal fermoral nail anti-rotation,PFNA)在治疗高龄骨质疏松性股骨粗隆间骨折临床疗效。方法应用PFNA治疗36例75岁以上高龄骨质疏松性股骨粗隆间骨折患者,手术采用闭合复位,小切口置入PFNA内固定,同时注重围手术期处理及抗骨质疏松治疗。结果 36例获得随访,时间9～24个月,平均12个月。其中1例90岁患者,于术后9个月死于脑梗塞,其余35例骨折全部愈合,无感染、骨不连、髋内翻、内固定失效等并发症的发生。根据Harris功能评分标准:28例优,4例良,3例中,优良率91.4%。结论 PFNA对于高龄骨质疏松性股骨粗隆间骨折具有微创性,固定可靠,疗效满意等优点。     

老年股骨颈骨折与股骨转子间骨折围手术期失血量的临床对比研究

目的通过老年股骨颈骨折与股骨转子间骨折患者围手术期失血量的比较,为临床老年髋部骨折围手术期血液管理提供科学依据。 方法回顾性收集2018年7月至2020年4月间中国科学技术大学附属第一医院骨科收治的因低能量损伤导致的老年髋部骨折患者,共纳入69例。按照骨折类型分为股骨颈骨折组和股骨转子间骨折组,比较两组患者年龄、性别、骨折解剖部位以及术前合并症等基本信息,比较两组患者围手术期隐性失血量、显性失血量和总失血量。 结果股骨颈骨折组患者的平均年龄为（78±8）岁（男性10例,女性35例）,股骨转子间骨折患者的平均年龄为（75±10）岁（男性12例,女性12例）。两组患者术前隐性失血量[股骨颈骨折组：（238.33±97.82）ml ;股骨转子间骨折组：（344.80±130.01）ml,P<0.05]、围手术期隐性失血量[股骨颈骨折组：（314.46±130.30）ml;股骨转子间骨折组：（459.73±173.34）ml,P<0.05]、显性失血量[股骨颈骨折组：（77.78±27.29）ml;股骨转子间骨折组：（160.42±51.03）ml,P<0.05]和总失血量[股骨颈骨折组：（392.24±133.62）ml;股骨转子间骨折组：（620.15±171.11）ml,P<0.05]差异均具有统计学意义,股骨转子间骨折组均高于股骨颈骨折患者组。股骨转子间骨折组（半髋关节置换和PFNA内固定术）较股骨颈骨折组（全髋关节置换和半髋关节置换术）均有较多的显性失血量、术后隐性失血量、围手术期隐性失血量和总失血量（均P<0.05）。但两组内不同手术方式比较,差异无统计学意义。 结论老年股骨转子间骨折患者较股骨颈骨折患者有更多的围手术期隐性失血量、显性失血量和总失血量,在临床诊治中,尤其需要更加重视老年股骨转子间骨折患者的围手术期血液管理。     

Functional outcome, mortality and in-hospital complications of operative treatment in elderly patients with hip fractures in the developing world

Hip fracture has been increasing in frequency for several decades, and 70–90% of patients who sustain a hip fracture survive for at least one year. Many of these survivors fail to regain their prefracture functional status. No work in this regard has been done in the developing world. Elderly patients with acute intertrochanteric fracture and fracture of the femoral neck were followed up prospectively for 12 months after surgery to record the mortality, morbidity, functional status and complications. Three hundred and forty-five patients (61% female) were assessed at six and 12 months after surgery, which included 62.9% intertrochanteric fractures and 37% femoral neck fractures. The mechanism of injury was from a fall in 67% of the cases. Nineteen patients died within six months after surgery while another eight died during the next six months. Obesity, male gender, multiple comorbidities and below normal ambulation status before fracture were identified as major determinants of bad functional outcome.     

重建粗隆及股骨矩关节置换治疗高龄不稳定粗隆间骨折

目的探讨高龄不稳定型股骨粗隆间骨折人工关节置换的治疗效果。方法 2004年3月至2009年12月对38例高龄股骨粗隆间骨折行股骨粗隆、股骨矩修复重建人工关节置换术。患者年龄78～91岁,平均83.6岁,按Evans-Jensen分型均为不稳定型骨折,所有病例都合并有内科疾病及骨质疏松。术后早期康复训练。结果住院期间无一例死亡,37例于术后2周内下床负重,均获得3～36个月随访,无骨不愈合、关节感染、关节脱位、假体松动、下肢深静脉血栓形成等并发症,3例于术后5～13个月死于其他疾病。术后6个月按Harris髋关节功能评分标准,髋关节功能优良者31例。结论股骨粗隆、股骨矩重建人工关节置换治疗不稳定型股骨粗隆间骨折具有卧床时间短、可早期负重、髋关节功能恢复快、术后并发症低的优点,对高龄不稳定型股骨粗隆间骨折是一种较合理的治疗方法。     

老年患者不同部位的髋部骨折对预后的影响

目的:研究骨折部位对老年髋部骨折预后的影响。方法:自2012年1月至2014年12月,共收治髋部骨折患者667例,根据骨折部位将髋部骨折分为股骨转子间骨折组和股骨颈骨折组,其中股骨转子间骨折组304例,男96例,女208例,平均年龄(80.33±7.94)岁;股骨颈骨折组217例,男74例,女143例,平均年龄(79.82±9.33)岁。比较两组患者入院资料、术后死亡率及独立生活能力的差异。结果:两组年龄、性别、合并症、ASA分级、麻醉方式差异不明显,但入院至手术等待时间、手术时间、术中出血量、术后引流量以及输血量差异有统计学意义。股骨转子间骨折术前、术后1、3、5 d白细胞计数较高,血红蛋白、白蛋白较低。股骨转子间骨折住院期间、术后1、3、6、12个月内死亡率较股骨颈骨折高,但差异无统计学意义。在存活患者中,出院时、术后1、3个月股骨颈骨折患者日常生活能力较股骨转子间骨折患者恢复更为满意,术后6、12个月,两组患者相比,日常独立生活能力差异无统计学意义。结论:尽管股骨转子间骨折对机体应激较大,但排除年龄、性别、合并症等因素的影响后,股骨转子间骨折和股骨颈骨折术后1年内死亡率差异不明显。和股骨转子间骨折患者相比,股骨颈骨折关节置换后早期功能恢复良好,但手术后1年,两者功能恢复差异不明显。