Nonunion after periprosthetic femoral fracture associated with total hip arthroplasty.

BACKGROUND: Nonunion after a periprosthetic femoral fracture associated with total hip arthroplasty occurs rarely. There is little information, to our knowledge, regarding the prevalence of this complication, its treatment, and the functional outcomes of treatment. The purpose of this study was to identify the patterns and frequency of nonunions of femoral fractures around total hip prostheses and to evaluate the results and problems associated with treatment of this complication in a consecutive series of patients. METHODS: The study included twenty-three nonunions of periprosthetic femoral fractures in twenty-three patients with an average age of fifty-five years (range, twenty-two to eighty-five years) at the time of the initiation of treatment of the nonunion. Thirteen of the fractures occurred during or after a primary total hip arthroplasty, and ten occurred during or after a revision total hip arthroplasty. According to the classification system of Duncan and Masri, there were six B1 fractures (associated with a well fixed prosthesis), seven B2 fractures (associated with a loose stem), and ten B3 fractures (associated with very poor proximal bone). Ten patients were managed with revision to a long-stem prosthesis. Six patients had revision to a proximal femoral replacement prosthesis. A two-stage technique consisting of removal of the prosthesis and open reduction and internal fixation of the nonunion followed by reimplantation of the prosthesis was used in two patients. Two patients were managed initially with bone-grafting alone, and two patients were managed nonoperatively. One patient who had an infection at the site of the nonunion was managed definitively with resection arthroplasty. RESULTS: The duration of clinical follow-up averaged 8.3 years (range, three months to twenty-three years), and that of radiographic surveillance averaged 7.0 years (range, eight months to seventeen years). Of the thirteen patients in whom an attempt to achieve union was made and for whom radiographs were available, nine eventually had bone-healing. Five of the twenty-three femora became infected and were treated with resection arthroplasty. Of the seventeen patients who had not had a resection arthroplasty for infection and for whom radiographs were available at the time of the most recent follow-up, eleven had a stable and well fixed implant and six had a loose implant as seen radiographically or had had a revision because of aseptic loosening. Seventeen patients had no or mild pain at the time of the most recent follow-up, but ten required two-handed support to walk. The overall complication rate was 52 percent (twelve of twenty-three patients). CONCLUSIONS: Nonunion of a femoral fracture associated with a total hip prosthesis is an infrequent problem. Treatment is difficult, with a high rate of complications and relatively poor functional outcomes. The data from this series must be interpreted with caution, as patients were managed over a period of three decades and many did not have the advantage of modern techniques of revision hip arthroplasty. Prevention of nonunion by optimum treatment of the initial fracture is most important. Treatment of a femoral nonunion about a total hip implant should be implemented on the basis of the status of the fixation of the prosthesis and the quality of the surrounding bone.     

股骨颈骨折全髋关节置换术后股骨近端形态变化

目的:观察全髋关节置换(THA)治疗股骨颈骨折及股骨头坏死术后股骨近端形态改变,分析是否存在差异及其表现形式.方法:2014年1月至12月同一手术组连续股骨颈骨折和股骨头坏死行THA治疗的病例进行对比分析,其中股骨颈骨折患者22例,男11例,女11例,年龄44~83岁,平均(66.18±11.47)岁;股骨头坏死患者23例,男12例,女11例,年龄19~68岁,平均(51.91±11.76)岁.测量THA术后股骨高度,Offset,截骨位置和调整方式,进行统计分析.结果:全部患者获得测量,行THA治疗后,股骨颈骨折病例较股骨头坏死病例有更低的股骨高度,更小的Offset,更低的截骨位置,并发现了3种低位截骨后的调整方式.结论:股骨颈骨折行THA手术,有产生低截骨、较小Offset的可能,因低位截骨而进行的调整可能会对近远期疗效产生不良影响.     

全髋关节置换术后温哥华B型假体周围骨折的治疗

背景:全髋关节置换手术是目前最为成功有效的外科手术之一,与之伴随的是多种术后并发症的出现,假体周围骨折是其中最显著的并发症之一,发病率有上升趋势。目的:回顾性研究全髋关节置换术后温哥华B型股骨假体周围骨折的治疗措施。方法:2006年1月至2011年1月收治全髋关节置换术后股骨假体周围骨折33例,男17例,女16例;年龄38～81岁,平均68.2 岁。33 例均为温哥华 B 型假体周围骨折:B1 型骨折组 11 例,采取切开复位钢丝捆扎固定或接骨板固定+异体皮质骨板植骨;B2型骨折组16例,采用记忆合金环抱器+大量植骨或长柄全涂层假体联合钢丝捆扎+局部异体松质骨植骨;B3型骨折6例,采用长柄生物性假体或组配型假体+同种异体骨板联合钢丝捆扎。结果:全部获得随访,随访时间为0.5～5.5年,平均3.6年。髋关节功能恢复良好,骨折愈合,对位对线良好。骨折愈合时间为3～22个月,平均6.5个月。B1型骨折组中1例术后因跌倒再次骨折,行二次翻修手术,末次随访时Harris评分为82～96 分,平均 91.2 分;B2 型骨折组中 1 例术后 3 年出现假体松动下沉,行二次翻修手术,末次随访时 Harris 评分为 76～92 分,平均 87.0 分;B3 型骨折组中 1 例术后 3 个月出现移植骨排异反应与感染,经治疗无效,再次手术取出同种异体骨板,抗生素药物治疗后症状缓解,末次随访时Harris评分为66～80分,平均71.5分。无一例发生深静脉血栓形成、神经损伤等并发症。结论:股骨柄假体周围骨折中温哥华B型较常见,根据骨折类型选择不同的治疗方法,均可获得满意疗效。     

股骨近端骨折内固定术后慢性感染的二期全髋关节置换

 目的 探讨二期全髋关节置换(total hip arthroplasty,THA)治疗成人股骨近端骨折内固定术后慢性感染的近期临床疗效。方法 回顾性分析2006年9月至2011年6月采用二期THA手术治疗的成人股骨近端骨折内固定术后慢性感染9例患者的临床资料,男8例,女1例;年龄31~74岁,平均52.6岁。股骨颈骨折3例,股骨转子间骨折6例。术前行关节腔穿刺液及术中取关节周围组织送细菌培养及药敏试验。一期手术取出内固定,清除感染病灶,植入抗生素骨水泥临时假体。术后静脉滴注及口服抗生素。停用抗生素后复查红细胞沉降率、C反应蛋白,间隔1个月连续两次正常后,行二期手术取出抗生素骨水泥临时假体,植入非骨水泥全髋关节假体。结果 2例细菌培养阳性,其中1例为表皮葡萄球菌、1例为金黄色葡萄球菌,其余7例细菌培养阴性。一期术后静脉应用抗生素6~8周,平均6.4周;口服抗生素6~9周,平均6.7周。一期与二期手术间隔6~14个月,平均9个月。9例患者均获得随访,随访时间6~50个月,平均23.2个月。随访期间无一例发生感染复发或新发假体周围感染,假体松动、脱位及假体周围骨溶解。Harris髋关节评分由术前平均74.6分(64~86分)提高至末次随访时平均90.9分(86~97分)。结论 二期THA手术治疗股骨近端内固定术后慢性感染,可以重建关节功能,术后近期无感染复发。     

Periprosthetic femoral fractures after total hip arthroplasty

BACKGROUND: The management of periprosthetic fracture following a total hip arthroplasty is difficult, requiring expertise in both trauma and revision surgery. With rising numbers of patients in the population living with hip prostheses in situ, the frequency of these fractures is increasing, and controversy remains over their ideal management. The objective of this study was to review all periprosthetic fractures at a single institution to identify injury and treatment patterns and their associated clinical outcomes. METHODS: Fifty-four periprosthetic fractures in 50 patients were reviewed to determine the relative frequency of fracture types, their complication rates and the clinical outcomes. Patient data were obtained through review of the clinical notes and individual patient follow up. Clinical outcomes were evaluated using the Oxford Hip Score and Harris Hip Score. RESULTS: The 54 fractures were classified using the Vancouver system, most of which were type B1 (20) or type B2 (10). The mean time to union for all fracture types was 4.6 months. A high non-union rate was seen among fractures fixed operatively. Fifteen per cent of fractures went on to develop loosening following treatment, suggesting an underrecognition at the time of injury. The average Harris Hip Score was 73.1 and Oxford Hip Score 30.3 for all fracture types at a mean follow up of 3.3 years. In the 15 patients treated with revision surgery, the most common complication was dislocation (27%). CONCLUSION: Treatment of patients with periprosthetic fractures requires recognition of the challenging nature of these injuries, the associated poor prognosis and the high complication rate.     

老年股骨颈骨折患者行全髋关节置换术后体重的变化

目的了解老年股骨颈骨折患者行全髋关节置换术(THA)术后体重的变化。 方法回顾性分析2013年1月至2016年6月在聊城市第二人民医院关节外科接受单侧初次THA的股骨颈骨折患者。以BMI为分组依据,18.5 kg/m²≤BMI<24.0 kg/m²为体重正常组,24.0 kg/m²≤BMI<28.0 kg/m²为超重组,BMI≥28.0 kg/m²为肥胖组。采用Kaplan-Meier法分析比较THA后人体质量指数(BMI)减少超过5%的时间间隔。 结果共有78例患者纳入本研究,体重正常组28例患者、超重组46例患者、肥胖组4例患者,3组患者之间的年龄、性别构成差异无统计学意义,P>0.05。3组患者在THA术后人体质量指数减少超过5%的中位时间分别为52个月(43, 69)个月、48个月(40,67)个月、47个月(41,60)个月,行log-rank检验,差异没有统计学意义(χ²＝4.72,P>0.05)。 结论体重正常组、超重组、肥胖组患者在THA术后BMI减少超过5%的中位时间基本一致。     

股骨近端形态对全髋关节置换术后下肢不等长的影响

目的:探讨不同股骨近端形态对全髋关节置换术(total hip arthroplasty,THA)后重建下肢不等长(leg length discrepancy,LLD)的影响.方法:选取2013年6月至2019年6月接受单侧生物型全髋关节置换术的131例髋关节骨关节炎或股骨头坏死的患者,回顾性分析年龄、性别、侧别和骨...     

Function after primary hemiarthroplasty and secondary total hip arthroplasty in femoral neck fracture

Four to 12 years after primary treatment of femoral neck fracture with hemiarthroplasty in a group of Finnish patients and secondary total hip arthroplasty as a salvage procedure for healing complication after orimary osteosynthesis in a group of Swedish patients, function was classified and the Nottingham Health Profile questionnaire was applied. The two groups were comparable with regard to age, sex, and social status. The patients with secondary total hip arthroplasty used walking aids to a lesser extent than the patients with hemiarthroplasty and experienced less problems in several aspects of life. Walking ability was considered unchanged, compared to prefracture, to a larger extent in the secondary total hip arthroplasty group. Thus, secondary total hip arthroplasty in patients with healing complication following primary osteosynthesis gives better long-term functional capacity than that obtained with a primary hemiarthroplasty.     

股骨近端缩短及全髋置换术治疗陈旧股骨颈骨折伴严重髋关节脱位

目的 探讨陈旧股骨颈骨折伴严重髋关节脱位的有效治疗方法及临床疗效。方法 自1996年4月采用股骨近端缩短及全髋置换术治疗7例陈旧股骨颈骨折伴严重的髋关节脱位的患者。结果 7例患者平均为51岁,术后随访平均为27．3个月,在近期随访过程中,按Harris评分由手术前的36．7分增加至术后84．3分,髋臼及股骨柄假体位置良好,未出现假体松动和下沉,也未出现截骨处骨不愈合。结论 股骨近端缩短及全髋置换术治疗陈旧股骨颈骨折伴严重髋关节脱位,近期疗效十分满意,其后期疗效有待进一步随访观察。     

Periprosthetic femoral fracture after total hip arthroplast

Periprosthetic femoral fractures represent a significant complication in total hip arthroplasty. based on originand treatment considerations, these fractures are best considered on the basis of the proximal region, and middle region below the lesser trochanter, and distal region at the prosthetic tip and beyond. Proximal-region fractures are usually wired and treated conservatively. Middle-region fractures may require prosthetic revision in addition to fracture fixation.Distal-region fractures are most difficult and may need advanced techniques, such as distal prosthetic fixation and allograft femoral plates.     

髋部骨折内固定失败后的全髋关节置换术疗效评估及影响因素分析

目的探讨股骨转子间骨折及股骨颈骨折复位内固定失败后全髋关节置换术临床疗效及影响因素。方法自1998年8月至2009年3月,本组收治股骨转子间骨折及股骨颈骨折复位内固定失败患者21例,其中男11例,女10例,年龄37～87岁,平均66.3岁。其中股骨颈骨折12例,股骨转子间骨折9例。内固定种类：动力髋螺钉（DHS）5例,动力髁螺钉（DCS）2例,股骨近端髓内钉（PFN）1例,伽马钉2例,Hansson针1例,合并股骨上段粉碎性骨折行交锁钉内固定1例,空心钉9例。失败原因：股骨头坏死7例,骨折不愈合7例,不愈合合并股骨头坏死2例,钉松脱、切割致骨折移位或不愈合5例。以上21例内固定失败后致患肢缩短19例。置换术使用的皆为标准假体,无应用加长柄,无应力性骨折病例。假体类型：生物型6例,全骨水泥型4例,混合型11例。就术前术后功能改善、肢体长度恢复、手术并发症等进行评估,并分析其与患者年龄,两次手术间隔时间、术前肢体缩短畸形程度等因素间关系。结果无住院死亡患者。随访中,4例死于系统性疾病。Harris评分由全髋关节置换术前（27.53±2.96）分提高到置换术后最后一次随访（80.76±4.25）分。术前患肢缩短（2.67±1.06）cm,术后改善致（0.85±0.88）cm。患者年龄越轻,内固定失败后再次手术时间间隔越长,肢体缩短更严重,术中肢体长度的恢复也更困难。并发症：术后创伤性精神障碍1例,治疗后好转;术后脱位1例,麻醉下手法复位,外展支具固定6周;术中股骨上段劈裂骨折1例,无特殊处理。松动1例,翻修术后2年死于脑血管意外。结论全髋关节置换术是髋部骨折内固定失败后有效的补救措施,宜尽早手术、并需因应病例个体病理改变情况,而相应作综合评估、考虑。     

Early mortality and morbidity after total hip arthroplasty in patients with femoral neck fracture

Background and purpose — Early postoperative mortality is relatively high after total hip arthroplasty (THA) that has been performed due to femoral neck fracture. However, this has rarely been investigated after adjustment for medical comorbidity and comparison with the mortality in an age-matched population. We therefore assessed early mortality in hip fracture patients treated with a THA, in the setting of a nationwide matched cohort study.

Patients and methods — 24,699 patients who underwent THA due to a femoral neck fracture between 1992 and 2012 were matched with 118,518 controls. Kaplan-Meier survival analysis was used to calculate cumulative unadjusted survival, and Cox regression models were fitted to compute hazard ratios (HRs) and 95% confidence intervals (CIs), with adjustment for age, sex, comorbidity, and socioeconomic background.

Results — 90-day survival was 96.3% (95% CI: 96.0–96.5) for THA cases and 98.7% (95% CI: 98.6–98.8) for control individuals, giving an adjusted HR of 2.2 (95% CI: 2.0–2.4) for THA cases compared to control individuals. Comorbidity burden increased in THA cases over time, but the adjusted risk of death within 90 days did not differ statistically significantly between the time periods investigated (1992–1998, 1999–2005, and 2006–2012). A Charlson comorbidity index of 3 or more, an American Society of Anesthesiologists (ASA) grade of 3 and above, male sex, an age of 80 years and above, an income below the first quartile, and a lower level of education were all associated with an increased risk of 90-day mortality.

Interpretation — The adjusted early mortality in femoral neck fracture patients who underwent THA was about double that in a matched control population. Patients with femoral neck fracture but with no substantial comorbidity and an age of less than 80 years appear to have a low risk of early death. Patients older than 80 years and those with a Charlson comorbidity index of more than 2 have a high risk of early death, and such patients would perhaps benefit from treatment strategies other than THA, but this should be investigated further.     

全髋关节置换术假体周围骨溶解的临床分析

目的分析股骨假体周围骨溶解的发生情况、程度和方式,了解骨溶解与假体松动的关系。方法根据Ｇｒｕｅｎ’ｓ分区法,在标准正位Ｘ光片上对１９８０年１９９６年间进行连续Ｘ线随防的全髋关节置换术病人共１１２例进行分析,其中骨水泥固定８４例,非骨水泥固定２８例,平均随访时间为８３月。结果骨水泥固定和非骨水泥固定的假体周围骨溶解的总发生率分别为５８．３％和２５．０％,假体周围骨溶解进行性发展的发生率分别为８６％和     

人工全髋关节置换中合并股骨近端畸形的股骨侧重建

目的探讨人工全髋关节置换中合并股骨近端畸形的股骨侧重建方法及疗效。方法 2004年3月-2009年6月,对25例26髋合并股骨近端畸形的髋关节疾病患者行人工全髋关节置换术,同时根据不同畸形部位重建股骨侧。其中男10例10髋,女15例16髋;年龄42～82岁,平均64岁。关节置换原因:原发性骨关节炎2髋,先天性髋关节脱位8髋,创伤性关节炎14髋,结核性关节炎2髋。病程10个月～25年,平均10.6年。术前Harris评分为(44.2±5.1)分,美国西部Ontario与McMaster大学骨关节炎指数(WOMAC)评分为(45.0±2.7)分。股骨近端畸形按照Berry分类系统,根据畸形原发病分类:先天性髋关节发育不良8髋,骨折畸形愈合7髋,陈旧性结核2髋,股骨头骨骺滑脱2髋,既往有粗隆下截骨手术史1髋,髋臼加盖术1髋,内固定术5髋;根据畸形部位分类:大粗隆5髋,股骨颈10髋,干骺端10髋,股骨干1髋。结果患者术后切口均Ⅰ期愈合;1周内3例发生下肢深静脉血栓形成,行制动及抗凝治疗后治愈;术后6周1例发生大转子滑囊炎,口服止痛药物缓解。25例均获随访,随访时间1年6个月～6年,平均3年3个月。末次随访Harris评分为(88.4±3.6)分,WOMAC评分改善至(82.0±5.2)分,与术前比较差异均有统计学意义(P<0.05)。X线片示1例术后8个月出现无菌性松动,行翻修术;其余患者假体无松动。结论对于伴有股骨近端畸形的患者,需要精确分类,有针对性地选择假体并设计个性化手术方案,才能获得良好的股骨侧重建,取得满意疗效。     

Cementless revision total hip arthroplasty without allograft in severe proximal femoral defects

This study evaluates the difficult reconstructive challenge of severe proximal femoral bone loss. We present intermediate-term results of 46 hips with extensive proximal femoral bone loss that underwent revision total hip arthroplasty using cementless distal fixation without supplemental allograft. All were evaluated with the Harris hip score at a minimum of 2 years. Radiographs were assessed using the Engh fixation scale. At a mean of 6.4 (range 2-12) years, 43 of the 46 prostheses were functioning well. Two patients required revision for symptomatic loosening, and 1 prosthesis remains radiographically loose with a fair clinical score. Mean Harris hip score was 77 at last follow-up. There were 6 intraoperative femur fractures, 9 dislocations, 10 cases of severe stress shielding, and no infections.     

Allograft reconstruction of large proximal femoral defects in revision total hip arthroplasty

Surgical Principles With the increasing frequency of total joint replacement, the orthopaedic surgeon is often confronted with cases of aseptic, time related loosening of total hip arthroplasties. This is compounded by the severe bone loss associated with loosening and the reaction to particular debris [3, 9, 11]. Conventional methods of revision can be difficult and even inadequate for some of these situations [2, 8, 15, 17]. The use of structural allografts for significant proximal femoral deficiencies can restore skeletal architecture and mechanical integrity to these patients. The aim of this technique is to allow the reconstruction of large structural defects with a physiologically compatible material rather than the traditional techniques of custom prosthetic replacement with or without extensive cement augmentation.     

Treatment of periprosthetic femoral fracture after cementless total hip arthroplasty with Ilizarov external fixation

A 72-year-old woman with periprosthetic femoral fracture after cementless total hip arthroplasty (THA) underwent external fixation using the Ilizarov method. Although open reduction and internal fixation with a condylar plate system were initially attempted, deep infection with methicillin-resistant Staphylococcus aureus at the fracture site occurred 2 weeks postoperatively. Six weeks after removal of the plating system, the fracture was stabilized with external fixation using the Ilizarov method and went on to successful fusion at 3 months. To our knowledge, this is the first report in which Ilizarov external fixation has been used for periprosthetic femoral fracture after THA. Although this is a rare situation, where periprosthetic fracture and infection coexist, Ilizarov external fixation is a safe and reliable method for periprosthetic femoral fracture with infection.     

Locked inferior fracture dislocation after total hip arthroplasty

Acetabular fracture in conjunction with dislocation after total hip arthroplasty is a rarely reported event. We describe such a case with a unique fracture dislocation pattern, whereby the prosthetic femoral component dislocated inferiorly, fracturing the pelvis, and was locked in this position. The patient was treated with closed reduction under anesthesia and the fracture healed without further surgical intervention. However, she has experienced subsequent instability episodes and we have recommended revision surgery.     

Arteriovenous malformation mimicking femoral osteolysis after total hip arthroplasty

We encountered a case of apparent progressive femoral osteolysis around a well-fixed cementless implant in a young patient. At the time of revision arthroplasty, massive hemorrhaging occurred during exposure and attempted femoral component extraction. Urgent packing of the exposed endosteum with polymethyl methacrylate controlled the bone bleeding. Emergent angiography confirmed an arteriovenous malformation with extensive proximal diaphyseal involvement directly at the site of osteolysis. This arteriovenous malformation was treated successfully with selective arterial embolization and second-stage resection. In retrospect, the index arthroplasty operative note indicated an excessive amount of blood loss, and prerevision radiographs showed osteolysis with uncharacteristic vascular markings. The presence of an osteolytic lesion in total hip arthroplasty should not be assumed to be attributed to polyethylene granuloma, and any atypical radiographic features should prompt further preoperative investigations.