Ⅰ期人工全髋关节置换术治疗有移位的老年股骨颈骨折

目的探讨Ⅰ期人工全髋关节置换术治疗有移位的老年股骨颈骨折的临床效果。方法采用髋关节后外侧改良Gibson入路对有移位的老年股骨颈骨折32例32髋行Ⅰ期人工全髋关节置换。结果32例均获随访,平均时间23.4(12~36)个月。1例术后出现伤口脂肪液化,经清创及伤口换药后愈合;2例出现一侧下肢轻度肿胀,考虑为深静脉血栓所致,予抗凝、抬高患肢等对症处理后肿胀消退。无关节感染、肺部感染等早期并发症,亦未发生假体松动、断裂、脱位和假体周围骨折等严重远期并发症。髋关节功能按Harris评分:优11例,良18例,可3例,优良率90.6%。结论采用Ⅰ期人工全髋关节置换术能降低患者术后再手术率和术后髋关节疼痛发生率,是治疗有移位的老年股骨颈骨折的有效方法。     

Results After Total Hip Arthroplasty With a Large Head and Bipolar Arthroplasty in Patients With Displaced Femoral Neck Fractures

The authors studied the short-term outcomes of total hip arthroplasty (THA) performed using large diameter femoral heads or bipolar arthroplasty (BA) in physiologically active elderly patients with displaced intracapsular femoral neck fractures. The THA group included 14 males and 66 females with a mean age of 75.5 years, and the BA group included 16 males and 73 females with a mean age of 77.6 years. Surgical procedures were performed by one surgeon using a modified Hardinge approach. Mean operation times were significantly longer in the THA groups. Pain, mobility, and walking ability scores were significantly better in the THA group than in the BA group. Despite no range of motion limitation during the early postoperative period, no dislocation was encountered in either group. The present study suggests that for displaced femoral neck fractures, THA with a large diameter femoral head results in less pain and better function than BA.     

Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced femoral neck fractures in patients over 70 years old

Objective:Total hip arthroplasty (THA)and hemiarthroplasty (HA) are effective methods currendy used to treat femoral neck fracture in elderly patients,but the two options remain controversial in patien...     

Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials

Purpose

Displaced femoral neck fractures in healthy elderly patients have traditionally been managed with hemiarthroplasty (HA). Recent data suggest that total hip arthroplasty (THA) may be a better alternative.

Methods

A systematic review of the English literature was conducted. Randomized controlled trials comparing all forms of THA with HA were included. Three authors independently extracted articles and predefined data. Results were pooled using a random effects model.

Results

Eight trials totalling 986 patients were retrieved. After THA 4 % underwent revision surgery versus 7 % after HA. The one-year mortality was equal in both groups: 13 % (THA) versus 15 % (HA). Dislocation rates were 9 % after THA versus 3 % after HA. Equal rates were found for major (25 % in THA versus 24 % in HA) and minor complications (13 % THA versus 14 % HA). The weighted mean of the Harris hip score was 81 points after THA versus 77 after HA. The subdomain pain of the HHS (weighted mean score after THA was 42 versus 39 points for HA), the rate of patients reporting mild to no pain (75 % after THA versus 56 % after HA) and the score of WOMAC (94 points for THA versus 78 for HA) all favored THA. Quality of life measured with the EQ-5D favored THA (0.69 versus 0.57).

Conclusions

Total hip arthroplasty for displaced femoral neck fractures in the fit elderly may lead to higher patient-based outcomes but has higher dislocation rates compared with hemiarthroplasty. Further high-quality randomized clinical trails are needed to provide robust evidence and to definitively answer this clinical question.     

大头金对金全髋关节置换治疗老年人股骨颈骨折近期疗效

目的 探讨大头金对金全髋关节置换术治疗老年人股骨颈骨折的近期疗效.方法 55例老年股骨颈骨折患者(55髋)中,26髋采用大头金对金全髋关节置换(观察组),29髋采用常规小头金属对聚乙烯全髋关节置换(对照组),比较两组的临床疗效,对并发症进行分析.结果 55例门诊随访12~23(18.3±5.4)个月.术后对照组发生脱位1例2次;观察组无脱位发生.观察组术后6、12周的髋关节活动范围和术后12个月的Harris评分优秀率均优于对照组,差异有统计学意义(P<0.05).结论 大头金对金全髋关节置换术治疗老年股骨颈骨折,具有术后脱位率低、关节活动范围大等优点,近期临床疗效满意.     

Dual mobility cup reduces dislocation and re-operation when used to treat displaced femoral neck fractures

Purpose

Total hip arthroplasty (THA) as primary treatment for displaced femoral neck fractures is controversial as THA is associated with higher rates of dislocation but lower rates of re-operation compared to hemiarthroplasty (HA). A dual mobility cup (DMC) design is associated with lower dislocation and re-operation rates in elective surgery. Is this also the case when used to treat displaced femoral neck fractures? The aim of this study is to compare rates of dislocation and re-operation of any kind following treatment for displaced femoral neck fractures with either bipolar HA or THA with DMC.

Methods

Two consecutive groups of patients treated for displaced femoral neck fractures at the Regional Hospital in Viborg in Denmark were included. In 2007–2008 171 patients (mean age 84.1 years) were treated with bipolar HA. In 2009–2010 175 patients (mean age 75.2 years) were treated with THA with DMC. Data regarding rates of dislocation and re-operation were obtained by retrospective review of medical records.

Results

We found a statistically significant difference regarding rates of dislocation and re-operation of any kind in favour of THA with DMC. Dislocation occurred in 25/171 patients [95 % confidence interval (CI) 9.3–19.9 %] treated with bipolar HA and 8/175 patients (95 % CI 1.5–7.7 %) treated with THA with DMC (p = 0.002). Re-operations were required in 32/171 patients (95 % CI 12.9–24.6 %) treated with bipolar HA and 16/175 patients (95 % CI 4.8–13.4 %) treated with THA with DMC (p = 0.01).

Conclusions

Our findings indicate that THA with DMC is superior to bipolar HA following treatment for displaced femoral neck fractures in regard to rates of dislocation and re-operation.     

金对金解剖直径头微创全髋关节置换术治疗高龄股骨颈骨折的近期疗效对照研究

目的探讨金对金解剖直径头和常规小直径头(28mm)全髋关节置换(total hip arthroplasty,THA)微创技术治疗高龄股骨颈骨折患者的临床疗效。方法 2006年1月至2007年12月间因股骨颈骨折在我中心行微创全髋关节置换手术并获得完整资料的高龄(70岁)患者61例61髋,其中采用常规直径头股骨头全髋关节假体(对照组)30例30髋,采用金对金大直径股骨头全髋关节假体(观察组)31例31髋。分析两组术后2周、6周髋关节活动范围,术后2年假体脱位率以及Harris评分结果的差异。结果术后对照组脱位2例6次,观察组0例。观察组的Harris评分优秀率高于对照组;术后2周(除后伸动作外)和6周的髋关节活动度均大于对照组,两组比较,差异有统计学意义(P0.05)。结论采用金对金解剖直径头THA微创技术治疗高龄股骨颈骨折患者,具有术后早期髋关节稳定性提高、主动活动范围增加、术后脱位率降低等优点,近期疗效满意。     

No Difference Between Hemiarthroplasty and Total Hip Arthroplasty in the Treatment of Pathologic Femoral Neck Fractures

BackgroundHemiarthroplasty (HA) and total hip arthroplasty (THA) have been widely discussed as treatment options for displaced osteoporotic femoral neck fractures. Pathologic femoral neck fractures from primary or metastatic tumors are comparatively rare and poorly investigated. The purpose of this study was to compare outcomes, complications, and perioperative survival for HA and THA in the treatment of pathologic femoral neck fractures of neoplastic etiology.MethodsA multicenter retrospective cohort study identified patients with pathologic femoral neck fractures treated with HA or THA from 2005 to 2018. Demographics, American Society of Anesthesiologists classification, Charlson comorbidity index, Dorr classification, histopathologic diagnosis, and surgical data were compared. The primary outcome was reoperation. Secondary outcomes included 90-day mortality, estimated blood loss, length of stay, periprosthetic fracture, periprosthetic joint infection, and Eastern Cooperative Oncology Group performance status.ResultsThere were 116 patients with HA and 48 patients with THA, with no differences between groups with regard to American Society of Anesthesiologists classification, Charlson comorbidity index, or Dorr classification. There were no differences between HA and THA in the primary outcome of reoperation (5.2% vs 4.2%, P = 1.00) or secondary outcomes of perioperative 90-day overall mortality (30.2% vs 25.0%, P = .51), estimated blood loss, transfusion rates, length of stay, discharge location, periprosthetic joint infection, periprosthetic fracture, or preoperative or postoperative Eastern Cooperative Oncology Group performance status.ConclusionsBoth HA and THA are viable options for the treatment of patients with pathologic femoral neck fractures and demonstrated no differences in reoperations, complications, perioperative 90-day mortality, or functional outcome scores.Level of EvidenceLevel III.     

Closed reduction and internal fixation versus total hip arthroplasty for displaced femoral neck fracture

Objective： To compare the clinical effects between closed reduction and internal fixation （CRIF） and total hip arthroplasty （THA） for displaced femoral neck fracture. Methods： In this prospective randomized study, 285 patients aged above 65 years with hip fractures （Garden III or IV） were included from January 2001 to December 2005. The cases were randomly allocated to either the CRIF group or THA group. Patients with pathological fractures （bone tumors or metabolic bone disease）, preoperative avascular necrosis of the femoral head, osteoarthritis, rheumatoid arthritis, hemiplegia, long-term bed rest and complications affecting hip functions were excluded. Results： During the had significantly higher 5-year follow-up, CRIF group rates of complication in hipjoint, general complication and reoperation than THA group （38.3% vs. 12.7%, P〈0.01; 45.3% vs. 21.7%, P〈0.01; 33.6% vs. 10.2%, P〈0.05 respectively）. There was no difference in mortality between the two groups. Postoperative function of the hip joint in THA group recovered favorably with higher Harris scores. Conclusion： For displaced fractures of the femoral neck in elderly patients, THA can achieve a lower rate of complication and reoperation, as well as better postoperative recovery of hip joint function compared with CRIF.     

老年股骨颈骨折左心衰竭半髋与全髋置换比较

[目的]比较老年股骨颈骨折合并左心衰竭患者行半髋置换(hemiarthroplasty,HA)与全髋置换(total hiparthroplas-ty,THA)的临床疗效.[方法]回顾性分析本院2017年-2019年有移位股骨颈骨折合并左心衰竭的45例老年患者的临床资料.依据术前医患沟通和心功能状态将患者分为两组,其中...     

不同手术方法治疗中老年移位型股骨颈骨折的疗效分析

目的评价不同手术方法治疗中老年移位型股骨颈骨折的疗效。方法回顾性分析2006年1月至2009年6月收治的80例分别采用内固定（A组,25例）、人工股骨头置换（B组,27例）及全髋关节置换（C组,28例）手术治疗的中老年移位型股骨颈骨折患者资料,分析比较其住院时间、手术时间、术中出血量、术后并发症、术后Harris评分总分及分类评分等指标。结果 A组手术时间最短,术中出血量最少,C组手术时间最长,术中出血量最多;A组术后并发症发生率较B、C组高;随访结果B组Harris评分最低,C组最高;分类评分中C组的疼痛评分较B组高;功能评分C组最高,B组最低,以上差异均有统计学意义。A组、B组、C组住院时间差异及三组患者间的行走评分、活动度评分差异均无统计学意义。结论空心加压螺钉内固定适于相对年轻,骨质条件好,伤前活动能力较好且术后能耐受晚期负重的中年患者,全髋置换适于外伤前身体状况良好、术前活动量多、预期寿命较长或已有髋关节疾病的老年患者,人工股骨头置换适于一般情况较差、有较严重内科合并症但术前评估能耐受一般手术的患者。     

Perioperative Outcomes of Hemiarthroplasty Versus Total Hip Arthroplasty for Geriatric Hip Fracture: The Importance of Studying Matched Populations

BackgroundGeriatric femoral neck fracture is a common injury for which hemiarthroplasty (HA) or total hip arthroplasty (THA) may be considered in select patients. As prior database studies comparing these have not used propensity matching, which is a robust statistical method of controlling for potentially confounding variables, unmatched and matched methodologies are contrasted in the present study.MethodsPatients aged ≥70 years who underwent HA or THA for hip fractures were identified from the 2012-2015 National Surgical Quality Improvement database. Propensity score 1:1 matching was performed. Differences in rates of 30-day postoperative adverse outcomes were compared using multivariate logistic regression for unmatched and matched cohorts.ResultsIn total, 15,558 patients (14,403 HA and 1155 THA) were evaluated. Although multivariate outcomes for the unmatched populations were different for blood transfusion, mortality, minor adverse events, major adverse events, and reoperation, multivariate outcomes for matched populations only differed for blood transfusion (odds ratio 0.6 for HA vs THA, P < .001). Of note, although readmissions were similar for the two groups, patients undergoing THA had a 5.4% greater rate of perioperative readmission due to dislocation.ConclusionGeriatric patients undergoing HA and THA for hip fracture were compared with and without propensity matching. Once matching was performed, the only differences in outcomes between the two groups were a lower transfusion rate among the HA group and a greater readmission rate due to dislocation among the THA group. This suggests that either procedure can be safely considered if found to be advantageous from a longer-term outcome perspective.Level of EvidenceLevel III, retrospective comparative study.     

髋关节置换术治疗老年股骨颈骨折的Meta分析

目的对国外有关人工髋关节置换术治疗老年股骨颈骨折的研究文献进行分析,评价老年股骨颈骨折的治疗效能。方法计算机检索PubMED和Ovid等数据库,检索时间从1991～2007年,有关人工关节置换治疗老年股骨颈骨折的文献资料。比较人工关节置换手术的死亡率、脱位、关节翻修率、关节功能。对数据进行异质性检验,用Meta分析方法对数据进行处理,估计其综合OR值和95%CI。结果共纳入10篇相关的、以半髋和全髋关节置换术对照治疗老年股骨颈骨折的文献。研究结果提示两者的死亡率之间无明显差异;脱位率和翻修率之间Q值分别为4.03和2.78,P0.1,不存在异质性,总体效应的P0.01,全髋关节置换术的脱位率高,但是翻修率低于半髋关节置换术;关节功能Harris评分的Q=23.94,P0.1,存在异质性,总体效应的P0.01,RR=0.79,OR=0.35,95%CI(0.23,0.53),全髋关节置换术后髋关节功能明显优于半髋关节置换术后的患者。结论全髋关节置换术优于半髋关节置换术,在选择关节置换治疗老年股骨颈骨折的时候,尽量行全髋关节置换术。对于不能耐受全髋关节置换手术和预期寿命低于3年的患者,则采用半髋关节置换术。     

Displaced femoral neck fractures in the elderly: outcomes and cost effectiveness

The optimal treatment for displaced femoral neck fractures in elderly patients is a matter of controversy. Four surgical options are well supported in the orthopaedic literature: reduction with internal fixation, unipolar hemiarthroplasty, bipolar hemiarthroplasty, and total hip arthroplasty. Based on a review of the outcomes literature regarding treatment of femoral neck fractures and a cost-effectiveness analysis, an algorithm for surgical treatment of displaced femoral neck fractures in elderly patients is presented. Cost-effectiveness analysis of these four surgical treatment options shows that arthroplasty is the most cost-effective treatment when complication rate, mortality, reoperation rate, and function are evaluated during a 2-year postoperative period. These data were strongly supported by a two-way sensitivity analysis that varied the effectiveness of the interventions and the costs. Literature derived outcome studies show that elderly patients with displaced femoral neck fractures achieve the best functional results with a well healed femoral neck without osteonecrosis after reduction and internal fixation. Achieving this result may be difficult, and it is not as cost effective as arthroplasty.     

Hemiarthroplasty for Displaced Femoral Neck Fractures in the Elderly Has a Low Conversion Rate

Background

Hemiarthroplasty (HA) has been a mainstay treatment for displaced femoral neck fractures for many years. The purpose of this study was to report the conversion rate of HA to total hip arthroplasty (THA) for displaced femoral neck fractures and compare outcomes between implant constructs (bipolar vs unipolar), fixation options (cemented vs cementless stems), and age groups (<75 years vs ≥75 years).

Treatment of femoral neck fractures with bipolar hemiarthroplasty using a modified minimally invasive posterior approach in patients with neurological disorders

Bipolar hemiarthroplasty is a useful treatment for displaced femoral neck fractures in elderly patients. Although uncommon, dislocation is problematic, particularly in older patients, and those with neurologic disorders are at an increased risk for this complication. Recently, a modified posterior approach to the hip intended to enhance hip joint stability by preserving the short external rotators was described. Therefore, the dislocation rate was compared after bipolar hemiarthroplasty using the modified or standard minimally invasive posterior approach.A retrospective analysis was performed of 67 patients older than 65 years with displaced femoral neck fractures and neurological disorders who underwent bipolar hemiarthroplasty using the modified and standard approaches in 28 and 39 hips, respectively. Follow-up averaged 19.3 months. Dislocation rates for the treatment and control groups were 0% and 7.7%, respectively (P<.01). No significant difference existed in postoperative bleeding, operative time, or length of hospital stay between groups. These data suggest a lower dislocation rate after bipolar hemiarthroplasty via the modified, short external rotator-sparing approach for treating displaced femoral neck fractures in elderly patients with neurological disorders.     

Total hip arthroplasty: optimal treatment for displaced femoral neck fractures in elderly patients

Although internal fixation is recommended for most nondisplaced fractures of the femoral neck, the optimal treatment for displaced fractures of the femoral neck is controversial. Options for operative treatment of displaced fractures of the femoral neck include: reduction and internal fixation; unipolar hemiarthroplasty; bipolar hemiarthroplasty; and total hip arthroplasty. One hundred eighty-six displaced fractures of the femoral neck in elderly patients were treated surgically with internal fixation (in 120 patients), hemiarthroplasty (in 43 patients), and total hip arthroplasty (in 23 patients). One hundred twenty patients with displaced fractures treated with internal fixation were compared with 66 patients with displaced fractures treated with arthroplasty. Criteria for comparison were reoperation, mortality, hospital discharge disposition, functional outcome, living status, and cost effectiveness. There was no difference in rates of reoperation or mortality, but arthroplasty produced a longer interval to reoperation or death. Arthroplasty was associated with more independent living, and arthroplasty was more cost-effective than internal fixation. Total hip arthroplasty was the best treatment for displaced fractures of the femoral neck in elderly patients in this series.     

Treatment options for displaced femoral neck fractures in the <60-year-old,active patient

Displaced femoral neck fractures are common injuries that can impart substantial morbidity, disability, and functional limitations to patients. Displacement of the fracture by greater than 50% has been shown to have a higher rate of subsequent osteonecrosis of the femoral head. In younger, active patients, open reduction and internal fixation (ORIF) may be desirable in order to preserve the patient’s own hip joint. However, in the last decade, arthroplasty technologies and techniques have improved substantially, making total hip replacement a viable option for younger patients. Furthermore, there are numerous clinical studies demonstrating that arthroplasty has superior functional results as compared to internal fixation in the treatment of displaced femoral neck fractures, namely higher clinical scores and a lower reoperation rate. A higher risk of dislocation has always been the concern with performing total hip arthroplasty in the setting of femoral neck fracture, but fortunately, there are newer technologies such as larger head sizes and dual-mobility bearings that can help reduce the risk of dislocation.     

Clinical results of short external rotators preserving posterolateral approach for hemiarthroplasty after femoral neck fractures in elderly patients

IntroductionEven though the dislocation rate is lower in the hemiarthroplasty (HA) than total hip arthroplasty, it has still developed as one of serious complications in elderly patients. We have used short external rotators (SER) preserving posterolateral approach to reduce dislocation after hip arthroplasty, especially in elderly patients. The present study was conducted to introduce SER preserving posterolateral approach and report the dislocation rate after HA via this approach in elderly patients with femoral neck fractures.MethodsBetween January 2015 and July 2019, 307 consecutive elderly patients aged over 70 years who underwent cementless bipolar HA for femoral neck fractures and were followed up for at least one year, were enrolled in this study. All surgeries were performed using the SER preserving posterolateral approach. The demographic and perioperative data were examined and the complications including dislocation were investigated.ResultsMean operation time was 54.3 min, and mean estimated blood loss was 252.4 cc. The mean follow-up time was 22.1 months, HHS was 67.5 points at the final examination Dislocation following HA developed in only one patient (0.3%) with dementia during hospital stay, which was reduced closely with no subsequent recurrence. Periprosthetic femoral fracture occurred in two patients, which was treated with internal fixation in one patient and with stem revision in the other patient. There was no surgical site infection or periprosthetic infection as complications.ConclusionThe SER preserving technique in posterolateral approach effectively can be effective for reducing the dislocation after HA in elderly patients with femoral neck fracture. It can be encouraged in posterolateral approach for HA, especially in elderly patients under the risk of dislocation.     

Lower reoperation rate for cemented hemiarthroplasty than for uncemented hemiarthroplasty and internal fixation following femoral neck fracture

Background and purpose Elderly patients with displaced femoral neck fractures are commonly treated with a hemiarthroplasty (HA), but little is known about the long-term failure of this treatment. We compared reoperation rates for patients aged at least 75 years with displaced femoral neck fractures treated with either internal fixation (IF), cemented HA, or uncemented HA (with or without hydroxyapatite coating), after 12–19 years of follow-up.

Methods 4 hospitals with clearly defined guidelines for the treatment of 75+ year-old patients with a displaced femoral neck fracture were included. Cohort 1 (1991–1993) with 180 patients had undergone IF; cohort 2 (1991–1995) with 203 patients had received an uncemented bipolar Ultima HA stem (Austin-Moore); cohort 3 (1991–1995) with 209 patients had received a cemented Charnley-Hastings HA; and cohort 4 (1991–1998) with 158 patients had received an uncemented hydroxyapatite-coated Furlong HA. Data were retrieved from patient files, from the region-based patient administrative system, and from the National Registry of Patients at the end of 2010. We performed survival analysis with adjustment for comorbidity, age, and sex.

Results Cemented HA had a reoperation rate (RR) of 5% and was used as reference in the Cox regression analysis, which showed significantly higher hazard ratios (HRs) for IF (HR = 3.8, 95% CI: 1.9–7.5; RR = 18%), uncemented HA (HR = 2.2, CI: 1.1–4.5; RR = 11%) and uncemented hydroxyapatite-coated HA (HR = 3.6, CI: 1.8–7.4; RR = 16%).

Interpretation Cemented HA has a superior long-term hip survival rate compared to IF and uncemented HA (with and without hydroxyapatite coating) in patients aged 75 years or more with displaced femoral neck fractures.