Primary repair for concurrent bilateral intertrochanteric fracture and femoral head necrosis with prolonged shank biologic total hip replacement: A case report and surgical techniques

For the treatment of an intertrochanteric fracture combined with femoral head necrosis in middle-age patients, it has been controversial whether to perform fracture reduction and fixation first then total hip replacement, or direct total hip replacement. We present a rare case of 53-year-old male patient suffered from bilateral intertrochanteric fracture caused by a road traffic injury. The patient had a history of femoral head necrosis for eight years, and the Harris score was 30. We performed total hip replacement with prolonged biologic shank prostheses for primary repair. One year after the surgery, nearly full range of motion was achieved without instability (active flexion angle of 110°, extension angle of 20°, adduction angle of 40°, abduction angle of 40°, internal rotation angle of 25°, and external rotation angle of 40°). The Harris score was 85. For the middle-aged patient with unstable intertrochanteric fractures and osteonecrosis of the femoral head, we can choose primary repair for concurrent bilateral intertrochanteric fracture and femoral head necrosis with prolonged shank biologic total hip replacement.     

Transphyseal fracture-dislocation of the femoral neck: a case report and review of the literature

We describe a case of transphyseal hip fracture-dislocation in a 7.5-year-old patient who was treated initially by open reduction and internal fixation. Soon after the injury, the femoral head developed avascular necrosis. The treatment was focused on maintaining adequate hip range of motion and providing femoral head containment with a combined subtrochanteric femoral osteotomy and shelf acetabuloplasty. The patient's young age and good hip remodeling potential contributed to the favorable clinical outcome 3 years after the injury. The long-term prognosis remains guarded, however.     

闭合复位DHS内固定治疗老年股骨转子间骨折61例

目的探讨老年股骨转子间骨折的治疗方法。方法采取闭合复位动力髋螺钉(DHS)内固定治疗老年股骨转子间骨折61例。结果随访1～3.3年,术后1年死亡4例,其余骨折在12～14个月内骨愈合,无髋内翻畸形、内固定断裂及松脱发生,患肢轻度外旋畸形2例,7例偶见髋关节行走痛、屈髋活动稍受限。结论闭合复位DHS内固定是治疗老年股骨转子间骨折的可靠方法。     

Physeal remodeling after internal fixation of slipped capital femoral epiphyses

Rounding off the femoral neck metaphysis helps improve hip function in slipped capital femoral epiphysis (SCFE). Remodeling by physeal growth, not previously reported, may also contribute. By studing the changes in physeal-shaft angle after internal fixation (IF), we found evidence of physeal remodeling in one of 21 mild, five of 23 moderate, and in all of 11 severe slips. Although the amount of remodeling averaged 11.7 degrees, it occurred in 100% of severe slips (p less than 0.001). This support the use of initial pin fixation and a wait of at least 2 years before realignment femoral neck osteotomies are considered.     

The place of threaded pin fixation in the treatment of slipped upper femoral epiphysis

Pin fixation in the treatment of slipped upper femoral epiphysis was evaluated in 60 patients admitted to the authors' hospital in Melbourne between 1970 and 1978. Forty-three cases were reviewed at an average of eight years following initial treatment. For chronic slips, in situ fixation with pins prevented further slip and promoted growth plate closure. The complication rate was low. Best results were achieved with two or three threaded pins placed into the posteroinferior segment of the femoral head to avoid avascular necrosis. Early upper femoral osteotomy was not required, as considerable bone remodeling occurred even after growth plate closure. In contrast, avascular necrosis was common following treatment of acute, severe slips, even with gentle internal rotation of the leg to reduce the acute component of the slip and pinning.     

Anterior perineal dislocation of the hip with fracture of the femoral head. A case report

Traumatic anterior perineal hip dislocation with an associated fracture of the femoral head is a rare entity. A 26-year-old man injured in a motorcycle accident was treated by closed reduction of the dislocation within three hours after admission. However, several reports of patients with anterior hip dislocation with associated femoral head fractures were treated nonoperatively and had unfavorable results when treatment failed to achieve anatomical position of the fragments. Consequently, this patient was treated by open reduction and internal fixation of the fractured fragment. Follow-up examination three and one-half years after the operation showed painless functional range of hip motion with only minimal discomfort after prolonged exertion.     

The geometry of slipped capital femoral epiphysis: implications for movement, impingement, and corrective osteotomy.

Metaphyseal impingement limits motion in high-grade slipped capital femoral epiphysis (SCFE). A three-dimensional volume/surface computer model was used to study the geometry of impingement, which may take the form of impaction, which causes levering or requires compensatory alteration in motion, or inclusion that occurs after remodeling and may lead to acetabular cartilage damage. The majority of deformities seen clinically can be reproduced with posterior epiphyseal displacement in the plane of the physis. By using the 3-D movements of normal walking, this model predicts little anterior metaphyseal impingement in the normal hip. As posterior slip angle increases to 25 degrees , minor impingement can be eliminated with as little as 20 degrees of external rotation. High-grade posterior slips (75 degrees ) require external rotation of 50-60 degrees during walking to minimize impaction. Sitting increases impingement for all slip geometries, requiring proportionately greater external rotation. As remodeling restores a more normal arc of motion, an increasing proportion of the femoral head is composed of the remodeled, included metaphyseal prominence. This study explores the potential role of contact between the acetabulum and the metaphysis in the production of abnormal range of motion after SCFE, and simulation estimates the correction needed by osteotomy to allow normal walking and sitting. The inclusion of significant metaphyseal surfaces in the remodeled hip may be one factor in subsequent degenerative changes associated with SCFE.     

股骨头骨折后并发股骨头缺血性坏死的治疗

目的 探讨股骨头骨折内固定术后并发股骨头缺血性坏死的治疗.方法 对单侧股骨头骨折内固定术后股骨头缺血性坏死采用带血运骨瓣转移术治疗的26例临床资料进行回顾分析.21例数字减影血管造影(DSA)检查明确股骨头及其周围骨的血供后行内固定物取出、带血运骨瓣转移术.1例内固定物取出后行全髋置换术.结果 施行带血运骨瓣转移术的术后平均随访23个月(12～38个月),根据Harris髋关节功能评分标准进行临床评价.根据手术前后Ficat分期改变进行影像学评价.对其中15例进行术后DSA检查以明确坏死股骨头血运重建情况.术后2髋改行人工全髋关节置换.股骨头得到重建的病例,术后Harris髋关节功能评分提高至平均86.2分(术前平均54分),其中临床成功率为92.0%,影像学成功率为84.0%.15例重建股骨头手术后DSA评估提示血管蒂充盈好,骨瓣血运丰富.结论 股骨头骨折内固定术后股骨头坏死发生率较高(可达40%).在取出内固定物同时行带血运骨瓣转移治疗股骨头缺血性坏死、股骨头血运重建良好,早期疗效满意.     

Osteotomy for femoral anteversion. Complications in 95 children

Totally, 95 children with increased femoral anteversion had derotational substrochanteric osteotomy with plate fixation. The mean anteversion angle was reduced from 48 degrees to 4 degrees, internal hip rotation from 81 degrees to 42 degrees, and external rotation increased from 9 degrees to 48 degrees. All the osteotomies healed, but serious complications occurred in 13 of the 95 patients. Because of the risk for complications and the trend towards spontaneous regression of femoral anteversion with age, we recommend a much more conservative attitude with regard to operative treatment.     

Osteotomy for femoral anteversion: Complications in 95 children

Totally, 95 children with increased femoral anteversion had derotational subtrochanteric osteotomy with plate fixation. The mean anteversion angle was reduced from 48° to 4°, internal hip rotation from 81° to 42°, and external rotation increased from 9° to 48°.

All the osteotomies healed, but serious complications occurred in 13 of the 95 patients. Because of the risk for complications and the trend towards spontaneous regression of femoral anteversion with age, we recommend a much more conservative attitude with regard to operative treatment.     

钉板内固定系统治疗股骨转子间骨折的疗效分析

目的探讨切开复位钉板系统内固术治疗股骨转子间骨折的临床疗效。方法应用动力髋螺钉（DHS）治疗A1、A2型骨折36例;动力髁螺钉（DCS）治疗A3型骨折22例。通过术前、术后影像学对比了解骨折愈合、颈干角改变及内固定并发症情况;根据Harris评分评估髋关节功能。结果58例均获随访,时间4-26（11.5±1.4）个月,骨折全部愈合,颈干角维持良好,无钢板松动、断裂。按Harris评分标准：优52例,良5例,差1例。结论钉板内固定系统治疗股骨转子间骨折操作简单,固定牢靠,术后髋关节功能恢复良好,是治疗股骨转子间骨折的有效方法,但必须严格把握DHS及DCS的适应证。     

股骨颈骨折内固定失败Ⅱ期行髋关节置换的早期疗效

目的:研究青壮年股骨颈骨折患者内固定失败后Ⅱ期行髋关节置换的早期临床疗效。方法:2008年6月至2010年6月,对24例股骨颈骨折内固定术后股骨头坏死患者行全髋关节置换术,其中男12例,女12例;年龄18～58岁,平均42.9岁。术后行X线检查,并根据Harris评分标准评价临床疗效。结果:23例获得随访,平均随访时间34.4个月(25～48个月),1例术后并发髋关节脱位,未发现髋关节感染、松动或假体周围骨折等并发症。Harris评分为90.9±4.3,优18例,良4例,可1例。结论:Ⅱ期全髋关节置换治疗股骨颈骨折内固定术后并发股骨头坏死,术中手术难度增加,但可以获得良好的早期疗效。     

关节镜下股骨头颈成形术治疗凸轮型股骨髋臼撞击症

 目的 探讨髋关节镜下股骨头颈成形术治疗凸轮（Cam）型股骨髋臼撞击症的可行性及临床疗效。方法 2007年10月至2009年4月收治Cam型股骨髋 臼撞击症患者31例,男12例,女19例;年龄18～45岁,平均34.1岁。术前行体格检查、X线摄片和三维CT明确诊断。所有病例均行髋关节镜下关节清理术和股骨 头颈成形术。术后1个月、3个月、6个月、1年及以后每年1次随访。比较术前和末次随访时的撞击试验结果、髋关节活动度、α角、疼痛视觉模拟评分（visual analogue scale,VAS）和改良Harris髋关节评分。结果 所有患者均得到随访,随访时间18~36个月,平均22.7个月。末次随访时撞击试验均为阴性,髋关节屈 曲活动度和屈曲90°位内旋活动度分别达到121.0°±11.7°和30.1°±12.7°,α角由术前74.2°±10.7°降至44.7°±8.3°,疼痛VAS由术前（6.1±1.1） 分降至（0.9±0.7）分,改良Harris髋关节评分由术前（41.2±5.7）分提高至（73.6±4.1）分,差异均有统计学意义（P<0.05）。结论 髋关节镜下股骨头颈 成形术能够切除股骨头颈结合部骨性隆起,恢复股骨头颈结合部的自然弧度,有效缓解Cam型股骨髋臼撞击症的症状和改善髋关节活动度。     

Peri-prosthetic femoral shaft fractures treated with plate and cable fixation.

Management of post-operative peri-prosthetic femoral shaft fractures remains difficult and controversial, with no widely accepted form of treatment. Fractures at the tip of a femoral component are associated with poor union rates. We present a series of 15 fractures at the component tip extending proximally in association with a loose cement mantle. All 15 patients were treated with open reduction and internal fixation using a plate and cable system. They were followed to clinical and radiological union, at an average of 3.5 months (range 3-5 months). At final review examination, 13 patients had achieved pre-fracture mobility, with one patient requiring a single walking stick, and one requiring a Zimmer frame. Three patients under-went revision surgery after successful fracture union and rehabilitation, with long stemmed femoral components. The plate and cable procedure is not technically demanding and avoids hip exposure. This form of internal fixation provides immediate fracture stability, allowing early ambulation, hence avoiding the complications and difficulties of other methods of treatment. Such fractures should be acutely treated to achieve fracture union with a plate, cable, and screw internal fixation technique. The loose components can be revised electively, preferably by a revision hip surgeon.     

关节镜下股骨头颈成形术治疗混合型股骨髋臼撞击症

目的评估和分析关节镜下股骨头颈成形术治疗混合型股骨髋臼撞击症(FAI)的疗效。 方法选取2016至2018年在青岛市市立医院收治的混合型FAI患者33例,其中男12例,女21例;年龄平均(38±3)岁,均经查体和X线片、CT确诊。髋关节镜下行关节清理和Cam成形,术后1、3、6、12个月进行随访,1年后每年随访1次。利用配对样本t检验比较术前和末次随访时患者撞击实验结果、髋关节活动度、α角、疼痛视觉模拟评分VAS疼痛评分、Harris髋关节功能评分及术后并发症发生情况。 结果术前与末次随访结果比较,撞击试验结果均为阴性,髋关节屈曲活动度(t＝－13.58,P<0.01)、屈曲90°内旋范围(t＝－13.22,P<0.01)、Harris髋关节功能评分(t＝－23.56,P<0.01)、α角(t＝15.08,P<0.01)、VAS疼痛评分(t＝17.05,P<0.01)较术前相比,差异均具有统计学意义。 结论髋关节镜Cam成形术治疗混合型FAI近期临床效果显著,有效缓解患者疼痛,改善髋关节活动度,提高关节功能。     

加长柄股骨头置换治疗固定失败的粗隆间骨折

目的探讨加长柄股骨头置换治疗内固定失败的高龄骨质疏松股骨粗隆间骨折的疗效，总结该治疗方法的临床经验。 方法2013年1月至2017年12月江门市新会区人民医院收治了l8例股骨粗隆间骨折内固定术后失败的患者，采用加长柄人工股骨头置换手术治疗，观察患者髋关节功能康复情况。纳入标准：年龄≥70岁；外伤引起股骨粗隆间骨折行内固定手术治疗后；影像学证实为粗隆间骨折内固定失败者。排除标准：有明显手术禁忌证；原骨折为肿瘤等病理性骨折；阿尔茨海默症或沟通障碍。Harris评分用于评定患者髋关节功能恢复，以术前术后Harris评分，假体松动、假体周围骨折、关节脱位等为随访内容，评分数据行t检验分析。 结果术后随访平均(16±4)个月，髋部疼痛消失或明显减轻，功能改善，均可辅助下步行活动，Harris评分由术前平均(34±3)分提高至术后12个月的(83±3)分，差异具有统计学意义(t ＝40.563，P <0.05)。 结论加长柄人工股骨头置换是治疗骨质疏松患者股骨粗隆间骨折内固定失败后的有效治疗方法，疗效满意，术后可以获得较好的功能恢复，减少卧床时间，提高生活质量。     

Screw head impingement after in situ fixation in moderate and severe slipped capital femoral epiphysis

In situ stabilization remains the standard of care in the treatment of stable slipped capital femoral epiphysis (SCFE). Screw placement perpendicular to the physis has shown satisfactory results with minimal complications. A prominent screw head may produce femoral acetabular impingement and pain after in situ fixation in severe SCFE. We performed a biomechanical study to establish whether screw head impingement occurs after in situ fixation of SCFE and to define the anatomy of slip severity and screw head position that may lead to impingement. A femoral neck dome osteotomy was created in a human cadaveric model simulating 2 conditions: a moderate and severe SCFEs. We tested the specimens after in situ fixation perpendicular to the simulated physis. The simulated SCFEs and normal control were tested through a full arc of motion. Coverage of the femoral head by the labrum was evaluated at 90 degrees of flexion using fluoroscopy. Impingement occurred at 70 degrees of hip flexion in the simulated moderate SCFE, and at 50 degrees of flexion in the severe simulated SCFE. Anteroposterior fluoroscopy revealed that screw heads lateral to the intertrochanteric line were unlikely to impinge on the acetabulum. Screw head impingement occurred with in situ fixation perpendicular to the physis in simulated moderate and severe SCFEs. Anteroposterior radiographs appear helpful in identifying a hip at risk for screw head impingement after in situ fixation. Alternative in situ fixation techniques (screw head resting lateral to the intertrochanteric line on the anteroposterior radiograph) may decrease the rate of screw head impingement in moderate and severe SCFEs.     

Mid-term results of concomitant epiphyseal fixation and trochanteric osteotomy for severe chronic slipped capital femoral epiphysis

The management of severe forms of slipped capital femoral epiphysis (SCFE) has been the subject of intense debate in the literature, and controversy remains as to whether the proximal femoral epiphysis should be realigned by intracapsular or extracapsular osteotomies or just fixated in situ. The aim of this study is to evaluate the late results of treatment of severe unreduced slipped capital femoral epiphyses by combined epiphyseal stabilisation in situ using a single cancellous screw and biplane corrective trochanteric osteotomy. Eighteen hips with severe chronic slipped capital femoral epiphysis before physeal closure were treated by combined epiphyseal fixation in situ using a single cancellous screw, and biplane corrective osteotomy fixed by an angled blade plate. The average follow-up period was 8 years. All patients achieved near-normal hip flexion, internal rotation and abduction, and most were able to bear weight in the early postoperative period. A satisfactory correction of the head-shaft angle was obtained post-operatively on both antero-posterior and frog leg lateral radiographs. There was no instance of chondrolysis, avascular necrosis or early osteoarthrosis. This procedure appears to offer a workable solution to the problem posed by the severely slipped capital femoral epiphysis.     

重建外侧壁及股骨矩治疗Evans-JensenⅤ型股骨转子间骨折的疗效分析

目的：探讨股骨近端防旋髓内钉（proximal femoral nail anti-rotation,PFNA）及重建钛板重建外侧壁及股骨矩治疗Evans-JensenⅤ型转子间骨折的手术疗效。方法：分析自2013年10月至2016年3月采用手术治疗的股骨转子间Evans-JensenⅤ型骨折患者30例。按手术方式分为两组：16例行闭合复位PFNA内固定（闭合复位组）;14例行小切口切开重建钛板重建股骨矩及外侧壁PFNA内固定（切开复位组）。观察比较两组患者手术中（失血量、手术持续时间）、手术后康复（手术后下床活动时间、骨性愈合时间）、手术相关并发症（内固定断裂、退出、螺旋刀片切出）,术后12个月行髋关节功能Harris评分,观察比较颈干角丢失度数。结果：30例患者均获随访,时间12~18个月。所有患者骨折顺利愈合,切开复位组患者手术失血量、手术持续的时间均明显大于闭合复位组（P<0.05）。切开复位组患者手术后下床活动时间、骨性愈合时间、手术相关并发症情况、术后12个月髋关节功能Harris评分、颈干角丢失度数均优于闭合复位组（P<0.05）。。结论：使用重建钛板对股骨矩及外侧壁进行复位和固定,PFNA髓内固定治疗Evans-JensenⅤ型的转子间骨折,能够恢复股骨矩及外侧壁对股骨头颈的支撑,有利于提高手术以后骨折断端及内固定的稳定性,减少单独采用PFNA治疗以后骨折断端移位、内固定松动、切出甚至断裂等风险。缩短老年患者卧床时间,减少手术相关的并发症,为Evans-JensenⅤ型股骨转子间骨折的治疗提供新的思路和方法。     

Differential diagnosis of a femoral neck/head stress fracture

STUDY DESIGN: Resident's case problem. BACKGROUND: Identifying stress fractures of the hip can be a challenging differential diagnosis. Pain presentation is not always predictable and radiographs may not show the fracture, especially during its early stages. Hip stress fractures left untreated can displace and necessitate open reduction internal fixation or total hip arthroplasty. DIAGNOSIS: A 70-year-old woman presented to the physical therapy clinic with complaints of right hip pain. She had been evaluated by a physician and radiographs of the hip, which revealed some arthritic changes, were otherwise normal. Upon examination, the physical therapist observed an antalgic gait, a noncapsular pattern of limitation of hip motion, an empty painful end feel at the end range of motion (ROM) for hip abduction, external rotation, and flexion, and extreme tenderness to palpation over the anterior hip region. The therapist suspected a more pernicious problem than osteoarthritis and discussed his suspicion with the physician. The physician subsequently requested an MRI that revealed a femoral neck and head stress fracture that was later confirmed with a bone scan. The patient was provided with a walker for ambulation with a non-weight-bearing status for 6 weeks, after which she returned to physical therapy for progressive weight bearing and strengthening. She was discharged with a relatively pain-free hip and was ambulating with a cane. A 2-month follow-up examination revealed a pain-free hip and a return to all premorbid activities, including ambulation without an assistive device. DISCUSSION: The presence of a normal radiograph of the hip should not be considered conclusive in ruling out a stress fracture in the hip region. The current case demonstrates how careful evaluation can reveal occult pathologies and prevent potentially catastrophic morbidity.