髋部脆性骨折病人股骨近端几何形态CT评估

目的探讨CT对股骨近端几何形态的评估价值,以及股骨近端几何形态与髋部脆性骨折的相关性。方法对33例股骨颈骨折和38例粗隆间骨折老年妇女,应用CT扫描股骨近端,并测量颈干角、股骨颈轴长、股骨头直径和股骨颈直径。结果在不同骨折组间,颈干角差异有显著相关性(P<0.01)。股骨颈轴长、股骨头直径与股颈直径呈正相关(P均<0.01),在不同的骨折组间三者差异没有显著相关性(P>0.05)。结论利用CT分析股骨近端几何形态,操作简单、精确性高。颈干角与髋部骨折的类型有显著相关性,颈干角越小易发生股骨颈骨折,而颈干角越大更易发生粗隆间骨折。     

股骨近端解剖钢板治疗粗隆间骨折失败原因分析

目的分析股骨粗隆间骨折内固定失败的原因，提出避免并发症的方法。方法对1998年1月至2006年1月间采用股骨近端解剖钢板手术治疗的146例股骨粗隆间骨折进行回顾性分析，总结骨折类型、骨骼质量、松质骨螺钉的位置及骨折复位的质量，分析造成手术失败的可能原因。结果共发现22例失败病例，其中松质骨螺钉松动、退出10例，髋内翻8例，股骨头切割4例。结论病例选择不当、骨折复位不良、松质骨螺钉位置不佳以及骨骼质量差均是股骨近端解剖钢板治疗股骨粗隆间骨折手术失败的原因。正确的手术指征和精确的手术操作是成功的关键。     

苏中地区3所中医院老年股骨颈与股骨粗隆间骨折的流行病学分析

目的分析苏中地区3所中医院老年股骨颈与股骨粗隆间骨折的流行病学特点。方法纳入自2010-09—2015-08靖江市中医院、扬州市中医院及江苏省中医院住院治疗的1 258例60~90岁老年股骨颈与股骨粗隆间骨折。检索各医院病例系统,记录患者年龄、性别、骨折类型、合并症、致伤原因、治疗方案、并发症、病死率等。结果 3所医院5年共诊治股骨颈骨折813例,股骨粗隆间骨折445例。股骨颈骨折中男387例,女426例;股骨粗隆间骨折中男228例,女217例;性别差异无统计学意义(P0.05)。股骨粗隆间骨折患者年龄小于股骨颈骨折患者,差异有统计学意义(P0.05)。3所医院5年内老年股骨颈与股骨粗隆间骨折发病率逐年增高,年均上升3.68%;其中股骨颈骨折发病率年均上升3.15%,股骨粗隆间骨折发病率年均上升4.48%。结论苏中地区3所中医院老年股骨颈与股骨粗隆间骨折发生率逐年上升,骨质疏松是高危因素,而正确的手术方式及围手术期处理可降低患者并发症发生率及死亡率。     

PFNA内固定与人工股骨头置换术治疗高龄股骨粗隆间骨折疗效比较

目的对比分析股骨近端防旋髓内钉(PFNA)内固定与人工股骨头置换术治疗高龄骨质疏松性股骨粗隆间骨折的疗效。方法 120例高龄股骨粗隆间骨折随机分为两组:A组(54例)采用股骨粗隆间骨折专用假体行人工股骨头置换术;B组(66例)采用PFNA内固定。结果 118例获随访12～52个月,平均32.6个月。两组扶拐下地活动时间(A组平均3.8 d,B组平均4.2 d)差异无统计学意义(P>0.05);手术时间、术中失血量及术后并发症发生率差异有显著统计学意义(P<0.01)。结论对高龄骨质疏松性股骨粗隆间骨折采用PFNA内固定后创伤小、效果良好,而人工股骨头置换创伤较大,是特殊情况下的选择。     

骨水泥型与生物型人工股骨头置换术治疗高龄股骨粗隆间骨折的疗效比较

目的比较骨水泥型与生物型人工股骨头置换术治疗高龄股骨粗隆间骨折的近期疗效。方法回顾性分析自2015-06—2016-12行人工股骨头置换术治疗的75例高龄不稳定股骨粗隆间骨折,37例采用骨水泥型股骨假体(骨水泥组),38例采用生物型股骨假体(生物型组)。结果与骨水泥组相比,生物型组手术时间更短,术中出血量更少,术后完全负重时间更长,差异有统计学意义(P0.05);但2组术后部分负重时间、髋关节功能Harris评分优良率差异无统计学意义(P0.05)。结论骨水泥型与生物型人工股骨头置换术治疗高龄股骨粗隆间骨折均可取得满意的近期疗效。骨水泥型人工股骨头置换术固定稳定性更好,但是术中发生骨水泥植入综合征的风险更高;生物型人工股骨头置换术手术时间更短、术中出血量更少、术中安全性高。     

股骨粗隆间骨折PFNA内固定远端2种锁定方法的生物力学研究

目的比较分析股骨粗隆间骨折股骨近端防旋髓内钉(PFNA)内固定时主钉远端一孔一钉(P1型)和二孔二钉(P2型)2种锁定方式的生物力学性能。方法选择24具人工股骨,按照Evans-Jensen分型制作股骨粗隆间骨折模型,其中Ⅱ型12具,Ⅴ型12具。将模型用PFNA固定,主钉长240 mm(标准型),远端分别采用P1型静态锁定或P2型静态锁定。结果在股骨轴向压缩强度、股骨刚度、股骨头颈部的剪断试验、抗扭转力学性能方面,PFNA远端P2型锁定要略强于P1型锁定,但差异均无统计学意义(P0.05)。而Evans-JensenⅠ型骨折PFNA内固定术后比Evans-JensenⅤ型骨折术后更加稳定,无论是P1型锁定还是P2型锁定。抗疲劳力学性能测试结果显示,P2型锁定后疲劳寿命较P1型锁定长10%~20%,差异有统计学意义(P0.05)。结论采用PFNA内固定治疗股骨粗隆间骨折,主钉远端P1型锁定的生物力学性能可达到P2型锁定的效果,因此临床中PFNA主钉可采用P1型锁定,以减少手术风险,缩短手术时间,提高手术成功率。不稳定骨折若采用P1型锁定,术后不能早期负重活动,需根据术中情况及术后骨折愈合情况指导患者进行功能锻炼。     

股骨近端防旋髓内钉内固定治疗累及股骨颈的股骨粗隆间骨折

目的探讨股骨近端防旋髓内钉（PFNA）内固定治疗累及股骨颈的股骨粗隆间骨折的临床疗效。方法12例累及股骨颈的股骨粗隆间骨折（多发骨折组）及12例单纯股骨粗隆间骨折（单纯骨折组）均采用PFNA内固定。比较2组手术时间、术中出血量、术后并发症、术后12周骨折愈合情况,以及髋关节功能Harris评分。结果多发骨折组手术时间、术中出血量及切开复位例数明显多于单纯骨折组,差异有统计学意义（P〈0．05）。多发骨折组术后12周髋关节功能Harris评分较单纯骨折组低,差异有统计学意义（P=0．003）。所有患者骨折均愈合,术后未出现感染、皮肤坏死、深静脉血栓等并发症。但多发骨折组1例于术后4周螺旋刀片切出股骨头。结论对于累及股骨颈的股骨粗隆间骨折采用PFNA内固定治疗可以达到较好的临床疗效．但需要更高超的复位及固定技术。     

人工股骨头置换术治疗高龄股骨粗隆间骨折中股距重建的策略

[目的]通过比较分析人工股骨头置换术治疗高龄股骨粗隆间骨折与股骨颈骨折的疗效及预后,评价双极骨水泥型人工股骨头置换术治疗高龄股骨粗隆间粉碎骨折的效果.[方法]2005年6月～2009年6月间本院采用人工股骨头置换术治疗高龄股骨粗隆间骨折和股骨颈骨折共112例患者,男35例,女77例,年龄75～96岁,平均81.4岁.其中股骨粗隆间骨折52例,股骨颈骨折60例.对手术时间、出血量、下地负重时间和髋关节功能进行评价.[结果]术后随访12～ 39个月,平均18.6个月.髋关节功能按Harris评分:股骨粗隆间骨折组,优良率92.1％(优22例,良25例,可3例,差1例).股骨颈骨折组,优良率91.3％(优28例,良25例,可4例,差1例).股骨颈骨折组在手术时间、出血量均显著优于股骨粗隆间骨折组.下地负重时间和髋关节优良率方面无显著差别.[结论]人工股骨头置换术可成为治疗高龄股骨粗隆间不稳定骨折的主要方法.     

加长柄人工股骨头置换术与PFNA内固定治疗高龄不稳定股骨粗隆间骨折的比较研究

目的比较加长柄人工股骨头置换术与股骨近端防旋髓内钉(PFNA)治疗高龄不稳定股骨粗隆间骨折的临床效果。方法回顾性比较分析自2013-06—2014-09诊治的65例高龄不稳定股骨粗隆间骨折,采用PFNA内固定治疗20例(PFNA组),采用加长柄人工股骨头置换术治疗45例(其中骨水泥组22例,生物型组23例)。比较3组手术时间、术中出血量、术后下地时间、并发症发生率,以及术后1、3、6、12个月髋关节功能Harris评分。结果 65例均获得随访9~18个月,平均12个月。3组手术时间差异有统计学意义(P0.05),PFNA组少于生物型组和骨水泥组,而生物型组少于骨水泥组。3组术中出血量差异有统计学意义(P0.05),PFNA组少于生物型组和骨水泥组,而骨水泥组少于生物型组。3组术后下地时间差异有统计学意义(P0.05),生物型组和骨水泥组明显早于PFNA组,而骨水泥组早于生物型组。生物型组和骨水泥组术后1、3、6个月髋关节功能Harris评分均优于PFNA组,但生物型组与骨水泥组比较差异无统计学意义(P0.05);术后12个月时3组髋关节功能Harris评分差异无统计学意义(P0.05)。结论对于身体状况较好、骨质稳定的高龄股骨粗隆间骨折,可首选PFNA髓内固定;对于伴有严重骨质疏松,不适合内固定治疗以及内固定失败,或预期置换后关节使用年限不长患者,加长柄人工股骨头置换术是安全、有效的手术方式。     

PFNA内固定与人工股骨头置换术治疗高龄股骨粗隆间骨折效果比较

目的探讨股骨近端防旋髓内钉(PFNA)内固定与人工股骨头置换术治疗高龄股骨粗隆间骨折的效果。方法对85例高龄股骨粗隆间骨折分别采用PFNA内固定(A组)和人工股骨头置换术(B组)治疗,比较2组手术时间、术中出血量、术后完全负重时间及髋关节功能评分。结果 A组手术时间较B组短,术中出血量较B组少,完全负重时间较B组长,差异均有统计学意义(P0.05)。2组术后6个月髋关节功能Harris评分差异无统计学意义(P0.05),但2 a后A组优于B组(P0.05)。结论 PFNA内固定与人工股骨头置换术治疗高龄股骨粗隆间骨折各有其优势,应严格掌握适应证。术后合理功能锻炼均可获得满意疗效。     

Lower hip bone mass and proximal femur fractures in elderly patients: more valuable than lumbar vertebrae bone mineral density

A decreased bone mineral density, such as osteoporosis, has been considered a factor closely associated with proximal femur fractures. We studied the relationship between osteoporosis and proximal femur fractures. Dual energy radiograph absorptiometry was used to measure the bone mineral density of 121 patients with a femur neck fracture and 134 patients with an intertrochanteric fracture. The bone density of the femoral neck, Ward's triangle, and the trochanteric region were measured. Two hundred seventeen normal patients who had undergone a bone mineral density test and were found to have no proximal femur fracture were used as the control group. Comparative analysis was performed after the patients were subdivided into different groups depending on sex and fracture type. The bone mineral density of the lumbar vertebra in patients with a proximal femur fracture was not significantly different from that of the control group, but the bone mineral density of the proximal femur in patients with a proximal femur fracture was significantly less than that of the control group. The bone mineral density of the group with an intertrochanteric fracture was lower than that of the femur neck fracture group. However, the difference was statistically insignificant. In bone mineral density comparisons, no significant differences were observed between the displaced and undisplaced femur neck fracture group and between the stable and the unstable intertrochanteric fracture group. The bone mineral density of elderly patients with a proximal femur fracture was significantly less than that of normal individuals. However, femur neck fractures in elderly men were less likely to be associated with a decreased bone mineral density. Little correlation between bone mineral densities of the proximal femur and fracture location (neck vs intertrochanter) and type (nondisplaced vs displaced neck, stable vs unstable intertrochanter) was found.     

Structural trends in the aging proximal femur in Japanese postmenopausal women

Hip structure analysis (HSA) can be used to measure proximal femur geometry using conventional DXA scans of the hip. This study is the first analysis of HSA data in Japanese women to evaluate apparent age trends in the geometry of cross-sectional regions in the proximal femur. 409 Japanese women aged from 50 to 93 years of age were measured by DXA at three sites (narrow neck, intertrochanter, shaft). Using the mean value those between 50-59 years as a reference value, age trends were evaluated using groupings of 5-year intervals and those over 80 as a single group. BMD at three measured sites and section modulus (index of bending strength) at narrow neck declined in a similar age dependent manner, but section modulus at intertrochanter and shaft showed a different pattern. The decline in section modulus at narrow neck occurs after 50-59 years of age, whereas section modulus at intertrochanter remain 70-74 years, after that began to decrease. Section modulus at shaft, an uncommon fracture location, remains fairly static through life. In conclusion, HSA in Japanese women showed that reduction in geometric strength, as reflected by the section modulus, was not dependent on decline in BMD.     

单侧多支点外固定器治疗股骨粗隆间骨折

目的 观察应用单侧多支点外固定器治疗股骨粗隆间折的疗效。方法 采用北大粗隆下穿针越过骨折断端达股骨头软骨下,股骨中上段另行穿针,针尾用外默写器固定治疗粗隆间骨折１０２例。结果 术后随访１年￣１年４个月,骨折均愈合。优８１例,可１４例,差８例。结论 单侧多支点外固定器可使骨折获得有效制动,口才能早期下床活动,术后护理方便。该术式操作简单,使用安全。     

Proximal femur bone mineral levels of US adults

This paper describes bone mineral levels in the proximal femur of US adults based on a nationally representative sample of 7116 men and women aged 20 years and older. The data were collected in phase 1 of the third National Health and Nutrition Examination Survey (NHANES III, 1988–1991) using dual-energy X-ray absorptiometry, and included bone mineral density (BMD), bone mineral content (BMC) and area of bone scanned in five selected regions of interest (ROI) in the proximal femur: femur neck, trochanter, intertrochanter, Ward's triangle and total. These variables are provided separately by age and sex for non-Hispanic whites (NHW), non-Hispanic blacks (NHB) and Mexican Americans (MA). BMD and BMC in the five ROI tended to decline with age, whereas area did not. BMD and BMC were highest in NHB, intermediate in MA and lowest in NHW, but areas were highest in NHW, intermediate in NHB and lowest in MA. Men had greater BMD, BMC and area than women in all three race/ethnic groups. Differences by age, sex or race/ethnicity tended to be the largest in Ward's triangle, followed by the femur neck; patterns in the trochanter, intertrochanter and total ROI were reasonably similar to each other. This report provides extensive data on femur bone mineral levels of adults from one of the largest samples available to date and should be valuable as reference data for other studies which examine this skeletal site in adults.     

绝经后女性股骨近端骨密度与骨质疏松性骨折相关性研究

目的：研究绝经后女性股骨近端骨密度的变化规律与骨质疏松症、骨质疏松性骨折间的关系。方法采用法国Medlink公司Osteocore 3型双能X线骨密度仪,对本地区417例绝经后女性股骨颈、大转子、粗隆间、全髋进行骨密度测定。结果骨折组各年龄段、各部位的BMD均比非骨折组低（ P＜0．05）。随着年龄的增长,股骨近端骨量逐渐丢失,除了45～50组,其余各年龄段骨折组的患病率明显高于非骨折组（ P＜0．05）,骨密度值越低,骨折危险性越大。结论绝经后女性股骨近端骨密度与发生骨质疏松性骨折的风险呈明显负相关性,应该注意预防。     

Effects of raloxifene treatment on the structural geometry of the proximal femur in Japanese women with osteoporosis

The purpose of this study was to clarify the effects of 2-year treatment with raloxifene on the proximal femoral geometry among Japanese patients with osteoporosis by hip structure analysis. One hundred ninety-eight community-dwelling postmenopausal women with osteoporosis were enrolled. The structural variables were areal bone mineral density (BMD), cross-sectional area (CSA), section modulus (index of resistance to bending forces), and buckling ratio (index of cortical instability). BMD, CSA, and section modulus at the narrow neck significantly increased by 1.27, 2.67, and 3.90% at 2 years, respectively. BMD, CSA, and section modulus at the intertrochanter significantly increased by 2.55, 4.49, and 6.60% at study termination, respectively. The buckling ratio at the intertrochanter decreased by 2.36% at 1 year, but differences at 2 years became non-significant. Parameters at the shaft were qualitatively similar to those of the narrow neck and intertrochanter. The percent change of the section modulus was significantly higher than that of BMD at 2 years in all three regions. The percent changes of the section modulus is strongly correlated with the percent changes of BMD and CSA, and negative correlated with the percent changes of buckling ratio in all regions. In conclusion, Japanese osteoporotic women on raloxifene therapy have significant improvements of both BMD and geometry in the proximal femur.     

The Influence of High‐Impact Exercise on Cortical and Trabecular Bone Mineral Content and 3D Distribution Across the Proximal Femur in Older Men: A Randomized Controlled Unilateral Intervention

Regular exercisers have lower fracture risk, despite modest effects of exercise on bone mineral content (BMC). Exercise may produce localized cortical and trabecular bone changes that affect bone strength independently of BMC. We previously demonstrated that brief, daily unilateral hopping exercises increased femoral neck BMC in the exercise leg versus the control leg of older men. This study evaluated the effects of these exercises on cortical and trabecular bone and its 3D distribution across the proximal femur, using clinical CT. Fifty healthy men had pelvic CT scans before and after the exercise intervention. We used hip QCT analysis to quantify BMC in traditional regions of interest and estimate biomechanical variables. Cortical bone mapping localized cortical mass surface density and endocortical trabecular density changes across each proximal femur, which involved registration to a canonical proximal femur model. Following statistical parametric mapping, we visualized and quantified statistically significant changes of variables over time in both legs, and significant differences between legs. Thirty‐four men aged mean (SD) 70 (4) years exercised for 12‐months, attending 92% of prescribed sessions. In traditional regions of interest, cortical and trabecular BMC increased over time in both legs. Cortical BMC at the trochanter increased more in the exercise than control leg, whereas femoral neck buckling ratio declined more in the exercise than control leg. Across the entire proximal femur, cortical mass surface density increased significantly with exercise (2.7%; p < 0.001), with larger changes (> 6%) at anterior and posterior aspects of the femoral neck and anterior shaft. Endocortical trabecular density also increased (6.4%; p < 0.001), with localized changes of > 12% at the anterior femoral neck, trochanter, and inferior femoral head. Odd impact exercise increased cortical mass surface density and endocortical trabecular density, at regions that may be important to structural integrity. These exercise‐induced changes were localized rather than being evenly distributed across the proximal femur. © 2015 American Society for Bone and Mineral Research.     

股骨头骨坏死范围对髋关节表面置换术后股骨近端力学分布的影响

目的探讨髋关节表面置换术后股骨头骨坏死范围对股骨近端与假体松动或股骨颈骨折相关的应力分布的影响。方法依据基于连续CT断层图像构建的股骨三维图形和髋关节表面置换假体，采用计算机辅助技术，建立股骨头部无坏死和前后位坏死角分别为60°、80°、100°、120°、140°的表面置换三维有限元模型，单腿负重条件下，模拟坏死骨未清除及清除后填充骨水泥的情形进行受力分析。结果骨坏死范围对股骨颈部的应力分布影响微小。股骨头近端骨质出现明显的应力遮挡。当坏死角≤80°时，骨水泥界面和头颈交界骨质中的Von Mises等效应力峰值变化较小；当坏死角≥100°时，应力峰值变化明显，其中水泥层外上缘的峰值增幅为22．3％和27．3％（坏死角120°和140°），头颈交界外上缘骨质的峰值增幅为13．2％、28．3％和53．3％（坏死角100°、120°和140°）。填充骨水泥后，主要应力集中区的等效应力峰值逐渐减小或变化不明显。结论髋关节表面置换术改变了股骨头内应力分布；股骨头近端出现明显的应力遮挡，允许股骨头负重区出现小的骨坏死（坏死角≤80°）；坏死角≥100°的骨坏死，是否适于髋关节表面置换术还需深入研究。     

Effects of Treatment of Ovariectomized Adult Rhesus Monkeys with Parathyroid Hormone 1-84 for 16 Months on Trabecular and Cortical Bone Structure and Biomechanical Properties of the Proximal Femur

Treatment of monkeys and humans with parathyroid hormone (PTH) 1-84 stimulates skeletal remodeling, which increases trabecular (Tb) bone mineral density (BMD) but decreases cortical (Ct) BMD at locations where these bone types predominate. We report the effects of daily PTH treatment (5, 10, or 25 μg/kg) of ovariectomized (OVX) rhesus monkeys for 16 months on bone structure and biomechanical properties at the proximal femur, a mixed trabecular and cortical bone site. PTH reversed the OVX-induced decrease in BMD measured by dual-energy X-ray absorptiometry at the proximal femur, femoral neck, and distal femur. Peripheral quantitative computed tomography confirmed a significant decrease in Ct.BMD and an increase in Tb.BMD at the total proximal femur and at the proximal and distal femoral metaphyses. The decrease in Ct.BMD resulted primarily from increased area because cortical bone mineral content was unaffected by PTH. Histomorphometry revealed that PTH significantly increased the trabecular bone formation rate (BFR) as well as trabecular bone volume and number. PTH did not affect periosteal or haversian BFR at the femoral neck, but cortical porosity was increased slightly. PTH had no effects on stiffness or peak load measured using a shear test, whereas work-to-failure, the energy required to fracture, was increased significantly. Thus, PTH treatment induced changes in trabecular and cortical bone at the proximal femur that were similar to those occurring at sites where these bone types predominate. Together, the changes had no effect on stiffness or peak load but increased the energy required to break the proximal femur, thereby making it more resistant to fracture.     

有限元法分析后内侧骨折对近端股骨的力学影响

[目的]研究后内侧骨折对近端股骨的生物力学影响。[方法]利用CT扫描图像建立高度仿真的完整近端股骨的三维有限元模型,并在此基础上建立累及小粗隆和内侧皮质的后内侧骨折模型,并对模型进行有限元分析。[结果]后内侧骨折后股骨最大应力出现在骨折缺损的前内侧。单独小粗隆骨折后股骨颈上下、内外侧皮质应力无明显变化;骨折累及1/2内侧皮质后,内侧皮质最大等效应力显著升高约47%,外侧皮质应力升高约12%;内侧皮质完全累及时,内侧皮质应力升高约247%,外侧升高约66%。[结论]不同大小的后内侧骨折块对近端股骨的应力大小及分布影响不同。从力学角度考虑,用动力髋螺钉治疗粗隆间骨折时,可根据后内侧骨折块大小作适当处理。