股骨颈骨折的手术治疗策略

颈骨折是老年人致残、甚至致死的常见骨折,随着社会人口的老龄化,股骨颈骨折的发生率正逐年增高,由此给社会带来的社会经济负担也在逐渐加剧.另外,髋部骨折伤后1年的死亡率可达30%,同时还可能造成暂时、甚至永久的功能障碍,影响患者的生活质量.     

Ipsilateral femoral neck and shaft fractures: complications and their treatment

An ipsilateral femoral neck fracture occurs in approximately 6% to 9% of all femoral shaft fractures. Despite this relatively common presentation, decision-making often is difficult. Furthermore, the risk for complications is greater in the treatment of this combination injury pattern than for single-level fractures. A retrospective review of the authors' large trauma database revealed 13 patients who had healing complications develop after their index surgical procedure. Six of the eight (75%) femoral neck nonunions occurring in these 13 patients developed after the use of a second generation, reconstruction-type intramedullary nail. Factors contributing to nonunion of the femoral shaft were the presence of an open fracture, use of an unreamed, small diameter intramedullary nail, and prolonged delay to weightbearing. The femoral neck nonunions healed after either valgus intertrochanteric osteotomy (seven patients) or compression hip screw fixation (one patient). The femoral shaft nonunion proved more difficult than expected to treat with some patients with femoral shaft nonunions requiring more than one operative procedure to achieve union. Lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization were associated with the fewest complications. Therefore, this approach is recommended as the treatment of choice.     

空心螺钉治疗股骨颈骨折术后并发症的分析

目的探讨影响空心螺钉治疗股骨颈骨折术后早期并发症及中晚期股骨头缺血性坏死的因素。方法对1994年1月～2004年1月间应用空心螺钉治疗的116例股骨颈骨折患者进行回顾性总结,将患者性别、年龄、骨折类型、骨折复位情况、外伤至手术时间与骨折术后早期并发症及中晚期股骨头缺血性坏死间的关系进行统计学分析。结果116例患者获平均(3．2±2．5)年(1～11年)随访。术后早期并发症包括：骨折内固定失败6例,骨折周围再骨折2例,感染2例,下肢深静脉血栓6例。年龄是引起骨折术后早期并发症的主要因素之一；骨折术后早期并发症还与骨质情况及内固定技术有关。本组16例出现股骨头缺血性坏死,其坏死率为13．8%。造成股骨头缺血性坏死的因素主要是骨折类型,其次为骨折复位情况。结论①年龄大于60岁的患者股骨颈骨折术后早期并发症相对多。②对于骨折移位严重的高龄患者,建议行人工关节置换术。③内固定术应尽可能解剖复位、坚强牢靠,以减少术后股骨头缺血性坏死的发生。     

股骨颈骨折治疗进展

随着社会老龄化,股骨颈骨折发病率越来越高.根据患者年龄、全身状况、骨折类型、功能要求等选择内固定或关节置换,可取得良好疗效.目前大多主张对较年轻患者(50岁以下)采用内固定治疗.老年患者初次治疗采用内固定还是全髋关节置换术仍有争议,目前倾向于对功能要求较高、相对年轻者采用内固定,对功能要求不高者采用半髋关节置换术,对相对健康、活动量大而无认知或精神疾病患者采用全髋关节置换术,对有认知或精神疾病者采用内固定或半髋关节置换术.该文就股骨颈骨折外科治疗进展及适应证选择方面的最新观点作一综述.     

Deyerle treatment for femoral neck fractures

Thirty-eight displaced intracapsular fractures of the femoral neck treated by the Deyerle method of internal fixation have been added to the previously reported series of sixty-three cases from the Walter Reed Army Medical Center Orthopaedic Service. A significant change in the incidence of non-union was found. In the over-all series of 101 patients, the incidence of non-union was 13.8 per cent and the incidence of segmental collapse due to avascular necrosis was 13.8 per cent. The roentgenographic and functional over-all end results were rated excellent in 67.7 per cent and poor in 32.3 per cent of the fractures. Some difficulties arising from the multiple-pin and plate technique and the associated morbidity are discussed. We now think that Deyerle method produces no better results than other methods of internal fixation of displaced intracapsular fractures.     

Algorithms for the treatment of femoral neck fractures

Worldwide prevalence of femoral neck fractures is increasing, doubling for patients older than 50 years. Age of the patient, prefracture activity level, and associated comorbidities must be considered when determining treatment. It seems that hemiarthroplasty is best suited for an elderly patient who is a household ambulator with low demands on the prosthesis. Younger patients, and those with minimally displaced fractures, should be treated with internal fixation in an attempt to preserve the natural hip. Proximal femur fractures in the pediatric population are associated with high complication rates. Because of vascular vulnerability, avascular necrosis of the femoral head continues to be the most frequent and serious complication after hip trauma in children. Femoral neck fractures in children also differ from those in adults because a child can tolerate immobilization much more readily than can an adult. As healthcare resources become more limited and their use becomes scrutinized more closely, cost-effective treatment algorithms for femoral neck fractures will dictate orthopaedic treatment. For some fractures, closed treatment is evolving toward interventional approaches to minimize late sequelae. With the availability of viable treatment options, the potential risks and benefits of individual treatment modalities as related to each fracture pattern must be reviewed.     

Charnley low-friction arthroplasty for the treatment of hips with late complications of femoral neck fractures

Two hundred five Charnley low-friction arthroplasties (LFA) were performed in 205 patients for late complications of femoral neck fractures. LFA was an excellent procedure for relieving pain and restoring function with a good range of movement. The deep infection rate was 3.9%. A detailed analysis of the patients with infection showed a high incidence of previous superficial wound infection or positive bacteriologic culture swabs obtained from the wound at the time of LFA.     

老年股骨颈骨折的治疗进展

股骨劲骨折是骨科临床上较常见的骨折之一.随着老龄化社会的到来,股骨劲骨折的发生率明显上升,预计到2040年全球每年新发患者数将达到50～60万能例次[1].     

Surgical treatment of unstable femoral neck fractures

Results of the treatment of 378 patients with unstable fracture of the femur neck were analyzed. The authors recommend to use osteosynthesis with a three-blade rod with an additional fixation by a lateral plank and screws to the femur diaphysis combined with osseous allotransplant introduced parallel to the metallic fixator. The follow-up studies for 6 years have shown the false joint to be formed in 5% of the patients operated by the proposed method while osteosynthesis by a three-blade rod only gave it in 23,8% of cases.     

Prediction of late complications of femoral neck fractures by scintigraphy

Summary A prospective study was undertaken to determine the value of scintigraphy in predicting nonunion or necrosis of the femoral head following femoral neck fractures. Scintigraphy was carried out in 49 patients before operation and in 37 one week after operation; in 18 it was done before and after operation. The uptake of isotope was estimated visually as either normal or reduced compared to the opposite side. All the patients were followed up for at least 2 years. The results indicate that pre-operative bone scintigraphy is useful in elderly patients to predict nonunion and necrosis, and therefore is recommended to select those patients who will benefit from primary arthroplasty instead of fixation of the fracture.

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Résumé Etude prospective de la valeur de la scintigraphie dans la prévision des complications tardives après fracture du col du fémur. Une scintigraphie a été réalisée avant l'intervention chez 49 patients et une semaine après chez 37 autres; dans 18 cas elle a été faite avant et après l'opération. La concentration d'isotopes a été évaluée visuellement et considérée comme normale ou comme diminuée par comparaison avec la hanche opposée. Tous les patients ont été suivis deux ans au moins. Les résultats permettent de penser que la scintigraphie pré-opératoire est un examen utile chez les sujets âgés présentant une fracture du col avec déplacement pour prédire pseudarthrose et nécrose de la tête fémorale. Elle permet de choisir les patients pour lesquels l'arthroplastie est préférable à l'ostéosynthèse.