Vitamin D insufficiency: A risk factor to vertebral fractures in community-dwelling elderly women

Objective

To determine the risk factors for the presence of moderate/severe vertebral fracture, specifically 25-hydroxyvitamin D (25-OHD).

Study design

Cross-sectional study conducted for 2 years in the city of São Paulo, Brazil including community-dwelling elderly women.

Methods

Bone mineral density (BMD), serum 25-OHD, intact parathyroid hormone (iPTH), calcium and estimated glomerular filtration rate (eGFR) were examined in 226 women without vertebral fractures (NO FRACTURE group) and 189 women with at least one moderate/severe vertebral fracture (FRACTURE group). Vertebral fracture assessment (VFA) was evaluated using both the Genant semiquantitative (SQ) approach and morphometry.

Results

Patients in the NO FRACTURE group had lower age, increased height, higher calcium intake, and higher BMD compared to those patients in the FRACTURE group (p < 0.05). Of interest, serum levels of 25-OHD in the NO FRACTURE group were higher than those observed in the FRACTURE group (51.73 nmol/L vs. 42.31 nmol/L, p < 0.001). Reinforcing this finding, vitamin D insufficiency (25-OHD < 75 nmol/L) was observed less in the NO FRACTURE group (82.3% vs. 93.65%, p = 0.001). After adjustment for significant variables within the patient population (age, height, race, calcium intake, 25-OHD, eGFR and sites BMD), the logistic-regression analyses revealed that age (OR = 1.09, 95% CI 1.04–1.14, p < 0.001) femoral neck BMD (OR = 0.7, 95% CI 0.6–0.82, p < 0.001) and 25-OHD <75 nmol/L (OR = 2.38, 95% CI 1.17–4.8, p = 0.016) remains a significant factor for vertebral fracture.

Conclusion

Vitamin D insufficiency is a contributing factor for moderate/severe vertebral fractures. This result emphasizes the importance of including this modifiable risk factor in the evaluation of elderly women.     

Haemoglobin predicts length of hospital stay after hip fracture surgery in older patients

Objectives

Treating anaemia in older patients who have undergone hip fracture surgery is to enhance functional recovery. The relationship between peri-operative haemoglobin levels and outcome after hip fracture surgery are controversial. We assessed whether higher haemoglobin levels predict length of hospital stay after hip fracture surgery in elderly subjects.

Study design

A follow-up study in a historical cohort was performed in 317 patients aged 65 years old undergoing hip fracture surgery over the period 2004–2006 at the Leiden University Medical Centre.

Mean outcome measures

Linear regression analysis was used to assess the association between pre- and post-operative haemoglobin level and length of hospital stay after controlling for age and sex.

Results

Anaemia after hip fracture surgery was present among 86% of the patients. Length of hospital stay after hip fracture surgery in elderly subjects with post-operative anaemia (10.7 days) was significantly longer than in elderly subjects without post-operative anaemia (7.5 days, p = 0.007). Post-operative haemoglobin levels and length of hospital stay were inversely related (p = 0.013). The length of hospital stay was not related with pre-operative haemoglobin level.

Conclusion

Higher postoperative haemoglobin levels predict shorter length of hospital stay after hip fracture surgery in the elderly. A definitive randomized clinical trial has to demonstrate whether this association is causal.     

人工关节置换术治疗高龄不稳定性股骨转子间骨折

目的探讨70岁以上高龄不稳定性股骨转子间骨折患者采用人工关节置换术的疗效。方法对2004年1月～2007年12月行人工关节置换术治疗的25例70岁以上不稳定性股骨转子间骨折患者进行回顾性分析。病人年龄70～85岁,平均76.5岁。随访期限6～24个月,平均15.2个月。应用Harris评分标准进行结果评价。结果患者均在术后4周下地负重行走。髋关节功能接近伤前水平,生活基本能够自理。髋关节功能按Harris评分：术前为84～97（90±4）分;术后为82～95（89±3）分。结论高龄股骨转子间骨折患者行人工关节置换术治疗,具有创伤小、手术时间短、卧床并发症减少、髋关节功能恢复快等优点,是一种比较理想的治疗手段。     

髋部骨折内固定术失败后行人工髋关节置换术的临床分析

目的 探讨髋部骨折内固定治疗失败的原因,并分析行人工髋关节置换术的临床疗效。方法 回顾性研究。纳入2011年3月—2018年7月哈尔滨医科大学附属第一医院收治的股骨颈及股骨粗隆间骨折内固定失败患者45例,其中男16例、女29例,年龄35~80岁,平均47.5岁;股骨颈骨折33例,股骨粗隆间骨折12例。股骨颈骨折依据Garden分型标准,Ⅱ型6例、Ⅲ型20例、Ⅳ型7例;股骨粗隆间骨折依据改良Evan分型标准,Ⅲ型1例、Ⅳ型4例、Ⅴ型7例。45例患者中,采用全髋关节置换术35例,人工股骨头置换术10例。观察患者手术时间、术中出血量、骨折愈合时间及术后并发症发生情况;末次随访时采用Harris评分评定髋关节功能及疗效,并与术前Harris评分进行对比分析;同时分析内固定失败原因。结果 所有患者均顺利完成手术,术中假体周围骨折1例,给予钢丝捆扎固定。手术时间50～150 min,平均72 min。术中失血量150～600 mL,平均260 mL。术后下肢深静脉血栓形成5例、浅表感染4例,予相应处理后治愈,肢体不等长(超过2 cm)2例,未给予特殊处理。45例患者均获随访,随访时间5～30个月,平均10.5个月。随访期间无感染、假体周围骨折、关节脱位、假体松动等并发症发生。假体周围骨折于术后3个月愈合。末次随访时Harris评分82～94(88±6)分,明显高于术前的32～36(34±2)分,差异有统计学意义(t=49.258, P＜0.01)。采用Harris评分评定疗效,优16例、良24例、可4例、差1例,优良率88.9%(40/45)。初次手术失败原因:内固定手术技术原因27例,其中螺钉置入位置或长度不理想12例、内固定物选择不当8例、骨折复位不良10例;股骨颈骨折手术时间＞伤后72 h 18例,其中＞1周9例;术后负重时间过早(＜12周)15例;术后再次跌倒或碰撞伤6例;原因不明7例。结论 导致髋部骨折内固定失败的原因包括医源性因素与患者源性因素。对于髋部骨折内固定术失败的患者,依据患者年龄及全身状况,采用全髋关节置换术或人工股骨头置换术治疗临床效果良好。     

术前评分系统在高龄老年患者髋部骨折围手术期风险评估中的应用探讨

目的 探讨术前评分系统在高龄老年髋部骨折围手术期风险评估中的应用价值,并评估短期随访效果。方法2017年3月至2019年3月本科对94例75岁以上的高龄老年髋部骨折患者行微创手术治疗,术前将患者的生理指标进行赋值评分,结合手术风险的赋值评分,二者之和作为整个手术风险分值,以20分为低风险组,21～25分为中风险组,26～30分为高风险组,30分为极高风险组,将其分组后比较各组之间术后并发症的发生率和术后1个月内的死亡率。结果 根据术前整个手术风险分值的高低,将患者划分到不同的风险组,分值越高所在的风险组级别越高,术后并发症的发生率低风险组与高、极高风险组之间、中风险组和极高风险组之间比较,差异有统计学意义(0.05)。本组94例纳入研究的病例中术后1个月内除了极高风险组死亡1例外,其余风险组未发生死亡病例,统计学比较差异无统计学意义(0.05)。结论 术前评分系统可以客观地预估高龄老年髋部骨折患者的手术风险和预后,对临床有指导意义。     

Vertebral fracture assessment in Moroccan women: Prevalence and risk factors

Introduction

Vertebral fracture assessment (VFA) is a fast, low-radiation technique which produces images that are of sufficient quality to be used to diagnose the presence of vertebral deformity consistent with fracture.

Objective

To study prevalence and risk factors of vertebral fractures using VFA in asymptomatic Moroccan women.

Methods

The study cohort consists of a population of 328 consecutive women aged over 50 (mean age, weight and BMI of 65 ± 6.5 (50–84) years, 72.0 ± 12.8 (42–125) and 29.4 ± 5.0 (17.1–45.8) kg/m², respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. Vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry.

Results

68% of vertebrae from T4–L4 and 75% from T8–L4 were adequately visualized on VFA. Vertebral fractures (grades 2 or 3) were detected in 25.6% (84/328) of these women. Thirty-two of women with VFA-identified fracture (38.0%) had only a single vertebral fracture, while the other 61.9% had two or more. Fractures were most common in the mid-thoracic spine and at the thoraco-lumbar junction. As would be expected, the prevalence of VFA-detected fractures increased with age and as BMD declined. Stepwise regression analysis showed that presence of vertebral fracture was mainly related to the spine osteoporotic status, age older than 65, history of peripheral fracture and more than six parities.

Conclusion

Vertebral fractures are common in asymptomatic Moroccan women and are related to age, low BMD, history of fracture and multiparity.     

合并脑卒中史的老年髋部骨折患者的临床特征及治疗效果分析

目的 探讨合并脑卒中病史的老年髋部骨折患者的临床特征,以及在老年髋部骨折共管模式下的治疗效果。方法 回顾性队列分析。纳入2018年11月—2019年11月在北京积水潭医院手术治疗的1 092例老年髋部骨折患者的临床资料,其中男306例,女786例,年龄65~95岁（平均79.6岁）。根据既往是否有脑卒中病史分为脑卒中组155例和非脑卒中组937例。脑卒中组患者发生脑卒中至髋部骨折手术时间均大于30 d。观察指标：（1）分析脑卒中组患者的临床特征（脑卒中类型、发病史、后遗症发生率、遗留肢体不利情况,以及肢体不利侧与肢体利侧发生骨折的占比）。（2）比较2组患者的年龄、性别、骨折类型、骨折侧别、伤前能否户外活动、伤前行走是否需要辅具等临床特征的差异。（3）比较2组患者的入院48 h内手术率、术前等待时间、住院时间,比较不同观察时间的死亡率、再手术率,以及并发症发生率、活动恢复情况、健康相关生活质量等结果的差异。结果 （1）脑卒中组155例患者的临床特征：其中,脑梗死141例（91.0%）,脑出血14例（9.0%）;1次脑卒中发病史148例（95.4%）,≥2次发病史7例（4.5%）;有脑卒中后遗症60例（38.7%）;遗留肢体不利的患者43例（27.7%）,其中81.4%（35/43）骨折发生在肢体不利侧,18.6%（8/43）发生在利侧。（2）2组患者的性别、骨折侧别比较差异均无统计学差异（P值均>0.05）;脑卒中组患者较非脑卒中组患者的中位年龄小（79岁与81岁）,脑卒中组患者股骨颈骨折发生率（58.7%,91/155）、辅具帮助行走的比例（43.9%,68/155）及无法户外活动的比例（11.6%,18/155）均较非脑卒中患者高（49.6%,465/937;23.5%,276/937;5.7%,53/937）,差异均有统计学意义（P值均<0.05）。（2）2组患者的入院48 h内手术率、术前等待时间、住院时间、再手术率及并发症发生率比较差异均无统计学意义（P值均>0.05）;院内死亡率及入院后30 d、120 d、1年死亡率差异均无统计学意义（P值均>0.05）;入院后30 d、120 d、1年骨折术后并发症发生率与再手术率差异均无统计学意义（P值均>0.05）;患者恢复伤前活动能力的比较,入院后30、120 d差异均无统计学意义（P值均>0.05）,入院后1年随访脑卒中组（48.9%,68/139）低于非脑卒中组（59.8%,468/782）,差异有统计学意义（χ²=5.79,P<0.001）。脑卒中组入院后30 d、120 d、1年健康相关生活质量评分为0.62（0.46,0.74）、0.78（0.57,0.90）和0.83（0.57,0.94）分均低于非脑卒中组的0.69（0.51,0.78）、0.83（0.73,0.94）和0.93（0.75,1.00）分,差异均有统计学意义（Z=-3.12、-2.97、-4.83,P值均<0.05）。结论 合并脑卒中史的老年髋部骨折患者,骨折总体发病年龄稍早于无脑卒中史者,既往多有1次脑梗死病史发作,少部分人遗留有后遗症,伤前活动能力较差,髋部骨折多发生在脑卒中后遗留肢体活动不利侧。共管模式下对于脑卒中病史超过30 d的老年髋部骨折患者尽早实施手术是安全有效的。     

PKP治疗骨质疏松性椎体压缩骨折疗效分析

目的总结经皮椎体后凸成形术(Percutaneous kyphoplasty,PKP)治疗骨质疏松性椎体压缩骨折的临床疗效。方法收集2009年08月~2013年08月泰州市中医院骨科采用PKP治疗的72例(80个椎体)患者资料;采用疼痛视觉模拟评分(Visual analogue scale,VAS)进行手术前后疼痛评估,观察Cobb角变化及并发症情况。结果术后随访1年以上;所有病例疼痛症状均缓解,VAS评分术前(8.0±0.82)分、术后(3.7±0.66)分,差异有统计学意义(0.05);Cobb角术前为(23.49±12.75)°,术后(10.35±5.57)°,差异均有统计学意义(0.05);本组病例手术均获得成功,12例患者出现骨水泥渗漏,8例渗漏到椎体旁,未出现椎体后缘渗漏,均未出现神经症状;相邻椎体骨折2例,伤椎再骨折3例。结论 PKP治疗骨质疏松性椎体压缩骨折可快速有效地缓解患者疼痛、恢复病椎高度,术中术后并发症发生率低。     

16例中青年股骨头骨折的临床治疗

[摘要] 目的 探讨和总结中青年股骨头骨折治疗的临床疗效。方法 随访我院自2001年2月~2012年5月手术治疗的16例中青年股骨头骨折病例，男12例，女4例；年龄23~54岁，平均（38.39±8.63）岁。PipkinⅠ型5例；Ⅱ型7例；Ⅲ型1例；Ⅳ型3例。采用Smith-Peterson入路10例，Kocher-Langenbock入路4例，Moore入路2例。骨块摘除3例，拉力螺钉固定13例，3例合并髋臼后壁骨折病例中2例采用重建钢板内固定，1例采用铆钉固定。结果 平均随访时间为（40.1±8.56）月（25.1~50月），所有骨折均愈合，无感染发生，无内固定失败，无接受髋关节置换的病例。按照Merle d’Aubigne和Postel评分，优良率为（9/16）56.3%，中（3/16）18.7%，差（4/16）25%。4例患者发生股骨头内固定术后缺血性坏死，5例患者发生了异位骨化，1例继发创伤性关节炎。结论 运用空心螺钉治疗中青年股骨头骨折可获得满意的早期疗效，但股骨头骨折术后并发症发生率相对较高，需对术后髋部功能进行长期随访     

Subsequent hip fracture in osteoporotic hip fracture patients

Purpose: A significant number of patients who have experienced previous surgical treatment for an osteoporotic hip fracture experience a subsequent hip fracture (SHF) on the opposite side. This study aims to analyze the risk factors and the correlation between osteoporosis and SHF on the opposite side in order to assess the usefulness of bisphosphonate treatment for the prevention of SHFs. Materials and Methods: We included 517 patients treated from March 1997 to April 2009 in this study. The inclusion criteria included previous unilateral hip fracture, without osteoporotic treatment, and a T-score less than -3.0 at the time of the fracture. We studied these patients in terms of death, SHF, alcoholism, living alone, dementia, dizziness, health status, osteoporotic treatment after fracture and bone mineral density (BMD). In total, 34 patients experienced a SHF. We selected another 34 patients without a SHF who had similar age, sex, body mass index, BMD, diagnosis, treatment and a follow up period for a matched pair study. We compared these two groups. The average follow up was 8.3 years and 8.1 years, respectively. Results: The mortality rate of the 517 patients was 138 (27%). The BMD at the time of fracture demonstrated no statistical difference between the two groups (p>0.05). Nine patients (26%) within the SHF group were prescribed Risedronate and 18 patients (53%) received the same treatment in the non-SHF group. There was a statistical relationship with the treatment of osteoporosis (p=0.026). The average BMD of patients with SHF was -5.13 and -5.02 in patients without SHF was (p>0.05). Conclusion: Although primary surgical treatments are important for an excellent outcome in osteoporotic hip fractures, treatment of osteoporosis itself is just as important for preventing SHFs.     

Calcium-vitamin D3 supplementation is cost-effective in hip fractures prevention

Objective: To assess the cost implications for a preventive treatment strategy for institutionalised elderly women with a combined 1200 mg/day calcium and 800 IU/day vitamin D₃ supplementation in seven European countries. Design: Retrospective cost effectiveness analysis based on a prospective placebo-controlled randomised clinical trial. Data sources: Recently published cost studies in seven European countries. Clinical results from Decalyos, a 3-year placebo-controlled study in elderly institutionalised women. Trials: Decalyos study, with 36 months follow-up of 3270 mobile elderly women living in 180 nursing homes, allocated to two groups. One group received 1200 mg/day elemental calcium in the form of tricalcium phosphate together with 800 IU/day (20 μg) of cholecalciferol (vitamin D₃), the other placebo. Results: In the 36 months analysis of the Decalyos study, 138 hip fractures occurred in the group of 1176 women, receiving supplementation and 184 hip fractures in the placebo group of 1127 women. The mean duration of treatment was 625.4 days. Adjusted to 1000 women, 46 hip fractures were avoided by the calcium and vitamin D₃ supplementation. For all countries, the total costs in the placebo group were higher than in the group receiving supplementation, resulting in a net benefit of €79 000–711 000 per 1000 women. Conclusion: This analysis suggests that the supplementation strategy is cost saving. The results may underestimate the net benefits, as this treatment has also shown to be effective in decreasing the incidence of other non-vertebral fractures in elderly institutionalised women.     

老年髋部骨折围手术期深静脉血栓形成的危险因素分析

目的 探讨影响老年髋部骨折患者围手术期下肢深静脉血栓（DVT）形成的相关危险因素。方法 回顾性分析2016年1月至2018年12月上海市浦东新区人民医院收治的363例60岁及以上老年髋部骨折患者的临床资料。其中,男118例,女245例;年龄60 ～ 97岁,平均（73.9±8.6）岁;股骨转子间骨折134例,股骨颈骨折229例;髋关节置换184例,内固定179例。采用多普勒彩超诊断下肢深静脉血栓。采集病例资料包括一般资料（性别、年龄、体重指数（BMI）、既往病史、吸烟史、损伤类型、受伤至手术时间）,实验室检查（血浆D-二聚体浓度）,手术相关资料（手术时间、术中出血、术中输血、手术方式）。对数据进行统计学分析。结果 363例中56例检测出DVT,总体发病率15.4%。一般资料对比显示年龄≥80岁、BMI≥25 kg/m²、有吸烟史、有心脑血管疾病史、高能量损伤、受伤至手术时间＞2 d时DVT发病率较高（P＜0.05）;D-二聚体≥5 μg/mL时DVT发病率较高（P＜0.05）;手术相关资料对比显示手术时间＞2 h、术中出血＞200 mL,术中输血、人工关节置换的患者DVT发病率较高（P＜0.05）。多因素Logistic回归分析显示：年龄≥80岁、吸烟史、手术时间＞2 h、人工关节置换及D-二聚体≥5 μg/mL是影响老年髋部骨折围手术期DVT形成的独立危险因素。结论 老年髋部骨折围手术期DVT发病率较高,围手术期应根据相关危险因素对患者采取早期积极的预防措施,降低DVT的发生率。     

加速康复外科在老年髋部骨折治疗中的应用进展

髋部骨折病人多为骨质疏松较为严重的老年病人。随着老龄化社会的到来以及人口增长加速,髋部骨折病人数量呈现明显上升趋势。老年髋部骨折病人卧床时间长,基础疾病多,具有较高的并发症发生率和死亡率。加速康复外科(Enhanced Recovery After Surgery,ERAS)被证明是有效的围手术期处理措施。通过降低手术创伤的应激反应、减少并发症、降低死亡率,达到加速康复的目的。本文就ERAS在老年髋部骨折病人治疗中的应用进展进行综述。     

Individualizing fracture risk prediction

Low bone mineral density (BMD) and clinical factors (CRF) have been identified as factors associated with an increased relative risk of fractures. From this observation and for clinical decision making, the concept of prediction of the individual absolute risk of fractures has emerged. It refers to the individual's risk for fractures over a certain time period, e.g. the next 5 and 10 years. Two individualized fracture risk calculation tools that are increasingly used and are available on the web are the FRAX algorithm and the Garvan fracture risk calculator. These tools integrate BMD and CRFs for fracture risk calculation in the individual patient in daily practice. Although both tools include straightforward risk factors, such as age, sex, previous fractures, body weight and BMD, they differ in several aspects, such as the inclusion of other CRFs, fall risks and number of previous fractures. Both models still need to be validated in different populations before they can be generalized to other populations, since the background risk for fractures is population specific. Further studies will be needed to validate their contribution in selecting patients who will achieve fracture risk reduction with anti-osteoporosis therapy.     

股骨颈骨折直接行髋关节置换术与内固定失败后再行髋关节置换术的比较

目的 通过对股骨颈骨折直接行髋关节置换术与内固定失败后再行髋关节置换术临床结果的比较,为股骨颈骨折手术方式的选择提供依据.方法 回顾性分析随访2年的43例股骨颈骨折内固定失败后冉次行髋关节置换术(A组)和52例股骨颈骨折直接行髋关节置换术(B组)的临床资料,比较两组患者的手术情况、术后并发症、术后2年的髋关节功能和生活质量.采用Charnley评分法评定手术侧髋关节的疼痛、活动度和运动情况.采用欧洲生活质晕评分EQ-5D评分体系评定病人的健康生活质量.结果 A组和B组的手术时间、术中出血量、术后2年的髋关节功能评分和生活质量评分分别为:1.9±0.2和1.4±0.2小时、525.6±50.8和462.3±47.8ml、13.4±2.3和15.2±2.4、0.67±0.26和0.72±0.25分,两者比较均具有统计学意义(P<0.05).结论 内固定失败后再次行髋关节置换术临床效果较股骨颈骨折直接行髋关节置换术差,对于股骨颈骨折内固定容易出现骨折不愈合或缺血坏死的病例宜直接选择髋关节置换术.     

Clinical analysis of the rap stress stimulator applied for crus fracture after skeletal external fixation

Introduction

Open crus fracture is still difficult in clinical treatment because of the delayed fracture union and high rate of nonunion after the operation. A consensus has been reached that mechanical stress can promote fracture healing. We independently developed a stress stimulator, which can provide longitudinal pressure for the fixed fracture end of the lower legs to promote fracture healing. The purpose of this study is to explore the advantages and clinical effect of the rap stress stimulator applied for open crus fracture after skeletal external fixation.

Material and methods

One hundred and sixty-five patients (183 limbs) who suffered from open tibia and fibula fracture received skeletal external fixation, of which 108 limbs were treated with the rap stress stimulator after external fixation and 75 limbs were treated with regular functional exercises of muscle contraction and joint activity only. Then the fracture healing time and rate of nonunion were compared between the two groups.

Results

The mean fracture healing time and rate of nonunion in the group treated with the rap stress stimulator were 138.27 ±4.45 days and 3.70% respectively, compared to 153.43 ±4.89 days and 10.67% in the group treated without the stimulator.

Conclusions

The rap stress stimulator significantly shortened the fracture healing time and reduced the rate of nonunion for treating open tibia and fibula fractures.     

老年髋部骨折围手术期失血量的临床观察

目的通过观察髋部骨折围手术期血红蛋白水平改变,总结髋部骨折患者围手术期隐形失血量、总失血情况,探讨围手术期失血量的危险因素。方法选择北京市顺义区医院骨科2011年12月至2013年12月老年髋部骨折患者,记录患者一般情况,包括性别、年龄、并发症、骨折类型,手术方式（分别按照空心钉、关节置换、动力性髋螺钉和髓内钉的标准流程操作）、抗凝药物使用情况、出血量、手术时间等,根据患者血红蛋白水平波动、输血量计算患者隐形失血量、总失血量,通过方差分析及多因素线性分析计算围手术期间总失血量的独立危险因素。结果 2011年12月至2013年12月共有161例老年髋部骨折患者入选,经单因素方差分析及多因素线性回归分析,发现服用抗凝药物（均P=0.000）、手术方式（P=0.000,P=0.004）是围手术期出血量较多的独立危险因素。结论老年髋部骨折围手术期隐形失血量远远大于术中出血量,髓内钉术中出血量较关节置换、动力性髋螺钉（DHS）系统少,但隐形失血量、总失血量较其他三种手术方式明显增多,此外,服用阿司匹林等抗凝药物可增加术中出血量、隐形失血量及总失血量。     

髋部骨折围术期区域阻滞的解剖学研究进展

目的 总结髋部骨折手术治疗所涉及的组织结构的神经支配、走行及阻滞方法,为髋部骨折围术期区域阻滞镇痛提供解剖学基础。方法 以“髋部骨折”“神经阻滞”“髋关节”“神经支配”“解剖”“髂筋膜”和“hip fracture”“nerve block”“hip joint”“innervation”“anatomy”“fascia illaca”等为中、英文关键词,在中国知网、万方数据库、PubMed、Web of Science数据库中检索2021年11月之前发表的有关髋关节神经支配及髋部骨折围术期区域阻滞研究的文献1 722篇,通过阅读文章标题与摘要,剔除与研究方向不符、内容重复、无法获取全文的文献,共纳入文献43篇,并查阅解剖学著作2部,进行研读与分析,重点是总结与髋部骨折区域阻滞相关的解剖学成果。结果 髋部骨折手术治疗涉及的组织结构之支配神经来源于腰丛、骶丛及脊神经,选择髂筋膜间隙阻滞或股神经联合股外侧皮神经、闭孔神经阻滞可有效完成围术期镇痛。结论 髋部骨折病变部位及手术区域的神经支配明确;进行有效的区域阻滞可满足手术对麻醉的要求,并能提供良好的术后镇痛,建议临床推广。     

人工股骨头置换术治疗老年患者不稳定型股骨粗隆间骨折

目的通过对比人工股骨头置换术(artificial femoral head replacement,AFHR)与股骨近端防旋髓内钉(proximal femoral nail antirotation,PFNA)在治疗高龄患者不稳定型股骨粗隆间骨折的疗效,探究人工股骨头置换术在治疗高龄患者不稳定型股骨粗隆间骨折的可行性。方法回顾性分析2015年1月至2016年6月本院治疗的不稳定型股骨粗隆间骨折高龄患者共47例(均为单侧骨折),男28例,女19例,平均年龄为(80.83±4.83)岁。AFHR组27例,男17例,女10例,平均年龄(81.26±4.87)岁,A2.2型17例,A2.3型10例;PFNA组患者20例,男11例,女9例,平均年龄(79.56±4.75)岁,A2.2型13例,A2.3型7例。对比分析两组患者术前术后血红蛋白、红细胞比积、白蛋白、手术时间和术后下地负重时间等指标,并通过Harris评分、VAS评分评估患者术后恢复情况。结果所有患者均进行了6个月的随访,术后均未发生严重并发症;两组患者术前术后血红蛋白、红细胞比积差值组间比较,差异具有统计学意义(P0.05);两组患者术后下地负重时间、手术时间、Harris评分比较,差异具有统计学意义(P0.05)。术前术后白蛋白差值和术后VAS评分方面,两组患者比较差异无统计学意义(P0.05)。结论人工股骨头置换术具有下地负重时间早、髋关节功能恢复快等优势,可作为治疗高龄不稳定型粗隆间骨折的可选方法;但手术出血量较多、手术时间长,因此需要根据患者实际情况及手术医师熟练程度进行选择。