髋关节软骨修复技术临床应用的策略

<正>一、髋关节软骨损伤成因及影响关节软骨是关节表面上的透明软骨组织,具有超低摩擦系数并可以分散关节负荷。由于多种原因导致的关节软骨受损,可引起关节疼痛、畸形和功能障碍。导致股骨头骨软骨损伤的致病因素包括多种情况,如机械性损伤,包括造成股骨头软骨急性暴力损伤或长时间高负荷运动所致的慢性损伤。其次,风湿性疾病如强直性脊柱炎等会导致股骨头病理性骨软骨损伤。此外,股骨头坏死也是导致股骨头软骨损伤的一种重要因素。如果这些股骨头软骨损伤不得到及时治疗,     

缝匠肌骨瓣加内固定治疗青壮年股骨颈骨折后股骨头坏死分析

目的探讨缝匠肌骨瓣加内固定治疗青壮年股骨颈骨折术后股骨头坏死发生的影响因素。方法回顾性分析从2005年2月至2015年1月我院采用空心钉内固定加缝匠肌髂骨瓣移植治疗的青壮年股骨颈骨折患者113例,其中男64例,女49例;年龄21~50岁,平均36.3岁。按患者末次随访时是否发生股骨头坏死分为非股骨头坏死组和股骨头坏死组,根据患者的临床资料以及影像学资料,选用可能与术后股骨头坏死发生相关的因素如性别、年龄、受伤至手术时间、骨折Garden分型、手术时间、手术复位情况、术后开始负重时间以及内固定是否取出等8个因素,对这些因素分别给予分组、统计和赋值,采用单因素卡方检验去除无关因素后进行多因素Logistic回归分析。结果113例患者获得23~105个月的随访,末次随访时共23例患者发生股骨头坏死。对上述8个因素进行单因素χ2检验分析,两组间骨折Garden分型、手术时间、手术复位情况的差异有统计学意义(P0.05),其他因素组间差异无统计学意义(P0.05)。对这3个有统计学意义的因素进行多因素Logistic回归分析,表明手术复位情况是股骨头坏死发生的独立危险因素。结论受伤后骨折的类型事先影响缝匠肌骨瓣加内固定治疗青壮年股骨颈骨折术后是否发生股骨头坏死。手术医生争取一次复位成功以缩短手术时间,提高骨折复位质量,可减少股骨头坏死的发生率。     

评估髋臼骨折的手术疗效及相关因素

目的评估髋臼骨折的手术疗效及影响手术疗效的相关因素。方法回顾整理1999年3月至2004年10月期间63例因髋臼骨折在我院行手术治疗患者的流行病学及并发症资料。结果52例患者（82．54％）至少合并1个其他部位的损伤。14例患者（22．22％）有坐骨神经损伤表现。29例患者（46．03％）有术后并发症但大多数没有影响手术效果。再手术率4％。59例患者（93．65％）有门诊随访和X线片复查结果，平均随访时间为2年4个月。44例患者（69．84％）的疗效为优／好。结论疗效优／好的与早期手术和解剖复位等因素相关。疗效差的与手术延迟、复位失败或内固定不牢靠以及受伤时合并股骨头骨折等因素相关。     

儿童股骨颈骨折疗效及股骨头坏死相关因素分析

目的回顾性分析我院24例儿童股骨颈骨折的临床资料,评价骨折复位质量与股骨头缺血坏死及疗效的关系,评估股骨头坏死的相关因素。方法回顾性分析我院2004年1月至2015年12月收治的24例儿童股骨颈骨折患者,均为闭合性损伤,均采用手术治疗。按Delbet分型,Ⅰ型0例,Ⅱ型7例,Ⅲ型12例,Ⅳ型5例。早期手术11例,延迟手术13例。采用闭合复位16例,切开复位8例。术后功能评价采用Ratliff分级。结果无伤口感染及神经损伤并发症,股骨头缺血坏死4例,骨骺早闭4例,下肢不等长6例,髋内翻4例,骨不愈合3例,内固定失效1例。按Ratliff标准进行疗效评价,优15例,良6例,差3例,优良率87.5%。结论骨折解剖复位、坚强内固定可提高儿童股骨颈骨折患者疗效,骨折复位质量与股骨头缺血坏死、骨不愈合及疗效相关;股骨头缺血坏死与螺钉通过骺板、骨折分型相关;与手术时机、关节囊减压、复位方式无关。     

影响距骨骨折手术疗效的相关因素分析

目的:探讨影响距骨骨折手术疗效的相关因素。方法:通过对收治的58例距骨骨折患者的临床资料进行回顾性分析,观察损伤性质(开放、闭合)、骨折损伤部位、内固定方式、骨折复位情况等因素对手术治疗效果的影响。结果:距骨坏死率与骨折的开放性、粉碎程度及骨折复位不良有显著统计学差异(P<0.05);创伤性关节炎的发生率与骨折部位、是否合并距骨周围骨折及复位程度有显著统计学意义(P<0.05);骨折愈合不良率与骨折复位不良及骨折部位有显著统计学意义(P<0.05)。结论:距骨骨折的损伤性质、损伤部位、复位情况是影响骨折术后的重要影响因素,根据距骨骨折本身创伤特点、手术时良好的复位和内固定,有助于距骨骨折术后功能的恢复,减少术后并发症的发生     

股骨头坏死误诊相关因素研究

目的 :分析股骨头坏死误诊现状及相关因素,为股骨头坏死的准确诊断提供依据。方法 :收集自2015年3月至2016年3月髋关节疾病患者314例,设定首次诊断后,同样症状体征半年内第2次就诊与首诊不一致或与专家组所给诊断不一致者为误诊标准。将一般资料、发病诱因、发病时间、就诊医院、临床表现、髋关节X线片、MRI等资料进行统计处理。用Logistic回归模型对股骨头坏死误诊相关因素分析研究。结果:共127例曾经历过股骨头坏死误诊,总误诊率达到40.8%,其中股骨头坏死被误诊为其它疾病占77.2%,其它疾病被误诊股骨头坏死占22.8%;采用单因素分析,误诊与发病诱因、激素使用史、饮酒史、发病侧别、疼痛侧别、疾病隐匿情况、首诊医院级别、首诊专家级别等有相关性(P0.05),误诊与性别、年龄、使用激素原发疾病、激素使用方法、激素使用时间、饮酒种类、饮酒年限等均无相关性(P0.05)。股骨头坏死被误诊为其他疾病Logistic回归分析显示,隐匿起病和患者首次就诊时医生级别有较高的相对危险度,其OR值分别为3.059和2.778(P0.01);激素使用史的危险度较低,OR=0.387(P0.05)。其他疾病被误诊为股骨头坏死Logistic回归分析显示,患者首次就诊时医生级别有较高的相对危险度,其OR值为3.573(P0.01)。结论 :股骨头坏死误诊率较高,隐匿起病和患者首次就诊时的低级别医生是股骨头坏死被误诊为其他疾病较高的相对危险因素,而激素使用史则是误诊的保护性因素;患者首次就诊时的低级别医生是其他疾病被误诊为股骨头坏死较高的相对危险因素。     

股骨颈骨折闭合复位加压螺纹钉内固定术后股骨头坏死多中心多因素相关分析

 目的 调查股骨颈骨折闭合复位加压螺纹钉内固定术后股骨头坏死的发生率,探讨各影响因素与股骨头坏死的相关性。方法 对江苏地区2001至2010年期间接受闭合复位加压螺纹钉内固定治疗的股骨颈骨折患者进行回顾性调查。以股骨头坏死作为观察指标,将患者的年龄、性别、伤侧、损伤机制、骨折类型(移位程度)、手术前时间间隔、骨折复位质量、术后患肢不负重时间、内固定排列方式以及内固定是否取出作为相关影响因素,运用logistic回归进行多因素分析。结果 共随访获得1849例患者的完整资料,平均随访时间(6.5±2.7)年。共有246例患者发生股骨头坏死,股骨头坏死发生率为13.3%。发生股骨头坏死的时间平均为伤后(17.0±4.6)个月(8～72个月)。未发生股骨头坏死的1603例患者调查时髋关节Harris评分平均为(93.8±8.9)分(78～100分)。多因素回归分析显示骨折移位程度、骨折复位质量与股骨头坏死有相关性(OR＝2.078,3.423)。结论 闭合复位加压螺纹钉内固定治疗股骨颈骨折可以取得满意的效果,股骨头坏死的发生与骨折移位程度及骨折复位质量明显相关。     

282例患者住院治疗股骨头坏死相关因素的分析

目的探讨非创伤性股骨头坏死的临床流行病学以及股骨头坏死发生的相关危险因素、治疗,以期对我国股骨头坏死发病及治疗现状进行分析,提高股骨头坏死早期筛查、诊断及治疗整体水平。方法设计相关调查表格,对2010年1月至2010年12月间入住四川大学华西医院骨科的282例股骨头坏死患者进行相关因素调查,包括一般情况,危险因素及诊断、治疗情况。在此基础上,对上述因素进行分析、总结。结果期间共收治非创伤性股骨头坏死患者282例,其中男210例,女72例,年龄19—80岁,平均42．6岁。股骨头坏死相关危险因素分析,激素性股骨头坏死50例,平均激素（强的松）摄入10mg／d,平均持续4年;酒精性股骨头坏死202例,平均酒精摄入量2413ml／周,饮酒时间平均20年。双侧发病142例（50．5％）。初次诊断股骨头坏死分期,FicatⅠ期17髋占4％,Ⅱ期79髋占18％,Ⅲ期123髋占29％,Ⅳ期215髋,占49％。双侧同时发生股骨头坏死142例占50．5％。78例（28％）患者既往曾接受过药物治疗;其中27例（27髋）为无症状股骨头坏死。结论四川地区股骨头坏死男：女为2．92：1;发病年龄在42．6岁。酒精摄入和大剂量糖皮质激素的应用是诱发股骨头坏死的主要原因。除关节置换术外,股骨头髓芯钻孔减压术是最常采用的保留股骨头的外科治疗措施。此股骨头坏死临床流行病学及相关研究分析,将对更好的认识我国股骨头坏死发病情况疾病因研究,对股骨头坏死早期预防、诊断和治疗提供可靠的数据和依据。     

股骨髋臼撞击征关节镜下翻修手术16例

目的探讨髋关节镜手术失败后进行髋关节镜翻修的原因。方法 2012年7月~2016年7月我科对16例股骨髋臼撞击征(femoroacetabular impingement,FAI)行髋关节镜翻修手术,在C形臂X线机透视和下肢牵引下,行髋关节镜探查:首先进入中央间室依次检查盂唇、髋臼关节面、股骨头软骨、髋臼顶软骨及圆韧带。对撕裂退变的髋臼盂唇根据损伤情况行盂唇缝合术或盂唇修整术。Outerbridge系统对软骨损伤进行分级清理损伤软骨组织。处理中央间室后放松双下肢牵引,关节镜进入周围间室。根据术中股骨头颈和髋臼动态撞击情况、部位行股骨头颈成形术(Cam畸形)或髋臼成形术(Pincer畸形)。如果术前检查伴有大转子压痛及MRI显示臀中肌止点炎症,术中清理大转子滑囊和损伤的臀中肌止点。利用CT三维重建检查,比较髋臼股骨头成形术前后股骨髋臼形态、骨量磨除情况和确认撞击因素去除。结果 16例随访16~60个月(中位数38个月)。16例VAS评分术前中位数4.5分(4~6分),末次随访时中位数1分(0~1分),明显降低(Z=-4.953,P=0.000);髋关节功能Harris评分由术前(69.88±9.33)分提高至末次随访时(88.69±4.33)分(t=-8.377,P=0.000)。总体患者满意度平均8.46分(4~10分)。无进行第2次翻修手术和接受全髋关节置换术者。结论髋关节镜翻修手术最主要的原因是股骨头髋臼撞击因素未彻底去除,残余的骨性撞击导致疼痛和盂唇软骨再次损伤。翻修手术去除骨性撞击因素,修复损伤盂唇软骨,明显改善患者临床症状和关节功能,短中期内提高患者生活质量,减少髋关节置换发生。     

切开复位内固定治疗髋臼骨折

1995年～ 2 0 0 1年 ,我们对 12例髋臼骨折行切开复位内固定 ,取得了较满意疗效。报告如下。1　临床资料　　本组 12例 ,男 10例 ,女 2例。年龄 18～ 5 5岁。均为外伤所致。受伤至手术时间 11例为 3～ 10天 ,仅 1例因合并其他部位严重损伤 ,至伤后 73天手术。所有患者均摄骨盆正位及左右侧斜位 X线片及髋部 CT扫描加三维及四维重建。 1例合并股骨头中心脱位 ,2例合并股骨头后脱位 ,1例伴有坐骨神经损伤。对股骨头中心脱位行闭合复位、胫骨结节及股骨粗隆间骨牵引 ;股骨头后脱位予以 Stimson手法复位 ,必要时硬膜外麻醉下行闭合复位 ,胫骨…     

Terrible triad of the hip: A case report

IntroductionPipkin-III femoral head fracture dislocation is a rare injury and its outcome is guarded. Some authors believe femoral neck fracture of Pipkin-III injury is largely iatrogenic. Recent literature showed none of these injuries had excellent outcome, and most patients end up with hip replacement.Presentation of caseA 34-year-old man sustained a traumatic hip injury with fracture-dislocation and an iatrogenic femoral neck fracture during reduction. A modified Gibson approach was performed to reduce and fix the femoral head and neck fractures in a retrograde fashion. Follow-up at 26 months assessment showed viable femoral head, and excellent functional outcome.DiscussionIatrogenic femoral neck fracture in the setting of femoral head dislocation is not uncommon. Clinical and radiological signs of irreducible dislocation can easily be missed which might lead to devastating complications like iatrogenic femoral neck fracture. Recognition of this unique injury, timely intervention, and meticulous dissection might positively alter the patient’s outcome.ConclusionThis case serves to enlighten orthopedists about the risk of iatrogenic femoral neck fracture, methods to avoid such complication, and the proper management.     

Fractures of the head and neck of the femur in children: an outcome study

Fractures of the head and neck of the femur in children are very rare, occurring only after a high-velocity trauma, e.g. a fall from a height. This analysis shows the clinical course of traumatic femoral head and neck fractures in paediatric patients. Predisposing factors for poor outcome or fracture complications, such as non-union or femoral head necrosis, are described. Between 1993 and 2006, 16 paediatric patients with proximal femoral fractures were treated at the Level One Trauma Centre of the Medical University of Vienna. The minimum follow-up was two years. Inclusion criteria were age less then 16 years, intact growth plate and a proximal femoral fracture according to the classification by Delbet and Colonna. Exclusion criteria were pathological fractures or fractures of the subtrochanteric region (6/16). Ten patients met the inclusion criteria. Two patients were lost to follow-up. Therefore eight patients were included in the study. All patients except one were operated upon within 48 h after the injury (“primary”) and healed without further complications. A single case was managed by “secondary” surgical treatment, two weeks after the initial trauma resulting in femoral head necrosis that healed without any subjective complaints. This case series confirms the importance of early surgical fixation of proximal femoral fractures in paediatric patients. An operative intervention later then 48 h after the initial trauma may increase the risk of complications such as femoral head necrosis, particularly in Delbet type I fractures (traumatic slipped capital femoral epiphysis).     

Avascular necrosis of the femoral head--an unusual complication of an intertrochanteric fracture.

Avascular necrosis of the femoral head is an uncommon complication after intertrochanteric fracture. We report six patients with this unusual complication 1-5 years after intertrochanteric fracture. The possible etiologies of this complication include a more proximal intertrochanteric fracture, a high-energy injury with fracture displacement resulting in vascular damage, and adverse influences of the operative procedures on the vascularity of the femoral head.     

股骨转子周围骨折的髓内钉固定96例

应用国产Gamma钉治疗股骨转子周围骨折 96例 (97髋 )的疗效。对稳定性骨折 4 0例、不稳定性股骨转子周围骨折 56例 (57髋 )采用亚太型Gamma钉治疗。平均随访 1 2个月 ,骨折愈合率 98% ,髋关节功能优良率 90 2 %。并发症 :股骨干骨折、拉力螺钉切出股骨头及退出各 1例 ,迟发感染 3例。Gamma钉可用于各种类型的股骨转子周围骨折 ,具有操作简便、手术损伤小、出血少、固定牢固等优点。熟练掌握Gamma钉技术 ,术中认真、细致操作 ,有些并发症是可以避免的。Gamma钉是治疗股骨转子周围骨折的理想方法之一。     

Three part posterior fracture dislocation of the hip without fracture of the femoral head: review of literature and a case report

This case report describes a rare posterior dislocation of the hip with fractures of the ipsilateral femoral neck and greater trochanter, without fracture of the femoral head, in a young adult male following a railway accident. This patient was managed within 6h of injury by open reconstruction. This unusual injury has not been reported previously. Cases of posterior fracture dislocation of the hip with a fracture of the femoral neck without fracture of the femoral head were reviewed from the literature. Mechanism of injury, controversies regarding operative procedures and appropriate surgical approach are discussed. The authors also believe that this injury pattern merits inclusion in the existing classification system of fracture dislocation of hip for management and prediction of outcome.     

Dilemma for Fracture Fixation of Paediatric Ipsilateral Neck with Shaft Femur Fracture

BackgroundIpsilateral femoral neck with shaft fracture (IFNSF) in the paediatric population is a rare injury. This high-impact trauma is often associated with other orthopaedic and systemic injuries. Prognosis is usually guarded as both these osseous injuries are serious and exist together. We report two such patients of IFNSF.MethodsTwo children with IFNSF were admitted at our hospital in 2018. The first patient had an associated head injury, while in the second patient, the shaft femur fracture was open. We report on the treatment and results in these two patients. Both the patients were serially assessed and followed 2 years after the injury.ResultsUnion was achieved in neck and shaft femur fractures in both the patients by 3 months. Complications like avascular necrosis (AVN) of the femoral head, coxa vara, non-union or malunion of fractures, limb length discrepancy, knee and hip stiffness were not seen in either of the patients.ConclusionIFNSF is a rare injury pattern seen in children, usually associated with concomitant orthopedic and other systemic injuries. Early operative stabilization is the preferred modality of treatment. For an undisplaced neck fracture, a provisional temporary fixation of a relatively less displaced neck fracture, definitively stabilizing the shaft fracture, and thereby returning to fix neck fracture is advocated. For displaced neck fractures, a direct open reduction is advocated. Anatomical fixation with separate implants and a relatively longer immobilization can provide the best-expected results. Long-term follow-up is needed to foresee any complications.Level of EvidenceV (case series). Therapeutic.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43465-020-00315-z.     

Femoral intramedullary nailing: comparison of fracture-table and manual traction. a prospective,randomized study

BACKGROUND: The purpose of this study was to compare manual traction and fracture-table traction for the reduction and nailing of femoral shaft fractures. We evaluated the quality of the reduction, operative time, complications, and functional status of the patient. METHODS: Eighty-seven consecutive adult patients with a unilateral fracture of the femoral diaphysis that did not extend into the knee joint or proximal to the lesser trochanter were enrolled in the study. Patients who were transferred to our institution more than forty-eight hours after injury; those with multiple-system injuries, injury to the ipsilateral lower extremity, or pathological fracture; and those who were unable or unwilling to provide consent or to return for follow-up were excluded. Forty-five patients were randomized to manual traction and forty-two, to fracture-table traction; all were treated in the supine position. The number of surgical assistants, operative and fluoroscopy time, complications, functional scores, and other outcomes were recorded. RESULTS: There were no significant differences between the groups with respect to age, gender, Glasgow Coma Score, Injury Severity Score, side or mechanism of injury, fracture type, or time from injury to treatment. Internal malrotation was significantly more common when the fracture table had been used: twelve (29%) of the forty-two femora were internally rotated by >10 compared with three (7%) of the forty-five treated with manual traction (p = 0.007). Total operative time, from the beginning of the patient positioning to the completion of the skin closure, was decreased from a mean of 139 minutes (range, 100 to 212 minutes) when the fracture table was used to a mean of 119 minutes (range, sixty-five to 180 minutes) when manual traction was used (p = 0.033). There was no significant difference between the two treatment groups with regard to the number of assistants per case (mean two; range, zero to three), fluoroscopy time, other complications including femoral shortening or lengthening, or functional status of the patient at one year. CONCLUSIONS: Compared with fracture-table traction with the patient in a supine position, manual traction for intramedullary nailing of isolated fractures of the femoral shaft is an effective technique that decreases operative time and improves the quality of the reduction.     

Operative treatment of displaced fractures of the acetabulum. A meta-analysis

Over the past 40 years, the management of displaced fractures of the acetabulum has changed from conservative to operative. We have undertaken a meta-analysis to evaluate the classification, the incidence of complications and the functional outcome of patients who had undergone operative treatment of such injuries. We analysed a total of 3670 fractures. The most common long-term complication was osteoarthritis which occurred in approximately 20% of the patients. Other late complications, including heterotopic ossification and avascular necrosis of the femoral head, were present in less than 10%. However, only 8% of patients who were treated surgically needed a further operation, usually a hip arthroplasty, and between 75% and 80% of patients gained an excellent or good result at a mean of five years after injury. Factors influencing the functional outcome included the type of fracture and/or dislocation, damage to the femoral head, associated injuries and co-morbidity which can be considered to be non-controllable, and the timing of the operation, the surgical approach, the quality of reduction and local complications which are all controllable. The treatment of these injuries is challenging. Tertiary referrals need to be undertaken as early as possible, since the timing of surgery is of the utmost importance. It is important, at operation, to obtain the most accurate reduction of the fracture which is possible, with a minimal surgical approach, as both are related to improved outcome.     

Femoral neck fracture in a child with autosomal-dominant osteopetrosis: failure of spica cast treatment and successful outcome by internal fixation

A case report of a 6-year-old child with autosomal dominant osteopetrosis who sustained a closed femoral neck fracture initially treated with a spica cast with subsequent fracture displacement is presented. Further treatment included closed reduction and operative fixation, first, with a guide pin placement for a cannulated screw insertion that was abandoned because of the hardness of the bone. Three Kirschner wires were then inserted to maintain the closed reduction, followed by immobilization in a spica cast. At the 2-year follow-up, the child was completely free of any complications resulting from her injury and treatment. Radiographs showed no evidence of avascular necrosis in the affected femoral head. Review of the literature supports evidence for early operative fixation of such cases, whether or not the femoral neck fracture is nondisplaced or displaced.     

Traumatology in the elderly. Problems exemplified by femoral neck fractures]

The most frequent complications in response to a fracture of the femoral neck, a typical injury of the elderly, are necrosis of the head of femur and pseudoarthrosis of the femoral neck. Only the around dressed down fracture can be conveyed to conservative treatment. The classification of AO takes these problems into consideration. One possibility to preserve the femur head is by operative insertion of a dynamic hip screw (DHS). Specific problems of the diverse types of fracture and their surgical details are taken into special account.