髋臼骨折--开放复位内固定与全髋关节置换的比较

病例组研究的结果说明:选择开放复位内固定或全髋关节置换对结果影响不大,但并发症如异位骨化等前者比后者的发生率高。研究人群的不同,尤其是年龄因素,可以单独影响结果。全髋置换的研究人群年龄大于开放复位内固定者,这使得关于更佳方法的结论不具有可行性。还需要随机对照试验提供更具有说服力的证据。     

A cetabular fractures

AMEDLINE searchwas conducted to identify studies published between January 1999 and November 2003 on OR IF and THA for tream ent of ace tabu lar fractu res. The search strategy identified 37 articles on OR1F and 56 articles on THA. From those identified, …     

Transverse posterior wall acetabular fracture pattern is associated with increased risk of periprosthetic joint infection after conversion total hip arthroplasty

IntroductionAcetabular fracture subtypes are associated with varying rates of subsequent conversion total hip arthroplasty (THA) after open reduction internal fixation (ORIF) with transverse posterior wall (TPW) patterns having a higher risk for early conversion. Conversion THA is fraught with complications including increased rates of revision and periprosthetic joint infections (PJI). We aimed to determine if TPW pattern is associated with higher rates of readmissions and complications including PJI after conversion compared to other subtypes.MethodsWe retrospectively reviewed 1,938 acetabular fractures treated with ORIF at our institution from 2005 to 2019, of which 170 underwent conversion that met inclusion criteria, including 80 TPW fracture pattern. Conversion THA outcomes were compared by initial fracture pattern. There was no difference between the TPW and other fracture patterns in age, BMI, comorbidities, surgical variables, length of stay, ICU stay, discharge disposition, or hospital acquired complications related to their initial ORIF procedure. Multivariable analysis was performed to identify independent risk factors for PJI at both 90-days and 1-year after conversion.ResultsTPW fracture had higher risk of PJI after conversion THA at 1-year (16.3% vs 5.6%, p = 0.027). Multivariable analysis revealed TPW independently carried increased risk of 90-day (OR 4.89; 95% CI 1.16–20.52; p = 0.03) and 1-year PJI (OR 6.51; 95% CI 1.56–27.16; p = 0.01) compared to the other acetabular fracture patterns. There was no difference between the fracture cohorts in 90-day or 1-year mechanical complications including dislocation, periprosthetic fracture and revision THA for aseptic etiologies, or 90-day all-cause readmission after the conversion procedure.ConclusionAlthough conversion THA after acetabular ORIF carry high rates of PJI overall, TPW fractures are associated with increased risk for PJI after conversion compared to other fracture patterns at 1-year follow-up. Novel management/treatment of these patients either at the time of ORIF and/or conversion THA procedure are needed to reduce PJI rates.Level of evidenceTherapeutic Level III (retrospective study of consecutive patients undergoing an intervention with analyses of outcomes).     

Open reduction and internal fixation alone versus open reduction and internal fixation plus total hip arthroplasty for displaced acetabular fractures in patients older than 60 years: A prospective clinical trial

IntroductionThe optimal treatment of elderly patients with an acetabular fracture is unknown. We conducted a prospective clinical trial to compare functional outcomes and reoperation rates in patients older than 60 years with acetabular fracture treated with open reduction and internal fixation (ORIF) alone versus ORIF plus concomitant total hip arthroplasty (ORIF + THA). Our hypothesis was that patients who had ORIF + THA would have better patient reported outcomes and lower reoperation rates postoperatively.MethodsInclusion criteria were patients older than 60 years with acetabular fracture plus at least one of three fracture characteristics: dome impaction, femoral head fracture, or posterior wall component. Eligible patients were operative candidates based on fracture displacement, ambulatory status, and physiological appropriateness. Patients received either ORIF alone or ORIF + THA (accomplished at same surgery through same incision). Outcome measurements included Western Ontario and McMaster Universities Osteoarthritis Index hip score, Short Form 36, Harris Hip Score, and Patient Satisfaction Questionnaire Short Form scores. Additionally, patients were monitored for any unplanned reoperation within 2 years.ResultsForty-seven of 165 eligible patients with an average age of 70.7 years were included. The mean Harris Hip Score difference favored ORIF + THA (mean difference, 12.3, [95% confidence interval (CI), -0.3 to 24.9, p = 0.07]). No clinically important differences were detected in any other validated outcome score or patient satisfaction score 1 year after surgery. ORIF + THA decreased the absolute risk of reoperation by 28% (95% CI, 13% to 44%, p < 0.01). No postoperative hip dislocation occurred in either group.ConclusionsIn patients older than 60 years with an operative displaced acetabular fracture with specific fracture features (dome impaction, femoral head fracture, or posterior wall component), treatment with ORIF + THA resulted in fewer reoperations than treatment with ORIF alone. No differences in patient satisfaction and other validated outcome measures were detected.     

Clinical results of conversion total hip arthroplasty after failed bipolar hemiarthroplasty

Total hip arthroplasty (THA) has been the most common surgery performed for complications of bipolar arthroplasty. We wanted to evaluate functional results and complications after conversion of bipolar hemiarthroplasty to THA in 25 patients followed for an average of 7.2 years. Indications for conversion included acetabular erosion with well-fixed femoral stem in 13 patients, acetabular erosion with femoral loosening in 8 patients, and periprosthetic fracture in 4 patients. The average Harris Hip Score improved from 41 (34 to 67) before conversion to 85 (65 to 95) at final follow-up. The average Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) score improved from 81 (41 to 96) before conversion to 17 (8 to 36) at final follow-up. Pain component of WOMAC improved from an average of 15 (7 to 20) to 4 (0 to 11). The stiffness component of WOMAC improved from 6 (2-8) to 30 (0-4) and the function component improved from 59 (36-68) to 17 (8-36). The complications included 2 recurrent dislocations, 2 dislocations, 1 acetabular loosening, and 1 trochanteric nonunion. One patient required revision of acetabular component. The conversion THA after symptomatic bipolar arthroplasty can offer reliable pain relief and functional improvement. The perioperative complications approximate those of revision THAs.     

Outcomes of Total Hip Arthroplasty After Acetabular Open Reduction and Internal Fixation in the Elderly—Acute vs Delayed Total Hip Arthroplasty

BackgroundOptimum management for the elderly acetabular fracture remains undefined. Open reduction and internal fixation (ORIF) in this population does not allow early weight-bearing and has an increased risk of failure. This study aimed to define outcomes of total hip arthroplasty (THA) in the setting of an acetabular fracture and compared delayed THA after acetabular ORIF (ORIF delayed THA) and acute fixation and THA (ORIF acute THA).MethodsAll acetabular fractures in patients older than 60 years who underwent ORIF between 2007 and 2018 were reviewed (n = 85). Of those, 14 underwent ORIF only initially and required subsequent THA (ORIF delayed THA). Twelve underwent an acute THA at the time of the ORIF (ORIF acute THA). The ORIF acute THA group was older (81 ± 7 vs 76 ± 8; P < .01) but had no other demographic- or injury-related differences compared with the ORIF delayed THA group. Outcome measures included operative time, length of stay, complications, radiographic assessments (component orientation, leg-length discrepancy, heterotopic ossification), and functional outcomes using the Oxford Hip Score (OHS).ResultsOperative time (P = .1) and length of stay (P = .5) for the initial surgical procedure (ORIF only or ORIF THA) were not different between groups. Four patients had a complication and required further surgeries; no difference was seen between groups. Radiographic assessments were similar between groups. The ORIF acute THA group had a significantly better OHS (40.1 ± 3.9) than the ORIF delayed THA group (33.6 ± 8.5) (P = .03).ConclusionIn elderly acetabulum fractures, ORIF acute THA compared favorably (a better OHS, single operation/hospital visit, equivalent complications) with ORIF delayed THA. We would thus recommend that in patients with risk factors for failure requiring delayed THA (eg, dome or roof impaction) that ORIF acute THA be strongly considered.     

Total hip arthroplasty following failed fixation of proximal hip fractures

Background:

Most proximal femoral fractures are successfully treated with internal fixation but a failed surgery can be very distressing for the patient due to pain and disability. For the treating surgeon it can be a challenge to perform salvage operations. The purpose of this study was to evaluate the short-term functional outcome and complications of total hip arthroplasty (THA) following failed fixation of proximal hip fracture.

Materials and Methods:

In a retrospective study, 21 hips in 20 patients (13 females and seven males) with complications of operated hip fractures as indicated by either established nonunion or fracture collapse with hardware failure were analysed. Mean age of the patients was 62 years (range 38 years to 85 years). Nine patients were treated for femoral neck fracture, 10 for intertrochanteric (I/T) fracture and two for subtrochanteric (S/T) fracture of the hip. Uncemented THA was done in 11 cases, cemented THA in eight hip joints and hybrid THA in two patients.

Results:

The average duration of follow-up was four years (2-13 years). The mean duration of surgery was 125 min and blood loss was 1300 ml. There were three dislocations postoperatively. Two were managed conservatively and one was operated. There was one superficial infection and one deep infection. Only one patient required a walker while four required walking stick for ambulation. The mean Harris Hip score increased from 32 preoperatively to 79 postoperatively at one year interval.

Conclusion:

Total hip arthroplasty is an effective salvage procedure after failed osteosynthesis of hip fractures. Most patients have good pain relief and functional improvements inspite of technical difficulties and high complication rates than primary arthroplasty.     

Total hip arthroplasty for posttraumatic arthritis after acetabular fracture

Total hip arthroplasty (THA) outcomes for posttraumatic arthritis after acetabular fracture have yielded inferior results compared to primary nontraumatic THA. Recently, improved results have been demonstrated using cementless acetabular reconstruction. Thirty-two patients underwent THA for posttraumatic arthritis after acetabular fracture; 24 were treated with open reduction internal fixation, and 8 were managed conservatively. Time from fracture to THA was 36 months (6-227 months). Average follow-up was 4.7 years (2.0-9.7 years). Harris Hip score increased from 28 (0-56) to 82 points (20-100). Six patients required revision. Five-year survival with revision, loosening, dislocation, or infection as an end point was 79%. Survival for aseptic acetabular loosening was 97%. Revision surgery correlated with nonanatomic restoration of the hip center and a history of infection (P < .05). Despite obvious challenges, advances in fracture management and cementless acetabular fixation in THA demonstrate improved results for posttraumatic arthritis following acetabular fracture.     

Total hip arthroplasty after ipsilateral intra-articular steroid injection: 8 years follow up

The purpose of the study was to assess the safety of Intra-articular steroid hip injections (IASHI), prior to ipsilateral total hip arthroplasty (THA). We investigated whether there was an excess of infection in such a group 7-10 years after total hip arthroplasty. A database of 49 patients who had undergone IASHI followed by ipsilateral THA was reviewed. The mean length of time between injection and arthroplasty was 12.1 months (5.1-19 months). We found 7 major complications. Ten patients died with no further hip surgery at a mean of 28 months from surgery ; 3 were lost to follow-up. The remaining group (36) were contacted by telephone at a mean of 97.8 (85-117) months from their surgery. No objective signs of joint infection were found. We believe our results show that ipsilateral steroid injection does not confer an increased risk of complications following subsequent THA, over an extended follow up.     

Total hip arthroplasty following failed internal fixation of hip fractures

A retrospective review was performed on 27 consecutive patients with total hip arthroplasty (THA) following failure of internal fixation of fractures of the proximal femur. The results were comparable to primary THA in femoral neck fractures. Considerably less satisfactory results were obtained in THA in intertrochanteric fractures. Bone loss and medial displacement of the femoral shaft led to high incidence of intraoperative complications and postoperative dislocations. Extreme care must be taken to avoid fracture and penetration of the femoral shaft. Autograft, allograft, or head and neck replacement components should be available for reconstruction of the difficult cases.     

Anatomic hip range of motion after implantation during total hip arthroplasty as measured by a navigation system

Simulation of prosthetic impingement is important for preventing complications after total hip arthroplasty (THA). Although the anatomical hip range of motion (ROM) in patients after THA is an essential parameter for these simulations, previous simulation studies substituted various clinical hip ROMs for the anatomical hip ROM. Using a navigation system, anatomical hip ROM was accurately assessed after implantation during primary THA in 30 patients. We found that the hip could be passively moved to 113 degrees of flexion, 34 degrees of extension, 46 degrees of abduction, 75 degrees of internal rotation, and 36 degrees of external rotation. Almost all reference hip ROMs used in previous simulations were smaller than these values. Therefore, wider hip ROM values should be used as parameters for such simulations.     

初次全髋关节置换术后5年以上随访结果与分析

目的评估初次全髋关节置换术（THA）后5年以上患者的临床疗效、并发症及其影响因素。方法对中山大学附属第一医院关节外科2006年6月前行THA的273例患者（305髋）进行随访,截至末次随访时,191例（206髋）患者获得随访,随访时间平均为9.3年（5-21年）,临床随访内容包括SF-36量表、术前、术后Harris评分及各种并发症。影像学评估包括骨盆正位、患髋正侧位片,判断人工假体位置、假体周围骨质以及并发症情况。结果随访率为69.96%,SF3-6体能方面总分由术前的（30.92±3.90）分（24~39分）提高至（53.69±3.97）分（44~62分）,在精神方面的总分则由术前的（45.91±5.63）分（37~56分）提高至（57.06±7.26）分（43~72分）。术前Harris评分为（46.71±10.76）分（5~68分）,末次随访时为（92.83±4.88）分（56~100分）。假体的5年生存率为98.06%,10年生存率为94.17%,15年生存率为85.92%,20年生存率为81.55%。混合型假体、非骨水泥型假体的翻修率分别为2.4%、5.6%。术后并发症包括跛行（17例）、脱位（3例3髋）、深静脉血栓（1例1髋）、假体周围骨折（1例1髋）、无菌性松动（9例9髋）、异位骨化（6髋）和感染（0例）等。结论本组病例整体疗效满意、假体生存期长,但随访率偏低,病例数偏少,需进一步完善随访机制,提高随访率。     

Pipkin骨折术后髋关节功能恢复影响因素分析

目的探讨影响Pipkin骨折术后髋关节功能恢复的因素。方法回顾分析2002年5月-2009年2月收治的37例Pipkin骨折患者临床资料。男32例,女5例;年龄26～98岁,中位年龄43岁。致伤原因:交通事故伤31例,摔伤4例,高处坠落伤2例。受伤至手术时间1～28 d,平均8.6 d。骨折根据Pipkin分型标准:Ⅱ型23例,Ⅲ型8例,Ⅳ型6例。27例采用切开复位内固定(open reduction and internal fixation,ORIF),10例行人工全髋关节置换(totalhip arthroplasty,THA)。对性别、年龄、受伤至手术时间、骨折类型、治疗方式与术后髋关节功能恢复相关关系进行统计学分析。结果术后患者切口均Ⅰ期愈合,无感染及下肢深静脉血栓形成发生。患者均获随访,随访时间10～94个月,平均40.5个月。X线片复查ORIF患者骨折于术后5～11个月达骨性愈合,平均8.9个月;THA患者无假体松动、下沉。末次随访时牛津髋关节评分标准(OHS)评分为16～58分,平均37.2分;获优12例,良13例,可2例,差10例。单因素分析表明,骨折类型及治疗方式对术后髋关节功能恢复有显著影响,差异有统计学意义(P<0.05)。多因素分析表明,骨折类型及治疗方式对术后髋关节功能恢复影响无统计学意义(P>0.05)。结论 Pipkin骨折分型及治疗方式可能影响Pipkin骨折术后髋关节功能恢复,术前应根据骨折分型选择恰当治疗方式以保证关节功能恢复。     

Dual Mobility hip replacement in hip fractures offer functional equivalence and a stability advantage - A case-controlled study.

BackgroundHip fracture is a common and serious injury in the elderly. Hip arthroplasty is the most frequently performed procedure for patients with an  intracapsular hip fracture. The majority of national guidelines recommend total hip arthroplasty (THA) for more active patients. Literature indicates significant stability advantages for dual mobility (DM) acetabular components in non-emergent scenarios. Evidence supporting the use of DM in hip fracture patients is limited.AimWe set out to ascertain if DM implants offer stability and/or functional advantages over standard THA in patients with hip fracture.MethodsWe utilised our local National Hip Fracture Database to identify all patients undergoing either a standard or DM THA for hip fracture (n=477) We matched cohorts based on age, AMTS, mobility status pre-operatively, gender, ASA and source of admission. Our primary outcome of interest was functional status using the oxford hip score (OHS). Secondary outcome measures included  dislocation, fracture and deep infection requiring further surgery.Results62 patient pairs were available for this study. Mean OHS for DM THA was 41.5 and for standard THA this was 42.7 (p=0.58). There were 4 dislocations in the standard THA group and 0 with DM THA. No difference was seen with infection or peri-prosthetic fracture.ConclusionThis study demonstrates functional equivalence between DM and standard THA. In addition it shows a trend towards less dislocation with DM THA. Cost savings from less instability may outweigh initial prosthesis costs. This study suggests a suitably powered RCT using instability as the primary outcome measure is indicated.     

系统性红斑狼疮合并股骨头坏死行全髋关节置换术的特点及其并发症的防治

目的探讨全髋关节置换术（THA）治疗系统性红斑狼疮（SEE）合并股骨头缺血性坏死（ANFH）的临床特点、围手术期的处理、并发症的防治及早中期疗效。方法回顾性分析本组26例SLE合并中晚期ANFH行THA的患者,其中男1例,女25例,手术时年龄26—67岁,平均38．6岁;其中单髋置换11例,一期双髋置换15例。采用Harris评分和SF-36评分相结合的方法进行门诊随访。结果平均随访28个月,SF-36平均（67．2±6．9）分,Harris髋关节功能评分平均（91．6±5．4）分,优于术前的平均（42．6±9．3）分（t=4．73,P〈0．05）。X线显示假体位置均良好,无松动现象。共发生并发症4例,分别为1例关节脱位,1例大腿痛,1例股骨矩劈裂骨折,1例肾功能不全加重。结论THA能显著改善SLE合并中晚期ANFH患者的髋关节功能,提高生存质量。内外科医师密切合作制定围手术期的处理方案是提高疗效、预防并发症的关键。     

Systemic complications following total hip arthroplasty

Total hip arthroplasty (THA) has stood the test of time in improving the human quality of life. However, there remain associated complications. Although there is a low incidence of complications, the typical complications following THA have been well described in the literature, including infection, dislocation, wear, thromboembolic disorders, and intraoperative fracture. Knowledge of the systemic complications of THA can dramatically affect patient outcomes.     

Total Hip Arthroplasty After Prior Acetabular Fracture: Infection Is a Real Concern

BackgroundAcetabular fractures often require surgical intervention for fracture fixation and can result in premature osteoarthritis of the hip joint. This study hypothesized that total hip arthroplasty (THA) in patients with a prior acetabular fracture who had undergone open reduction and internal fixation (ORIF) is associated with a higher rate of subsequent periprosthetic joint infection (PJI).MethodsAbout 72 patients with a history of acetabular fracture that required ORIF, undergoing conversion THA between 2000 and 2017 at our institution, were matched based on age, gender, body mass index, Charlson comorbidity index, and date of surgery in a 1:3 ratio with 215 patients receiving primary THA. The mean follow-up for the conversion THA cohort was 2.9 years (range, 1-12.15) and 3.06 years (range, 1-12.96) for the primary THA.ResultsPatients with a previous acetabular fracture, compared with the primary THA patients, had longer operative times, greater operative blood loss, and an increased need for allogeneic blood transfusion (26.4% vs 4.7%). Most notably, PJI rate was significantly higher in acetabular fracture group at 6.9% compared with 0.5% in the control group. Complications, such as aseptic revision, venous thromboembolism, and mortality, were similar between both groups.ConclusionThe present study demonstrates that conversion THA in patients with prior ORIF of acetabular fractures is associated with higher complication rate, in particular PJI, and less optimal outcome compared with patients undergoing primary THA. The latter findings compel us to seek and implement specific strategies that aim to reduce the risk of subsequent PJI in these patients.     

Metabolic syndrome and hip fracture: Epidemiology and perioperative outcomes

IntroductionHip fractures and metabolic syndrome (MetS) are becoming major global healthcare burdens as populations age. This study sought to determine the impact of MetS in hip fracture patients on perioperative outcomes following operative fixation or arthroplasty.MethodsData from the 2004–2014 Nationwide Inpatient Sample was used to select 3,348,207 discharges with hip fracture. MetS patients were identified by having at least 3 of 4 component comorbidities: hypertension, dyslipidemia, obesity, and diabetes. Logistic regression was used to estimate odds ratios for the association between MetS and perioperative outcomes adjusted for age, gender, race, payer status, and comorbidities.ResultsOverall, 32% of hip fracture patients were treated with open reduction internal fixation (ORIF), 28% hemiarthroplasty (HA), 18% closed reduction with internal fixation (CRPP), and 3% primary total hip arthroplasty (THA). The remaining 19% of cases were either treated via unspecified procedure of hip repair (9%), managed non-operatively (2%), underwent multiple procedures during the hospital stay (6%), or the surgical procedure data was missing (2%) and were excluded from procedural analyses. The prevalence of MetS was 7.9% and increased among minorities, patients treated at urban hospitals, with comorbidities (heart failure, kidney disease, peripheral vascular disease), and with Medicare coverage. MetS was associated with increased odds of any adverse event (p < 0.0001), specifically: acute renal failure, myocardial infarction, acute posthemorrhagic anemia. MetS was also associated with increased LOS (p < 0.0001) and increased total charges (p < 0.0001). However, MetS was associated with reduced odds of postoperative pneumonia, deep vein thrombosis and pulmonary embolism, surgical site infection, septicemia, and in-hospital mortality (p < 0.0001). The above associations were maintained for MetS patients stratified according to their treatment groups: HA, CRPP, and ORIF.ConclusionsMetS is associated with increased odds of complications in hip fracture patients but decreased odds of in-hospital mortality. This may be related to patients’ nutritional status and catabolic states in the perioperative period.     

人工髋关节置换术失败原因分析

目的 对人工髋关节置换术后失败的病例进行分析。总结经验，提高人工髋关节置换术的长期疗效。方法 １９９６年１１月～１９９９年４月共进行人工髋关节翻修手术３５例（３６髋），根据前次手术失败的原因进行分组并分析。结果 根据病例统计，在同一失败病例中，失败的原因往往不止一个，最常见的原因是假体松动、假体周围骨溶解，共２４例次，其次为人工股骨头引起髋臼磨损７例次，假体置入位置不良６例次，人工髋关节脱位３例次，术后感染３例次，假体股骨西柄断裂２例次。结论 人工髋关节置换术作为髋关节重建的一种有效的治疗方法而得到广泛的应用。其长期可靠的疗效与严格掌握手术指征，假体的适当选择和手术中正确操作有关。     

Hemiarthroplasty and total hip arthroplasty in 30,830 patients with hip fractures: data from the Dutch Arthroplasty Register on revision and risk factors for revision

Background and purpose — In the Netherlands about 40% of hip fractures are treated with a hemiarthroplasty (HA) or a total hip arthroplasty (THA). Although these procedures are claimed to have fewer complications than osteosynthesis (i.e., reoperation), complications still occur. Analyses of data from national registries with adequate completeness of revision surgery are important to establish guidelines to diminish the risk for revision. We identified risk factors for revision.

Patients and methods — All patients older than 50 years of age with a hip fracture treated with arthroplasty by orthopedic surgeons and registered in the (national) Dutch arthroplasty register (LROI) were included in the study. In this register, patient characteristics and surgical details were prospectively collected. Revision surgery and reasons for revision were evaluated. A proportional hazard ratio model for revision was created using competing risk analysis (with death as competing risk).

Results — 1-year revision rate of HA was (cumulative incidence function [CIF] 1.6% (95% CI 1.4–1.8) and THA 2.4% (CI 2.0–2.7). Dislocation was the most common reason for revision in both groups (HA 29%, THA 41%). Male sex, age under 80 years, posterolateral approach, and uncemented stem fixation were risk factors for revision in both THA and HA. THA patients with ASA classification III/IV were revised more often, whereas revision in the HA cohort was performed more often in ASA I/II patients.

Interpretation — After arthroplasty of hip fractures, both a posterolateral approach and an uncemented hip stem have higher risks for revision surgery compared with an anterolateral approach and an cemented stem.