Posterior dislocation of the hip with concomitant ipsilateral fractures of both the femoral head and shaft: A case report

Summary we report a rare injury in a 32-year-old man victim of a high-energy motor vehicle accident who sustained a posterior hip dislocation with concomitant ipsilateral fractures of both the femoral head and femoral shaft. Closed reduction of the hip was attempted but failed. Surgical approach was necessary to reduce the hip and then femoral nailing was performed. The femoral head fragment was neglected. The patient died after 2 days of neurological complications. Combination of posterior hip dislocation with ipsilateral femoral shaft and head fractures is unusual.     

The 30 ml cement test

We describe a simple and reliable test which can be used while performing hip arthroplasty as an indicator of the size and volume of the femoral canal to roughly estimate the volume of cement required to fill the femoral canal for cementing the femoral prosthesis.     

应用重组生长激素对老年患者人工髋关节置换术后的影响

目的研究重组生长激素在老年患者人工髋关节置换术后的作用。方法66名老年股骨颈骨折行髋关节置换术的患者随机分成2组,进行前瞻、对照、双盲研究。一组给予重组生长激素皮下注射,另一组作为对照组,统计患者术后患肢恢复直腿抬高的时间、下地活动的时间、弃杖行走的时间及术后住院时间和费用,统计结果采用t检验,P值<0.05,有统计学意义。结果治疗组在术后患肢恢复直腿抬高的时间、下地活动的时间、弃杖行走的时间及术后住院时间均较对照组短,(P值<0.05),费用开支无明显差异,(P值>0.05)。结论在老年股骨颈骨折行髋关节置换术的患者中,应用重组生长激素可加快患者髋关节功能康复,减少术后住院天数,不增加患者的经济负担。     

青壮年股骨颈骨折手术治疗的回顾性分析

目的 探讨治疗青壮年股骨颈骨折的手术方法及临床疗效. 方法对2005年1月至2008年6月行手术治疗并获得随访的41例青壮年股骨颈骨折患者按照"难治性骨折的治疗研究随访表"进行随访,从骨折类型、手术时机、骨折复位质量、置入物类型、卧床时间以及髋关节功能等方面进行评估. 结果 41例患者获得10～52个月随访,平均30.5个月.37例(90.2%)患者在伤后2～5d内行手术治疗,平均3.6 d,Garden Ⅱ、Ⅲ型骨折采用闭合复位钛合金空心钉内固定术,Garden Ⅳ型及陈旧性骨折、病理性骨折采用切开复位钛合金空心钉内固定加髂骨瓣植骨术.术中复位评价平均4.83分,术后平均卧床时间3.5个月.髋关节功能按照Harris评分标准:优21例,良15例,可3例,差2例,优良率为87.8%.Garden Ⅳ型骨折优良率较Ⅱ、Ⅲ型骨折优良率低,但差异无统计学意义(χ2=1.35,P=0.25). 结论早期手术、解剖复位、多枚钛合金空心钉坚强内固定是青壮年股骨颈骨折手术治疗的关键,Garden Ⅳ型骨折髂骨瓣植骨、合理的早活动和晚负重是预防股骨头缺血坏死的有力保证.根据骨折的严重程度制定科学规范的治疗方案和合理的术后康复策略,对提高临床疗效具有极其重要的意义.     

两种髓内钉固定股骨干骨折合并同侧髋部骨折的疗效比较

目的比较防旋型股骨近端髓内钉(proximal femoral nail antirotation,PFNA)与重建钉微创治疗青壮年股骨干骨折合并同侧髋部"囊外型"骨折的疗效。方法回顾性分析2000年1月-2010年8月采用PFNA和重建钉微创治疗的69例青壮年股骨干骨折合并同侧髋部"囊外型"骨折患者临床资料,其中重建钉组44例,PFNA组25例。两组患者性别、年龄、体重、致伤原因、骨折类型及受伤至手术时间比较,差异均无统计学意义(P>0.05),具有可比性。对两组手术时间、术中失血量、骨折愈合时间、并发症及髋、膝关节功能等进行比较。结果 PFNA组手术时间及术中失血量均明显少于重建钉组,差异有统计学意义(P<0.05)。69例均获1年以上随访,PFNA组随访时间12～38个月,平均20个月;重建钉组随访时间12～48个月,平均22个月。两组均无伤口感染、深静脉血栓形成、肺栓塞、内固定断裂、股骨头缺血性坏死及肢体严重旋转与短缩畸形等并发症发生。术中PFNA组植钉困难1例,重建钉组近端锁钉技术困难7例;术中PFNA组医源性股骨干骨折3例,重建钉组6例;术后PFNA组股骨干骨折延迟愈合1例,重建钉组2例;PFNA组和重建钉组并发症发生率分别为20%(5/25)和34%(15/44),比较差异无统计学意义(χ2=1.538,P=0.215)。两组各部位骨折愈合时间比较差异均无统计学意义(P>0.05)。末次随访时,两组髋关节Harris评分和膝关节Evanich评分比较差异均无统计学意义(P>0.05)。结论 PFNA与重建钉固定股骨干骨折合并同侧髋部"囊外型"骨折的临床疗效均满意,但PFNA具有操作简便等优点。     

股骨头毁损三联征:股骨头骨折-脱位合并股骨颈骨折

股骨头合并同侧股骨颈骨折是一种严重而复杂的创伤,保髋手术大多会失败。其治疗的难点及预后的关键在股骨颈骨折上。鉴于股骨颈骨折的发生与股骨头骨折-脱位之间存在明显的、前后关联的贯序特点,笔者认为以股骨头毁损三联征（disastrous triad of femoral head,DTFH）来概括这种类型的损伤,更能反映其损伤机制和预后特点。结合临床观察和文献资料,DTFH可分为3个类型：Ⅰ型,普通型DTFH,股骨颈骨折的发生紧随于股骨头骨折-脱位之后,是同一暴力造成的损伤;Ⅱ型,医源型DTFH,是在股骨头骨折-脱位的诊疗过程中发生了医源性股骨颈骨折;Ⅲ型,应力型DTFH,发生于股骨头骨折-脱位的治疗之后,在股骨头骨折面的远侧缘发生应力性股骨颈骨折。本文对各型DTFH的临床特点进行了初步的讨论。     

髋关节后脱位伴同侧转子间骨折的治疗

我院自1987年8月-2000年3月采用Gibson切口治疗髋关节后脱位伴同侧转子间骨折16例,经0.5～5年随访,取得较好疗效,现总结如下.……     

Femoral neck fractures after removal of hardware in healed trochanteric fractures

IntroductionHardware removal in healed trochanteric fractures (TF) in the absence of infection or significant mechanical complications is rarely indicated. However, in patients with persistent pain, prominent material and discomfort in the activities of daily living, the implant is eventually removed. Publications of ipsilateral femoral neck fracture after removal of implants from healed trochanteric fractures (FNFARIHTF) just because of pain or discomfort are rare. The purpose of this systematic review of the literature is to report on the eventual risk factors, the mechanisms, the clinical presentation, and frequency, and to pay special emphasis in their prevention.Materials and methodsA comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of FNFARIHTF and series of TF with cases of FNFARIHTF due to pain or discomfort published between inception of journals to December 2016 were eligible for inclusion. Relevant information was divided in two parts. Part I included the analysis of cases of FNFARIHTF, with the objective of establishing the eventual risk factors, mechanisms and pathoanatomy, clinical presentation and diagnosis, treatment and prevention. Part II analyzed series of TF which included cases of FNFARIHTF for assessing the incidence of femoral neck fractures in this condition.ResultsOverall 24 publications with 45 cases of FNFARIHTF met the inclusion criteria. We found that the only prevalent factors for FNFARIHTF were: 1) preexisisting systemic osteoporosis, as most patients were older and elder females, with lower bone mineral density and bone mass; 2) local osteoporosis as a result of preloading by the fixation device in the femoral neck, leading to stress protection, reducing the strain at the neck, and increasing bone loss and weakness; and 3) the removal of hardware from the femoral neck, with reduction of the failure strength of the neck. The femoral neck fractures were spontaneous, i.e. not related to trauma or fall, in 87.5% of the cases, mostly subcapital, and with no prevalence between displaced and undisplaced fractures. The clinical presentation was that of a spontaneous fracture, and most of the patients consulted because of hip pain and presented in the emergency room walking by themselves which led to delayed diagnosis in several instances. Radiological diagnosis was mostly with radiographs, though in some cases CT scans or MRI were necessary. The overall median incidence of this complication was 14.5% after hardware removal because of pain or discomfort in healed trochanteric fractures.ConclusionThe risk factors for FNFARIHTF seem to be preexisisting systemic osteoporosis, local osteoporosis as a result of preloading by the fixation device in the femoral neck, and the removal of hardware from the femoral neck, with reduction of the strength of the neck. The clinical presentation may be obscure as most of the patients complain of hip pain of some days or weeks, and arrive in the hospital walking. Therefore, the attending physician should be alert in order to request the appropriate radiological investigation and if this is not clear CT scan or MRI should be done in order to diagnose promptly these “spontaneous” fractures. Treatment should be replacement surgery in most cases; however, there is some place for internal fixation especially in undisplaced fractures or younger patients. The occurrence of the femoral neck fracture after hardware removal may be prevented with re-osteosynthesis and the use of bone chips or bone substitutes. Finally, the relatively high incidence of this complication should alert orthopaedic surgeons to reduce the removal of hardware in healed trochanteric fractures to very selected cases.     

Antegrade nailing of femoral shaft fractures combined with neck or distal femur fractures

Introduction Complex femoral fractures pose considerable therapeutic challenges to orthopedic surgeons. We present a retrospective review of 25 patients with complex femoral fractures treated with intramedullary locked nailing and supplemental screw fixation.Materials and methods Fifteen patients with ipsilateral femoral neck and shaft fractures (group 1) and 10 patients with ipsilateral femoral shaft and distal femur fractures (group 2) were treated from 1990 to 1998. High-energy injuries occurred in all patients. There were 4 open fractures. Antegrade, locked nailing of diaphyseal fractures was performed in all cases. Supplemental screws for the neck were used in all patients in group 1 and in 3 patients in group 2.Results All of the fractures united during the follow-up. Five patients in group 1 underwent reoperation (33.3%): one due to a delayed union, the second due to an implant failure, the third due to a nonunion of a neck fracture, and the last two because of an initially missed femoral neck fracture. None of the patients in group 2 underwent reoperation. Angular malalignment of the shaft was found in 6 fractures in group 1 (average 4.8^o, range 3^o–11^o) and in 4 fractures in group 2 (average 6^o, range 3^o–12^o). Shortening of the limb occurred in 3 patients in group 1 (average 1.4 cm, range 1–1.8) and in 1 patient in group 2 (2 cm). Loss of fixation was seen in 1 patient in each group. Avascular necrosis and infection were not seen in any case in both groups.Conclusion Femoral intramedullary nails with antegrade or retrograde options for insertion and different locking possibilities have extended the indications to include both diaphyseal and metaphyseal fractures. New nail designs, usually more expensive than the conventional nails, have been introduced into the market for this purpose. One has to keep in mind that antegrade, locked nailing of femoral shaft fractures combined with neck or distal femur fractures is a technically demanding but efficacious procedure. The success rate is high when the technique is meticulously implemented.     

Association of low-energy femoral fractures with prolonged bisphosphonate use: a case--control study

Summary  Recent evidence has linked long-term bisphosphonate use with insufficiency fractures of the femur in postmenopausal women. In this case–control study, we have identified a significant association between a unique fracture of the femoral shaft, a transverse fracture in an area of thickened cortices, and long-term bisphosphonate use. Further studies are warranted. Introduction  Although clinical trials confirm the anti-fracture efficacy of bisphosphonates over 3–5 years, the long-term effects of bisphosphonate use on bone metabolism are unknown. Femoral insufficiency factures in patients on prolonged treatment have been reported. Methods  We performed a retrospective case–control study of postmenopausal women who presented with low-energy femoral fractures from 2000 to 2007. Forty-one subtrochanteric and femoral shaft fracture cases were identified and matched by age, race, and body mass index to one intertrochanteric and femoral neck fracture each. Results  Bisphosphonate use was observed in 15 of the 41 subtrochanteric/shaft cases, compared to nine of the 82 intertrochanteric/femoral neck controls (Mantel–Haenszel odds ratio (OR), 4.44 [95% confidence interval (CI) 1.77–11.35]; P = 0.002). A common X-ray pattern was identified in ten of the 15 subtrochanteric/shaft cases on a bisphosphonate. This X-ray pattern was highly associated with bisphosphonate use (OR, 15.33 [95% CI 3.06–76.90]; P < 0.001). Duration of bisphosphonate use was longer in subtrochanteric/shaft cases compared to both hip fracture controls groups (P = 0.001). Conclusions  We found a significantly greater proportion of patients with subtrochanteric/shaft fractures to be on long-term bisphosphonates than intertrochanteric/femoral neck fractures. Bisphosphonate use was highly associated with a unique X-ray pattern. Further studies are warranted.     

人工髋关节置换术后假体柄周围股骨骨折的治疗

目的探讨人工髋关节置换术后假体柄周围股骨骨折的治疗计划以及临床效果。方法回顾自1988年1月至2001年6月本组收治的45例患者,依Vancouver分类系统,共有7例A型骨折,24例B1型骨折,7例B2型骨折,4例B3型骨折以及3例C型骨折。分别根据假体稳定度作骨折内固定或人工髋关节翻修手术,应用钢板加钢丝或钢索、Dall—Miles钢板、异体结构骨、异体骨碎片等,翻修手术应用常规骨柄或组合式股骨柄,并分析各类型骨折及各种治疗方式的结果与并发症。结果A型及B1型骨折的愈合率高,但必须注意钢板的长度;B2型骨折要注意翻修手术时的角度,避免术后出现脱臼;至于B3及C型则由于骨折复杂,并发症及失败率极高。因此,本研究提出关于这类损伤的治疗流程,让整个复杂程序更具逻辑性、简单性。结论人工髋关节置换术后假体柄周围股骨骨折是一个较复杂的问题。要获得成功的治疗,必须清楚判断骨折的特性,善用各种骨折治疗材料,以一个逻辑性思考做术前治疗计划,因此适当的分类系统显得特别重要。     

Grose-Kempf 带锁髓内钉在股骨干骨折中的应用

作者从１９８８～１９９５年末用Ｇｒｏｓｅ－ｋｅｍｐｆ钉（简称ＧＫ钉）治疗股骨干骨折４９例（５０个股骨），其中新鲜骨折２９例（３０个股骨），陈旧性骨折１６例，病理骨折４例。外伤性骨折４５例中，随访半年以上４３例，骨折全部愈合，下肢功能及关节活动良好。４例病理骨折，其中３例术后分别存活１６个月、１８个月、２４个月，另１例为成骨不全，术后患肢功能较健侧无差别。ＧＫ钉扩大了髓内钉手术适应证，可用于股骨干的粉碎性骨折、多发性骨折、陈旧性骨折不愈合及病理性骨折。对于合并脑干损伤、血管损伤、骨筋膜室综合征的股骨干骨折，用ＧＫ钉固定，获得了理想的治疗效果。     

The learning curve with a new cephalomedullary femoral nail

IntroductionThe Cephalomedullary Nail (CMN) (Zimmer, Warsaw) was introduced in 2010 as part of a multicenter trial to evaluate its performance. At one year the CMN had results in keeping with other intramedullary devices with good union rates and low complication rates. In the second and third years of use an increased rate of implant failure was observed, towards the higher end of the 1–5% nail breakage rate seen in other studies. This study aims to evaluate if there any common features in this cohort of patients.Materials and methodsThis is a retrospective cohort study looking at patients who underwent femoral fracture fixation using the cephalomedullary nail between January 2011 and June 2014. The primary outcome measure was implant failure; secondary outcomes were; fracture reduction and bisphosphonate use.Results201 patients were included (135 female, 66 male) with an average age of 81 years. Ten (5%) nail breakages occurred in the study period at an average of 39 weeks (24–92); 9 were 125° nails 1 was a 130° nail and all fractured at the lag screw junction.ConclusionsImplant failure is a recognised complication of intramedullary nailing in cases of non-union. The increased rate of implant failure in our department required a change to a 130 ° CMN implant and a 3.2 mm diameter guide wire for placement of the lag screw. We continue to monitor this difficult group of patients very closely.     

The difficult primary hip

Hip arthroplasty is a common orthopaedic procedure with proven long-term success and reliable results. A wide range of associated conditions may affect the outcome of the arthroplasty and the surgeon has to keep these in mind when planning the surgery. In this article, such situations are discussed and recommendations are drawn from the evidence available in literature.     

股骨干骨折合并同侧股骨颈骨折的漏诊分析与对策

目的 分析同侧股骨干骨折合并股骨颈骨折出现漏诊的原因及治疗。方法 回顾性分析7例同侧股骨干骨折合并股骨颈骨折的治疗方法、结果和漏诊原因。结果 漏诊病例与入院时未重视髋部损伤及X线片未明确显示骨折有关,但经正确治疗后效果满意。结论 提高对股骨干骨折合并同侧股骨颈骨折损伤的注意并行相应的查体及影像学检查可避免股骨颈骨折的漏诊,出现漏诊后如果采取正确及时的治疗仍可得到较满意的效果。     

Treatment of the femoral shaft fracture with a curved heat-treated COP clover-leaf nail

Summary The commonly used straight intramedullary nail has certain limitations and disadvantages. Following radiographic and metallurgical studies we have developed a curved heat-treated clover-leaf nail using a newly developed precipitation hardening stainless steel (COP). The nail is bent with a slot on the convex side and the radius of curvature is 115 cm which corresponds to the anatomical antero-lateral convexity of the human femur. The nail has been satisfactory in clinical use since 1971 and has provided not only more stable internal fixation but also allowed fixation of fractures beyond the middle third of the shaft.

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Résumé Le clou droit intra-médullaire, d'usage courant, comporte un certain nombre de limitations et d'inconvénients. A la suite d'études radiographiques et métallurgiques, nous avons mis au point un nouveau clou courbe, en feuille de trèfle à la coupe, fabriqué avec un nouvel alliage nickel-chrome-cobalt (COP). Le clou est incurvé, avec un sillon sur sa face convexe et un rayon de courbure de 115 cm, correspondant à la convexité anatomique du fémur humain. Ce clou a été utilisé de façon satisfaisante depuis 1971, car il procure non seulement une fixation interne plus stable, mais permet également la synthèse des fractures situées au-dessous du tiers moyen de la diaphyse.

     

股骨干骨折合并同侧股骨颈骨折治疗的临床观察

目的：探讨股骨干合并同侧股骨颈骨折的治疗特点和不同固定方法的疗效。方法：股骨干骨折合并同侧股骨颈骨折27例,男22例,女5例;年龄14～65岁,平均35岁。动力髋螺钉（DHS）固定3例,加压钢板加空心加压螺钉固定12例,重建钉固定8例,顺行髓内钉加空心加压螺钉固定4例。13例固定术前用克氏针临时固定股骨颈骨折。结果：术后随访36～75个月,平均44个月。25例股骨颈骨折平均愈合时间4.5个月,2例股骨颈骨折不愈合。27例股骨干均愈合,平均愈合时间6个月。未用克氏针临时固定股骨颈骨折14例中,2例出现股骨颈不愈合,3例轻度髋内翻畸形。结论：股骨干合并同侧股骨颈骨折有许多固定方法可供选择,加压钢板加空心加压螺钉固定简便易用,在实施固定术前用克氏针临时固定股骨颈骨折可避免股骨颈骨折再移位和损伤。     

The Pauwels classification for intracapsular hip fractures: is it reliable?

The Pauwels classification for the femoral neck fracture is still broadly used in literature and clinical practise. However, this classification has never been tested for its reliability in terms of inter-observer agreement. We assessed whether or not it is reliable to use the Pauwels classification in pre-operative planning.Ten observers classified 100 intra-capsular femur fractures. The inter-observer agreement was calculated using the multi-rater Fleiss’ kappa.The Pauwels classification showed an inter-observer agreement of κ0.31 (0.01).Classification of intra-capsular hip fractures according to the Pauwels classification using the Pauwels angle is unreliable and its use should be avoided.     

数字技术在人工髋关节置换术中的应用

目的探讨数字化骨科技术在人工髋关节置换术中的应用。方法自2013-01—2013-12对12例髋关节周围疾病需要行人工髋关节置换术者采用计算机软件技术,术前将CT扫描数据导入Mimics软件建立骨盆和股骨近端的三维模型,计算机辅助分析髋臼及股骨近端的情况,确定合适的假体大小,并在计算机上模拟假体安装的手术过程,最后按照预定的手术方案实施手术。结果所有患者均获得随访6-10个月,平均8个月。末次随访时髋关节功能Harris评分：优6例,良5例,可1例。结论计算机三维重建、计算机辅助分析和模拟人工髋关节置换过程能提高手术的准确性和安全性,在人工髋关节置换术中具有良好的应用价值。