Evaluation of valgus intertrochanteric osteotomy in neglected fracture neck femur in young adults

BackgroundFemoral neck fractures in young adults have always presented a difficult problem with high rates of non-union and avascular necrosis. At our centre we have been using the traditional Pauwels intertrochanteric osteotomy for neglected un-united femoral neck fractures in young adults. We have made certain modifications in this procedure to suit our resources and so we evaluated the outcome of this procedure at our institute.MethodsThe study included fifty consecutive cases of neglected femoral neck fractures treated at our centre between February 1996 and October 2012. Patients in whom internal fixation had failed were excluded. The average age of the patients was 37 years (range: 17–55 years). Eleven of the patients were female & Thirty-nine were male. Fifteen patients belonged to Pauwels grade 1, Twenty-six patients belonged to grade 2, and nine belonged to grade 3. The interval between the injury and operation ranged from 1 to 12months (average: 4.3 months). The cases were operated on a normal table using a Watson Jones Approach. The fracture ends were freshened and fixed using a 6.5mm screw followed by a valgus osteotomy which was fixed by a double angle (120 degree) blade plate.ResultsA fracture union rate of 90% (45 cases) was achieved. Two of the healed cases developed avascular necrosis. Results were graded using Askin and Bryan's criteria. Overall, an excellent result was seen in 35 patients, good in 5, fair in 5 and poor in 5. Of the five patients having poor result (3 non-union, 1 implant breakage, 1 implant cut out), two refused revision surgery. In remaining three, one underwent total hip arthroplasty and in two revision osteotomy was performed.ConclusionWe believe that intertrochanteric osteotomy provides a good outcome for neglected femoral neck fractures. Performing the procedure on a routine table, with Watson Jones approach and fixing with double angle blade plate is a good option.     

Use of vascularized pedicle iliac bone graft combined with transtrochanteric rotational osteotomy in the treatment of avascular necrosis of the femoral head

Introduction A vascularized pedicle iliac bone graft combined with transtrochanteric anterior rotational osteotomy was performed in patients with extensive necrosis in whom the necrotic area occupied more than two-thirds of the weight-bearing zone of the femoral head. The purpose of this procedure is to supply vascularity and mechanical strength to the avascular femoral head.Materials and methods Seventeen hips in 14 patients (8 male, 6 female) whose average age at surgery was 37.9 (range 21–51) years underwent this procedure between June 1992 and December 2002. These hips (stage 2 in 3 hips, stage 3A in 13 hips, and stage 3B in 1 hip) were examined for changes according to the Japanese Orthopedic Association (JOA ) score and the presence or absence of progression of the clinical stage at least 1 year after surgery.Results The mean JOA score improved from 67.8 points preoperatively to 78.1 points by 18–133 (mean 50.7) months postoperatively. There was no disease progression to a more advanced stage in 12 of 17 hips (71%) postoperatively.Conclusion A vascularized pedicle iliac bone graft combined with transtrochanteric anterior rotational osteotomy to treat avascular necrosis of the femoral head is considered promising for joint preservation.     

运用钽棒植入术治疗股骨头坏死的研究进展

股骨头坏死治疗不及时或方法不当多诱发股骨头塌陷,给患者尤其是中青年患者造成严重伤害。钽棒因其与骨组织在结构学和力学特性上接近,且具有较高的强度,能很好的适应生物体内环境,因而在治疗股骨头坏死方面具有巨大的潜能。钽棒植入术作为早期股骨头坏死的治疗方法,在国内外已有着广泛运用,目前普遍认为其适合于ARCOⅠ、Ⅱ期患者,并具有手术过程相对简单、风险小和并发症少等特点。但由于股骨头坏死早期诊断困难、钽棒作用局限以及医务工作者相关经验差异等因素,造成了目前医学界对于钽棒疗效好坏,甚至是否继续使用钽棒等问题的争论。随着科技的发展,将钽棒植入术与相关生物技术结合,必定能提高股骨头坏死疾病的疗效。     

The value of trochanteric displacement in a varus producing intertrochanteric osteotomy

Surgical Principles In order to maintain or increase the abductor lever arm during a varus producing intertrochanteric osteotomy, distal displacement of the greater trochanter is often needed. Without displacing the trochanter, a significant weakness of the abductors would occur [4, 5]. With greater trochanter osteotomy, access to the hip joint is improved, permitting better visualization of the upper part of the femoral head and the roof of the acetabulum (ie, for a simultaneous shelf procedure). When a flexion component is added to the osteotomy, the trochanteric osteotomy increases the range of correction in the sagittal plane and reduces mechanical pressure on the anterosuperior surface of the femoral head [3]. The aim of an isolated greater trochanteric osteotomy is to advance distally and to lateralize the abductors. To achieve fixation, the preserved soft tissue layer, screws, or a tension wire cerclage are used [4–6, 10]. The indication of a trochanteric osteotomy combined with an intertrochanteric osteotomy has increased [1, 4, 10, 11]. The technique described in detail below is part of a varus osteotomy performed as previously described by M. E. Müller [7, 8, 10] and relies on the use of AO osteotomy plates [9]. Revised Version from: Operat. Orthop. Traumatol. 1 (1989), 211–218 (German Edition).     

The debrunner-cech valgus osteotomy in osteoporotic four-part intertrochanteric fractures

Summary The main problems encountered in the management of comminuted four-part intertrochanteric fractures in the elderly are instability, severe osteoporosis and the need for early mobilization. Thirty-one patients, average age 75 years, with such fractures were operated on using a sliding blade-plate and the Debrunner-Cech valgus osteotomy. The follow-up was from 1–5 years with an average of 3.2 years. All patients were got out of bed on the first postoperative day and walked with help on the second day. The fractures united in 29 patients. The one exception occurred when the blade cut out of the neck; the operation was repeated with a good result. Two further patients died in the postoperative period. We conclude that this method is the best treatment for osteoporotic four-part intertrochanteric fractures.

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Résumé Les principaux problèmes, dans le traitement des fractures per-trochantériennes comminutives du sujet âgé, sont l'instabilité, l'ostéoporose et la nécessité d'un lever précoce. Trente et un sujets, âgés en moyenne de 75 ans et porteurs de telles fractures, ont été opérés par ostéotomie de valgisation selon Debrunner-Cech et synthèsés par lameplaque à compression. Le recul est compris entre 1 et 5 ans, avec une moyenne de 3,2 ans. Tous les opérés ont été levés le lendemain de l'intervention et ont commencé à marcher, avec aides, dès le deuxième jour. Vingt-neuf patients ont consolidé avec une seule complication: la lame ayant traversé le col. L'opération a été reprise avec un bon résultat. Deux autres malades sont morts durant la période post-opératoire. Les auteurs concluent que cette méthode constitue le meilleur traitement des fractures per-trochantériennes comminutives.

     

蛋白质组学在股骨头坏死中的研究进展

蛋白质组学技术的兴起能快速筛选并鉴定疾病的特异性生物标记物,有助于揭示股骨头坏死的发生机制,早期诊断,从而寻找更有效的治疗方法和治疗靶点.目前以找出其发生机制、早期诊断和早期治疗的相关蛋白及其功能鉴定,建立相关数据库及蛋白提取方法的优化为研究热点和焦点.本文综述近年来股骨头坏死相关的蛋白质研究技术及其在股骨头坏死患者骨组织、血清及相关动物模型中运用,为进一步研究提供思路.     

老年转子间骨折围手术期并发症分析

目的分析围手术期75岁以上老年转子间骨折患者主要并发症,探讨其发生原因及应对措施。方法回顾2002年1月～2010年6月收治的279例75岁以上股骨转子间骨折病例的术前、手术及术后情况。结果 279例中,男107例,女72例,平均年龄78.6岁（75～103岁）。术前合并症依次为心血脑血管疾病、呼吸系统疾病、糖尿病、泌尿系统疾病、营养不良、消化系统疾病、下肢静脉炎、恶性肿瘤,平均合并2.4种。手术方法：髓外固定（DHS）177例,髓内固定102例。平均手术时间77min,术中及术后输血85例,输血量200～1200ml,平均360ml。59例术后6个月失随访,其中9例术后6个月内死亡。其余220例平均随访时间10.2个月（5～58个月）。208例骨折愈合（92.1%）。功能评定,优111例,良85例,优良率89%。术中及术后并发症主要为包括肺部感染、心脑血管意外、DVT等。结论老年转子间骨折患者内科合并症疾病复杂,围手术期需要全面评估,多科协作处置。早期手术、避免全麻、缩短手术时间、固定牢固有助于减少围手术期并发症。呼吸系统并发症是术后最常见的严重并发症之一。需要提高对围手术期DVT的重视。     

Significance of subsequent hip unloading after surgical intertrochanteric osteotomy of idiopathic femur head necrosis

PURPOSE: To judge the influence of consequent non-weight-bearing on the postoperative results, we reviewed 28 patients in whom we performed intertrochanteric osteotomies for idiopathic osteonecrosis of the femoral head during the years 1996 and 1997. Postoperatively 12 patients were supplied with a walking device for non-weight-bearing which was used for 1 year. 16 patients were mobilized by using 2 crutches for 15 kp partial weight-bearing until the osteotomy healed up and were then allowed to bear full weight. METHOD: For clinical evaluation of the early results after about 18 month the Merle d'Aubigné hip score was used. Furthermore we analyzed pelvic radiographs for assessing the stage of the necrosis (Ficat staging) and the necrotic angle. RESULTS: Overall 82% good and excellent results were achieved. Due to a longer period of non-weight-bearing the results were again clearly improved (92% versus 75% of patients with partial weight-bearing). It was noticed that there were discrepancies between good clinical results and the less satisfying radiographic findings. CONCLUSIONS: Postoperative non-weight-bearing for about 1 year with the use of a walking device by patients with idiopathic osteonecrosis of the femoral head has clearly a positive effect on clinical results.     

Corrective intertrochanteric osteotomy in the treatment of aseptic necrosis of the femur head in adults

Having analysed their experience in surgical treatment of 196 patients with aseptic necrosis of the femoral head (263 hip joint operations) the authors specify the indications for performing corrective intertrochanteric osteotomies of the femur, work out their tactics of differential approach and summarize the long-term results of the treatment. It has been established that the possibility of obtaining a positive result makes 84.5% if correct indications for the operation are observed.     

转子间外翻截骨治疗股骨头坏死塌陷

目的探讨转子间外翻截骨治疗股骨头缺血坏死塌陷的临床疗效。方法对96例(96髋)股骨头缺血坏死塌陷患者(Ⅰb型45例和Ⅱ型51例)行转子间外翻25°～30°截骨,解剖钢板固定。术后水平皮肤牵引3周,后持拐行走。结果96例均获随访,时间3～23年,术后3～4个月截骨愈合。按王岩评价法评价:优89髋(92.71%),良6髋(6.25%),可1髋(1.04%),优良率98.96%。结论转子间外翻截骨治疗股骨头坏死塌陷,疗效满意。     

股骨头缺血性坏死的X线漏诊原因分析

目的:探讨股骨头缺血性坏死的X线漏诊原因,旨在进一步减低漏诊率和提高早期诊断水平。方法:对99例123髋经MRI诊断为股骨头缺血性坏死患者的临床、X线资料进行回顾性分析,男56例,女43例;年龄21～84岁,平均53岁。髋区疼痛,伴屈曲、内收、外展、内旋髋关节功能受限,部分患者出现跛行。病史1周～2年。结果:99例123髋中,X线漏诊46例52髋,漏诊率42.27%,其中0期100.00%,Ⅰ期100.00%,Ⅱ期83.67%,Ⅲ期18.18%,Ⅳ期0.00%,Ⅴ期0.00%,X线分期与漏诊率呈负相关。漏诊的主要原因是阅片不细致和"抓大放小",其次为临床病史缺乏和X线投照质量低。结论:相应的临床病史和综合、细致地阅片是减低漏诊率的关键。     

Partial femur head necrosis in adults--results with intertrochanteric osteotomy and revascularization

Osteotomy and revascularization have both been used for many years in the therapy of partial aseptic necrosis of the femoral head in the adult. We first attempted a combination of the two techniques in 1978. Stress on the necrotic sector was relieved by intertrochanteric osteotomy, and the necrotic part of the bone was revascularized with a pedicled iliac crest bone graft based on the deep circumflex iliac vessels. Long-term results are now available in 45 hips in 38 patients, with a mean follow-up time of 32 months. Clinically, 71% of the hips were rated very good or good, and among those classed as stage II before surgery the results were rated as very good or good in as many as 90%. Subjective evaluation of the hips by the patients confirmed these results: 85% of the hips were judged to be optimal or markedly improved compared with before operation. Radiological evaluation showed further flattening of the femoral head in one case. A segmental collapse of the femoral head, i.e. stage III lesion according to Ficat, occurred in 2 hips with stage II preoperatively. In 6 hips with stage III necrosis preoperatively secondary arthritis developed. Computerized tomograms taken of all 25 hips from which metal implants had been removed showed signs of integration of the graft in 68%. Scintigraphy with 99-Tc-diphosphonate showed a homogeneous uptake in 42.8% and a non-homogeneous uptake in the remaining 57.2% of the cases. So-called photopenia was not observed in any of the hip joints treated.(ABSTRACT TRUNCATED AT 250 WORDS)     

钽棒植入治疗成人早期股骨头坏死

目的：探讨一种简单有效治疗成人早期股骨头缺血性坏死的新方法,以避免股骨头进一步塌陷和坏死,改善临床症状。方法：自2009年1月至2010年6月采用钽棒植入治疗9例（10髋）成人早期股骨头坏死,男7例,女2例;年龄29～63岁,平均44.1岁。术前均摄髋关节正侧位X线片,行CT和MRI扫描。按Steinberg分期：Ⅰ期1例1髋,Ⅱa期4例5髋,Ⅱb期4例4髋。手术在C形臂X线机定位下进行,从股骨大转子下钻入导针到股骨头坏死区中心,空心钻沿导针扩髓,刮除坏死区死骨,必要时植骨,选择合适长度的钽棒拧入,支撑坏死区关节面。术后3、6、9个月随访,采用JOA评分标准评价临床疗效,摄髋关节正侧位X线片,观察股骨头变化。结果：手术时间40～60min,平均50min;出血量60～100ml,平均80ml。术后无感染、骨折及下肢深静脉血栓形成等并发症,全部病例获得随访,时间9个月及以上,定期行X线检查未发现股骨头塌陷和坏死加重。JOA评分从术前平均（31.30±19.63）分增加至术后3个月平均（54.10±13.20）分,术后6个月（69.90±15.04）分,术后9个月（87.00±8.83）分。结论：钽棒植入治疗成人早期股骨头坏死手术简单易行,能有效避免坏死区股骨头塌陷,近期疗效满意。     

Avascular necrosis of femoral head after gamma-nailing for unstable intertrochanteric fractures

We reported on 7 cases of avascular necrosis ¶of the femoral head after treatment of an unstable intertrochanteric fracture with the Asian Pacific gamma-nail. The incidence was about 1.16% (7 of 604) in our series. Good reduction and good implant position were achieved in all 7 men. Avascular necrosis was found about 6 months to 3 years after the initial operation, and all the fractures were solidly united at the final diagnosis. The possible etiologies were initial high energy trauma and combining basal neck fracture and iatrogenic damage of the blood supply to the femoral head.     

股骨头坏死塌陷的预测和防治

对股骨头坏死(FHN)塌陷的预测和防治的各种方法加以综述,为以后临床应用提供理论参考。通过CNKI、VIP、CBM及外文相关的文献检索,并阅读、归纳,概述目前所用的相关方法和技术,发现影像学检查特别是X线、MRI对FHN塌陷的预测具有重大价值。防治的方法有多种,包括非手术和手术治疗。FHN塌陷受诸多因素影响,目前研究多局限于某个方面且样本量偏少,因此对预防塌陷所进行的大样本、不同方法分层比较的研究是非常必要的。对于FHN高危人群出现髋关节疼痛的应尽早行有效的影像学检查,对于已经坏死的股骨头应设法预测其塌陷的可能性,对于有可能塌陷的根据不同病变施以髓心减压术或带血管蒂骨移植术等方法。对高危人群股骨头塌陷早期预测,早期防治对FHN患者预后起至关重要作用。     

Polyaxial corrective osteotomy of the proximal femur using a gamma locking nail

Summary We report on a 57-year-old patient suffering from a complex malposition of proximal femur after osteosynthesis using a condylar plate. For polyaxial correction of the proximal femur we successfully used an intramedullary hip screw system.      

Joint-preserving osteotomy in segmental femur head necrosis

Joint-preserving osteotomies for segmental necrosis of the femoral head are clinically important, as necrosis often occurs in relatively young people in whom one is hesitant to perform femoral head replacement. The principle in all joint-preserving osteotomies is to remove the necrotic area from the zone subject to load, thereby guarding against indentation of the joint surface. The most universal and most frequently indicated osteotomy is intertrochanteric valgus flexion osteotomy with ventral capsule resection. The result of the operation depends mainly on the extent of the necrosis. If the angle of the necrosis is under 200 degrees, the hip joint can be preserved with great precision and in a good enough state to allow joint replacement to be postponed for many years.     

骨髓间质干细胞移植治疗股骨头缺血性坏死

近年随着干细胞技术的兴起和对股骨头坏死发病机制的深入认识，利用骨髓干细胞移植治疗股骨头缺血性坏死呈现了良好的发展前景。