关节置换治疗股骨粗隆间骨折内固定失败的疗效观察

目的观察人工髋关节置换治疗股骨粗隆间骨折内固定失败患者的临床疗效。方法对2007年6月至2013年6月收治的21例股骨粗隆间骨折内固定失败的患者采用人工髋关节置换,并随访其疗效。本组21例21髋,其中20例采用全髋关节置换,1例采用人工双动股骨头置换。年龄40~79岁,平均62.8岁。无一例术中发生不良反应,术后均在2~3 d下床活动,无肺炎、褥疮等并发症发生。结果随访时间5~48个月,平均15.6个月。本组病例均伤口愈合良好,未发生假体下沉、松动现象,部分患者假体长度未超过远端螺钉孔,但无应力骨折发生。术后早期脱位1例,复位并行前方松解后未再次脱位。术后行走功能恢复正常(Harris评分平均术前43.2分,术后84.5分)。结论人工关节置换治疗股骨粗隆间骨折内固定失败患者,可早期下地功能锻炼,减少卧床时间及并发症的发生,有利于早期功能恢复,远期疗效需要进一步观察。     

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery

BackgroundHip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA.MethodsPatients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications.ResultsNonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar.ConclusionConversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential “second hit” that both surgeons and patients should be aware of with initial decision-making.     

人工髋关节置换治疗内固定失败和高龄严重股骨粗隆间骨折

目的：探讨人工髋关节置换治疗高龄严重股骨粗隆问骨折和内固定失败病例疗效，初步总结分析此类手术的适应证及方法特点。方法：自1997年6月～2002年12月，收治股骨粗隆间骨折内固定失效8例，高龄严重粉碎移位股骨粗隆间新鲜骨折6例。采用全髋关节置换9例，双极人工股骨头置换5例，1例术中股骨近端骨折，加环抱器固定。结果：随访3个月～5年半，2例出现关节周围异位骨化，没出现感染、术后骨折、脱位、假体松动及血管栓塞等并发症，Harris评分，术前平均42分(24～56分)，术后平均86分(65～99分)。结论：股骨粗隆间骨折内固定失败及部分高龄严重移位股骨粗隆间骨折，人工髋关节置换是一种直接有效的治疗方法。     

Salvage Hip Arthroplasty After Failed Fixation of Proximal Femur Fractures

We reviewed 46 patients who underwent salvage hip arthroplasty (SHA) for revision of failed cannulated screws (CS), sliding hip screws (SHS), or intramedullary nails (IMN). The primary objective was to determine differences in operative difficulty. SHA after failed femoral neck fixation was associated with lower intra-operative demands than after failed peri-trochanteric fractures. Similarly, analysis by the index implant found that conversion arthroplasty after failed CSs was associated with lower intra-operative morbidity than failed SHSs or IMNs; differences between SHS and IMN were not as clear. Importantly, intra-operative data in cases of failed SHSs were similar regardless of the original fracture type, showing the device played a larger role than the fracture pattern. Complications and revision surgery rates were similar regardless of fracture type or fixation device. Our results suggest that operative demands and subsequent patient morbidity are more dependent on the index device than the fracture pattern during SHA.     

人工关节置换术治疗高龄股骨转子间骨折内固定失效

目的探讨人工关节置换治疗高龄股骨转子间骨折内固定失效的疗效。方法对2000年1月至2010年12月行人工关节置换术的28例70岁以上股骨转子间骨折内固定失效或骨折不愈合的患者进行回顾性分析。患者男10例,女18例;年龄70~86岁,平均76.5岁。随访期限6~60个月,平均24个月。应用H arris评分标准进行结果评价。结果患者均在术后15 d拄双拐下地负重行走,6~8周弃拐改用手杖,髋关节功能接近伤前水平,生活基本自理。髋关节功能按H arris评分标准,询问骨折前患髋功能及参照健侧予以评分84~97分,平均(90±4)分。人工关节置换术前40~48分,平均(45±3)分;术后82~95分,平均(89±3)分。结论人工关节置换治疗高龄股骨转子间骨折内固定失效或骨折不愈合可以有效减轻患者髋关节疼痛,降低并发症,提高生活质量,是高龄股骨转子间骨折内固定失效治疗的有效挽救手段。     

Hip Arthroplasty After Surgical Treatment of Intertrochanteric Hip Fractures

Background

Although use of intramedullary hip screws (IMHS) for intertrochanteric (IT) hip fractures has become more common, limited data have suggested difficulties in conversion to hip arthroplasty. The present study investigates whether conversion of failed IT fracture fixation with an intramedullary vs extramedullary device leads to different rates or types of complications or decreased arthroplasty survivorship.

Hemiarthroplasty for Unstable Intertrochanteric Hip Fractures: A Matched Cohort Study

BackgroundGeriatric intertrochanteric fractures remain a major public health concern due to the considerable disability, morbidity, mortality, and health care costs associated with these injuries. The underlying poor bone quality and unstable nature of these fractures makes them difficult to treat. The main purpose of this study was to evaluate the outcome of hemiarthroplasty for unstable intertrochanteric hip fractures when compared to the traditional treatment options of open reduction internal fixation (ORIF).MethodsA retrospective 1:1 matched cohort of 150 patients who had intertrochanteric fractures treated with either hemiarthroplasty or ORIF was developed using a local institutional database. Demographic, perioperative, and postoperative variables were collected with at least 1 year of patient follow-up. Statistical analyses were performed with use of Student’s t-tests, chi-square tests, and analysis of variance.ResultsUnstable intertrochanteric fractures treated with ORIF were associated with significantly more blood loss and an increased need for revision surgery. This effect was most pronounced in Arbeitsgemeinschaft für Osteosynthesefragen Orthopaedic Trauma Association classification type 31.A3 fractures, as patients treated with ORIF experienced significantly slower postoperative mobilization, increased blood loss, increased readmission, and revision surgery rates. Hemiarthroplasty was associated with an increased risk of greater trochanter escape, which did not appear to effect outcomes in this subset of patients.ConclusionHemiarthroplasty may improve outcomes for patients with unstable intertrochanteric fractures. The benefit of this technique is likely maximized in Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association type 31.A3 fractures. It remains a good option in the hands of experienced surgeons.     

Fixation Method for Hip Arthroplasty Stem Following Hip Fracture: A Population-Level Cost-Effectiveness Analysis

BackgroundHip arthroplasty is increasing in Australia. The number of procedures for fractured neck of femur was 7500 in 2017. Best practices for fixation method and procedure type require scrutiny. This paper is about the costs and health outcomes of cemented and uncemented hemiarthroplasty and total hip arthroplasty at a national level.MethodsWe created a Markov model for patients <75, aged 75-85, and over 85. Expected costs and health outcomes over 5 years from a decision to change from existing practice to a best practice policy in which all patients with fractured neck of femur received the same fixation method based on age and type of arthroplasty are estimated. The model was populated using prevalence and incidence data from the Australian Orthopedic Association National Joint Replacement Registry, costs from Metro North Hospital and Health Service in Queensland, and probabilities and utilities from the literature. We simulated the uncertainties in outcomes with probabilistic sensitivity analysis.ResultsWe found that uncemented stem procedures were more costly and provided worse health outcomes compared to cemented stem fixation for hemiarthroplasty and total hip arthroplasty for all age groups. Moving from existing practice to cemented stem arthroplasty could save the Australian health system $2.0 million over 5 years with a gain of 203 quality-adjusted life years.ConclusionWe suggest that consideration be given to cemented fixation of the femoral stem for patients receiving both hemiarthroplasty and total hip arthroplasty for fractured neck of femur. Best practice guidelines focused on cost-effectiveness should recommend cemented stem fixation to both save costs and improve patient quality of life.     

Internal Fixation After Subtrochanteric Femoral Fracture After Hip Resurfacing Arthroplasty

Periprosthetic fractures around total hip arthroplasty create surgical challenges with many described techniques of either fixation or revision. The increasing popularity of hip resurfacing arthroplasty poses different problems especially if there is a desire to retain the prosthesis rather than converting to a total hip arthroplasty. We describe a previously unreported technique of fixation for a comminuted, proximal femoral fracture, beneath a hip resurfacing.     

Outcomes of Total Hip Arthroplasty for Healed Intertrochanteric Hip Fractures. A Matched Retrospective Cohort Study

BackgroundMany studies have analyzed the outcomes of total hip arthroplasty (THA) after failed intertrochanteric fracture fixation, but not after healed fracture. The objective is to investigate the influence of a prior healed intertrochanteric fracture fixation on the outcomes of a subsequent THA for osteoarthritis.MethodsThis is a matched retrospective cohort study of THA between 43 patients who suffered a prior intertrochanteric fracture successfully managed with internal fixation and 43 patients without prior hip fracture. Mean age was 73.6 vs 74.2 years. A conventional cementless THA was used in both groups. Functional outcome was assessed by the Harris hip score (HHS) and reduced Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. Radiological assessment was also performed.ResultsMean follow-up was 6.6 (range, 5-8) years. The mean operative time and blood transfusion rate were significantly higher in the fracture group (P = .001), but there was no significant difference in the length of stay. HHS significantly improved in both groups. At final follow-up, HHS was significantly higher in nonfracture group (P = .008), but the rate of patients with excellent and good outcomes was similar (P = .616). Western Ontario and McMaster Universities Osteoarthritis Index score at the final follow-up was not different between groups (P = .058). Complication rate was similar between groups. There were no revisions, dislocations, or loose implants in the study group.ConclusionCementless THA provided successful functional outcomes and implant durability at medium term in patients treated for osteoarthritis following healed intertrochanteric fracture fixation, comparable to those without prior fracture who underwent primary THA. Surgical complexity and complication rate were low.     

Total Hip Arthroplasty After Failed Internal Fixation of Proximal Femoral Fractures

Between February 1987 and October 2008, we performed 102 total hip arthroplasties (THAs) after failed internal fixation of a prior hip fracture. There were 39 intertrochanteric fractures and 63 femoral neck fractures. Etiology of failure included 35 cases of osteonecrosis, 32 cases of arthritis, 25 cases of early failure of fixation, and 10 cases of nonunion. There were 12 patients who had early surgical complications related to the procedure (11.8%, 12/102). These included 5 patients who had dislocations (4.9%), 4 periprosthetic fractures (3.9%), 2 hematomas (2.0%), and 1 infection (1%). Of these 102 THAs, 50 were available for at least 2 years of follow-up (mean, 3.2 years). At a minimum 2-year follow-up, THA after failed internal fixation of hip fracture in these patients was clinically successful with an elevated risk of periprosthetic fracture and dislocation.     

Better Prognosis of Senile Patients with Intertrochanteric Femoral Fracture by Treatment with Open Reduction Internal Fixation than by Hip Arthroplasty

ABSTRACT

Purpose: To compare the postoperative survival and mortality rates in intertrochanteric femoral fracture (IFF) patients who underwent either open reduction internal fixation (ORIF) or hip arthroplasty. Methods: Clinical data from senior patients who had IFF and underwent ORIF or hip arthroplasty were analyzed retrospectively. Survival curves were compared between groups with Kaplan–Meier method and log-rank test. Significant independent prognostic factors were identified by Cox multivariate regression analysis. Results: All patients recovered fully post-surgery. Although 31 patients died during the follow-up period (ORIF, mean 45.4 months; arthroplasty, mean 51.6 months), mortality rate did not differ significantly between the groups. The 1-yr and 2-yr survival rate estimates for the ORIF group were 92.2%, and 86%, respectively; they were 85% and 74% for the arthroplasty group. Average survival lengths for ORIF and arthroplasty groups were 88 and 67 months, respectively. The effect of surgical approaches on survival differed significantly (log-rank test c2 = 6.402, p = 0.011). Multivariate Cox regression model indicated that surgical choice (p = 0.036) was a significant independent risk factor for the prognosis of senile IFF, even with adjustment for age (p = 0.002). Conclusion: The overall postoperative prognosis was superior in senile IFF patients treated with ORIF.     

Management of Failed Trochanteric Fracture Fixation With Cementless Modular Hip Arthroplasty Using a Distally Fixing Stem

Failure of internal fixation of intertrochanteric fractures is associated with delayed union or malunion resulting in persistent pain and diminished function. We evaluated 15 elderly patients treated with a tapered, fluted, modular, distally fixing cementless stem. At an average follow-up of 2.86 years, mean Harris hip score improved from 35.90 preoperatively to 83.01 (P < .01). Fourteen stems had stable bony ongrowth, and one stem was loose. Distal fixation with a tapered, fluted, modular cementless stem allows stable fixation with good functional outcome in a reproducible fashion in this challenging cohort of patients.     

内固定和人工关节置换治疗高龄不稳定性股骨转子间骨折疗效比较

目的：比较内固定和人工关节置换在高龄不稳定性股骨转子间骨折治疗中的疗效。方法：75岁以上患者97例,分别采用内固定（DHS、DCS、PFN）和人工关节置换术治疗,对其术后半年、1年和3年疗效分别进行比较。结果：术后半年、1年人工关节置换组疗效优于内固定组,术后3年两组疗效无显著性差异。结论：人工关节置换术对于高龄股骨转子间骨折的治疗,尤其是存在严重骨质疏松、骨折粉碎难以内固定者,具有一定优势。     

闭合复位动力髋螺钉固定治疗股骨转子间骨折

目的总结闭合复位动力髋螺钉（dynamic hip screw,DHS）内固定治疗股骨转子间骨折的疗效。方法股骨转子间骨折患者66例,均行闭合复位,DHS内固定,术后进行康复训练。结果均顺利完成手术。围术期并发症7例：心功能衰竭4例,肺部感染及呼吸衰竭2例,褥疮1例。1例因糖尿病合并肺部感染、呼吸衰竭而死亡。55例获随访,平均6（3-12）个月。疗效评价：优33例,良16例,可4例,差2例;优良率89.1%。复位不良及内固定失败4例。结论闭合复位DHS内固定治疗股骨转子间骨折安全、有效;术后合理有效的康复训练有助于骨折愈合。     

The Conversion Rate of Bipolar Hemiarthroplasty after a Hip Fracture to a Total Hip Arthroplasty

Background

Bipolar hip hemiarthroplasty is used in the management of fractures of the proximal femur. The dual articulation is cited as advantageous in comparison to unipolar prostheses as it decreases acetabular erosion, has a lower dislocation rates and is easier to convert to a total hip arthroplasty (THA) should the need arise. However, these claims are debatable. Our study examines the rate of conversion of the bipolar hemiarthroplasty to THA and the justification for using it on the basis of future conversion to THA.

Methods

All cases of bipolar hemiarthroplasty performed in our unit for hip fractures over a 9-year period (1999-2007) were reviewed. Medical notes and radiographs of all patients were reviewed, and all surviving patients that were contactable received a telephone follow-up.

Results

Of all 164 patients reviewed with a minimum of 1 year from date of surgery, 4 patients had undergone a conversion of their bipolar prosthesis to THA. Three conversions were performed for infection, dislocation, and fracture. Only one (0.6%) conversion was performed for groin pain.

Conclusions

Our study show that bipolar hemiarthroplasties for hip fractures have a low conversion rate to THAs and this is comparable to the published conversion rate of unipolar hemiarthroplasties.     

Risk of Total Hip Arthroplasty After Acetabular Fracture Fixation: The Importance of Age

BackgroundGeriatric patients are the most rapidly growing cohort of patients sustaining acetabular fractures (AFs). The purpose of this study was to examine the risk of a secondary total hip arthroplasty (THA) in older patients (>60 year old) with a prior AF open reduction internal fixation (ORIF) compared with younger patients (<60 year old) with an AF ORIF on a large population level.MethodsUsing administrative health care data from 1996 to 2010 inclusive of all 202 hospitals in Ontario, Canada, all adult patients with an AF ORIF and a minimum of two year follow-up were identified and included. The risk of THA was examined using a Cox proportional hazards model adjusting for patient risk factors. Secondary outcomes included surgical complications and all-cause mortality.ResultsA total of 1725 patients had an AF ORIF; 1452 (84.2%, mean age of 38.3 ± 12.1 years) aged <60 years (“younger”) and 273 (15.8%, mean age of 69.9 ± 7.8 years) > 60 years (“older”). The mean (SD) follow-up time for all patients was 6.9 (4.2) years. In older patients, 19.4% (53 of 273) went on to receive a secondary THA with a median time to event of 3.9 years, compared with 12.9% (187 of 1452) in the younger patient cohort with a median time of 6.9 years (HR 1.7, 95% CI: 1.2-2.3). As expected, older patients had a higher 90-day mortality rate compared with younger patients (7.7% vs. 0.7%, respectively; HR 9.2, 95% CI: 4.3-19.9; P < .001).ConclusionOlder patients with an AF ORIF are at a significantly higher risk for a secondary THA than younger patients with an AF ORIF.     

PFNA治疗老年不稳定股骨转子间骨折

目的总结PFNA治疗老年不稳定股骨转子间骨折的临床效果。方法采用PFNA治疗老年不稳定股骨转子间骨折17例。结果所有患者均获随访,平均24(6～54)周,骨折均愈合,愈合平均时间14(8～22)周。未见患肢短缩内翻、旋转畸形或内固定螺旋刀片切割,无感染等并发症。髋关节功能按Sanders评分标准[1]评价:优15例,良2例。结论PFNA治疗老年不稳定股骨转子间骨折具有操作简单、创伤小、稳定性好、并发症少等优点。     

Proximal Femoral Plate,Intramedullary Nail Fixation Versus Hip Arthroplasty for Unstable Intertrochanteric Femoral Fracture in the Elderly: A Meta-analysis

IntroductionMultiple operative modalities are available for management of unstable intertrochanteric femoral fractures. This meta-analysis was conducted to find out if there is superiority of surgical fixation by proximal femoral plate or surgical fixation by intramedullary nail over hip arthroplasty for management of unstable intertrochanteric femoral fractures in the elderly.MethodsA search for relevant studies that published from January 2000 to November 2018 through the electronic literature database of Cochrane library, Medline, Trip Database and Wiley online library.ResultsA total of 19 studies including 14 prospective RCTs, and five retrospective studies. This meta-analysis showed that nail group had shorter operative time than plate group (P < 0.0001), and less blood loss than the plate and arthroplasty groups (P < 0.0001), cut-out was higher in nail group than the plate group (P < 0.0001), mortality rate was higher in hip arthroplasty compared to other groups (P < 0.0001), Harris hip score within 6 months of the operation was higher in the arthroplasty group compared with the nail and plate groups, while within 1 year of the operation, nail group had higher Harris hip score than arthroplasty group (P < 0.0001).ConclusionsThis meta-analysis suggested that the intramedullary nail fixation method is a preferred method for management of unstable intertrochanteric femoral fractures in the elderly over hip arthroplasty and proximal femoral plate fixation.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43465-021-00426-1.