半髋柄固定方式对高龄股骨颈骨折疗效的影响

目的探讨半髋置换股骨柄在股骨近端髓腔不同形态固定方式对高龄股骨颈骨折疗效的影响。 方法回顾分析2007年1月至2017年2月在东莞市人民医院关节外科分别连续收治的75岁以上高龄股骨颈骨折患者100例,纳入标准：Garden Ⅲ、Ⅳ型、骨折前尚能独立行走;排除标准：股骨颈病理性骨折、同侧髋骨关节炎、严重内科疾病不能耐受手术。分为骨水泥组和生物组。骨水泥组行骨水泥股骨柄双动头置换术,生物组行生物双动头置换术,对比骨水泥组与生物组术中并发症,术后假体周围骨折情况,股骨近端髓腔Noble分型,股骨假体的初始位置,假体松动情况及其末次随访时的髋关节功能Harris评分差异,计量资料对比采用t检验,计数资料比较采用卡方检验。 结果100例患者均获得随访平均(15 ± 3)个月。骨水泥组术中出现明显骨水泥反应2例,未出现死亡病例,术后有2例出现假体周围骨折(Vancouver分型VB2型和VC型)。生物组术中出现股骨距骨折6例(Vancouver分型VAL型),术后假体周围骨折2例(Vancouver分型均为B2型),术后3个月内出现髋关节后脱位1例。术后3个月内死亡2例,均为肾功能衰竭患者。股骨柄的位置安放在内或外翻位>3°为异常时,100例中仅生物组1例烟囱型髓腔出现内翻位置达4°,异常率仅为1%。骨水泥型股骨柄容易出现外翻位放置,生物型股骨柄容易出现内翻位放置。术后末次随访髋关节功能Harris评分骨水泥组和生物组优良率分别为89%和83%,两组差异无统计学意义(χ²＝0.44,P>0.05)。 结论生物无领矩形股骨柄(LCU股骨柄)与有领骨水泥股骨柄(Classic股骨柄)双动头置换治疗高龄股骨颈骨折患者在股骨近端不同类型的髓腔中均能获得良好的治疗效果。     

人工股骨头置换与动力髋螺钉治疗老年股骨颈基底部骨折并骨质疏松的疗效比较

目的 分析人工股骨头置换术(artificial femoral head replacement,AFHR)与动力髋螺钉(dynamic hip screw,DHS)内固定在治疗老年股骨颈基底部骨折并骨质疏松患者中的应用,对比两者在疗效上的差异.方法 回顾性分析我科2008年6月至2014年6月期间收治的47例老年骨质疏松股骨颈基底部骨折患者,按照手术方式进行分组:AFHR组22例,DHS组25例.详细记录并比较两组患者术中的出血量、术后引流量、手术时间、手术前后血红蛋白量以及术后第6、12个月髋关节功能的Harris 评分.根据骨盆平片及患髋侧位X线片观察股骨假体及钢板周围骨质的变化情况.结果 AFHR组的术中出血量、术后引流量、手术时间、手术前后血红蛋白量以及术后髋关节功能Harris评分优于DHS组,差异有统计学意义(P＜0.05).结论 对于合并有骨质疏松的股骨颈基底部骨折的老年患者,AFHR手术时间短、出血少、近期髋关节功能恢复良好,临床效果较DHS更具优势.     

Stress fracture of the femoral neck as a complication of revision arthroplasty of the knee: a case report

Stress fracture of the femoral neck is a rare complication of total knee arthroplasty. We report a case of femoral neck fracture following revision arthroplasty of the ipsilateral knee. Contributing factors may have been the patient's osteoporosis and a period of immobilisation before the revision arthroplasty. The patient was treated successfully with hemiarthroplasty of the hip. In patients who have undergone total knee arthroplasty, complaints of groin pain that radiates to the involved knee should alert to the possibility of a stress fracture of the femoral neck.     

Current Trends of Stem Use in Hemiarthroplasty for Femoral Neck Fracture in South Korea

Background

Hemiarthroplasty is a common operation to treat femoral neck fracture in elderly patients. The choice of whether to use cemented stem or cementless stem in hemiarthroplasty has been controversial in clinical practice. However, recent trends regarding stem choice in South Korea are not known or documented. In this study, we assessed the trends of stem fixation in hemiarthroplasty for femoral neck fractures in South Korea.

Methods

Data of patients with femoral neck fractures, who were operated on between the years of 2007 and 2011 and were ≥ 50 years old at the time of operation, were obtained from the Health Insurance Review and Assessment Service. All new visits or admissions to clinics or hospitals for femoral neck fractures were identified using the International Classification of Disease Tenth Revision diagnostic code (S720). The trends in the utilization of cemented and cementless hemiarthroplasty were then analyzed.

Results

The proportion of cementless hemiarthroplasty increased from 42.7% of all surgical procedures in 2007 to 61.4% of all surgical procedures in 2011 (p < 0.001), while the use of cemented hemiarthroplasty demonstrated a corresponding decrease.

Conclusions

There was a current trends towards using cementless stems in hemiarthroplasty for femoral neck fractures in South Korea.     

The role of preoperative bone scan for determining the treatment method for femoral neck fracture

To evaluate the role of preoperative bone scintigraphy in determining the operative treatment method for femoral neck fracture, we reviewed the data of 83 patients who underwent preoperative bone scanning after femoral neck fracture. Fractures were classified using the Garden staging system. Radioisotope uptake in femoral heads was evaluated visually. Of 28 patients with Garden stage I or II, radioactivity of the femoral head was normal in 26, partially reduced in one, and generally reduced in one patient. Twenty-seven patients were treated by closed reduction and multiple pinning, and one patient was treated by bipolar hemiarthroplasty. Of 55 patients with Garden stage III or IV, femoral-head radioactivity was normal in three, partially reduced in seven and generally reduced in 45 patients. Fifty-four patients were treated by bipolar hemiarthroplasty or total hip arthroplasty, and one patient was treated by closed reduction and multiple pinning. In only one of the 83 cases was the operative method changed because of bone scan findings. Isotope uptake of the femoral head after femoral neck fracture generally corresponded with the degree of fracture displacement. Preoperative bone scans appear to have no significant role to play in determining the operative treatment method for femoral neck fracture.     

Cementless Bipolar Hemiarthroplasty Using a Micro-Arc Oxidation Coated Stem in Patients with Displaced Femoral Neck Fractures

Femoral stem fixation for displaced femoral neck fractures in osteoporotic patients is an ongoing debate. We evaluated the outcome of 136 cementless bipolar hemiarthroplasty using a Micro-arc oxidation (MAO) coated stem. All patients survived the procedure and were discharged from the hospital. Thirty- and 90-day mortality rates were 0.7% and 2.2%, respectively. Ninety-eight hips were followed for a minimum of 2 years (mean, 44 months) postoperatively. Three stems were revised because of a periprosthetic fracture. Although cortical stress shielding around the stem was observed in 3 hips, there was no loosening or osteolysis. Cementless bipolar hemiarthroplasty using a MAO-coated stem is a useful and safe option to treat displaced femoral neck fractures.     

高龄股骨颈基底型骨折人工关节置换与内固定术后生活质量评价

背景：股骨颈基底型骨折属于股骨颈骨折,同时又是囊外骨折,治疗方法有多种选择,由于发生率低故相关研究甚少。目的：比较分析高龄（70岁以上）股骨颈基底型骨折行人工股骨头置换与闭合复位内固定患者术后生活质量差异。方法：1995年9月至2009年6月共收治38例股骨颈基底型骨折患者,男12例,女26例;年龄70-91岁,平均79．4岁;全部患者均为外伤性新鲜骨折,其中16例选择人工股骨头置换为一组,另22例选择内固定术为一组。对比两组患者手术时间、术中出血量、术后下地时间及术后1年运用Harris评分中部分项目评定患者生活质量并结合术后1年髋部正侧位X线片。结果：两组在手术时间、术中出血量、术后下地时间等比较,差异有统计学意义（P〈0．001）。人工股骨头置换组在1年后生活自理、髋部疼痛及行走距离等方面较内固定组优异。人工股骨头置换组1年后均未出现假体松动,而内固定组骨折均愈合。结论：人工股骨头置换术治疗高龄股骨颈基底型骨折近期效果较理想,具有以下优点：（1）术后可早期负重活动,较快恢复伤前活动能力;（2）降低术后并发症和内科合并症的发生几率;（3）近期感觉及功能优于内固定。但同时股骨颈基底型骨折作为囊外骨折血供较好,骨折愈合率高,对于预期生存时间超过5年、骨质量较好的老年患者考虑行内固定治疗,可避免人工关节置换后期的磨损、松动及下沉。     

Association of intra-operative metaphyseal fractures with prosthesis size during hemiarthroplasty of the hip

PURPOSE: To study the possible causes of intra-operative metaphyseal fractures in elderly patients undergoing hemiarthroplasty for displaced intracapsular femoral neck fracture. METHODS: 36 men and 228 women aged 61 to 89 years with 273 displaced femoral neck fractures underwent hemiarthroplasty using a hydroxyapatite ceramic-coated Furlong bipolar prosthesis. Anteroposterior and lateral radiographs were taken immediately after surgery to evaluate the presence and type of any intra-operative fractures (classified according to the Vancouver system) and their effect on stem stability or osseointegration. Pain and clinical outcomes were evaluated using a visual analogue scale and the Harris Hip Score. RESULTS: Regarding the 273 surgeries for displaced femoral neck fracture, 28 (10%) were associated with intra-operative metaphyseal fracture (21 Vancouver type AL and 7 type AG). There was a correlation between intra-operative metaphyseal fractures and stem size. A size-9 stem was used in 64 surgeries without any fracture. A size-10 stem was used in 129 surgeries in which 11 (9%) sustained fractures, and a size-12 stem was used in 80 surgeries in which 17 (21%) sustained fractures. Postoperatively, 25 cases developed hip-related problems (thigh pain=14 and periprosthetic fractures=8) after 3 to 18 months. No patient whose metaphyseal fracture was fixed had hip problems. CONCLUSION: In elderly women with compromised bone quality, extra care is needed to achieve better fitting so as to avoid iatrogenic metaphyseal fractures. Under-sizing or cementing of the prosthesis is recommended when encountering difficulties.     

全髋和半髋置换治疗老年股骨颈骨折的比较研究

目的比较半髋关节置换与全髋关节置换治疗老年移位股骨颈骨折的安全性及有效性差异。方法1999年2月至2007年1月在我院行髋关节置换的老年移位股骨颈骨折（GardenⅢ、Ⅳ型）患者共133例,其中全髋关节置换78例,半髋关节置换55例。收集病例资料并进行随访,随访内容包括安全性评估指标及有效性评估指标,具体为术后并发症、术后疼痛率、翻修率及术后髋关节功能评分,统计学分析两种术式的安全性及有效性有无差异。结果8例失访,7例在随访过程中死亡,118例完成随访,随访时间2～10年,平均5．1年。全髋置换组术后并发症发生率高于半髋置换组,翻修率低于半髋置换组,但均无统计学差异;全髋置换组术后疼痛率低于半髋置换组,有统计学差异;术后髋关节功能评分高于半髋置换组,有显著统计学差异。结论全髋关节置换术的安全性和有效性均高于半髋关节置换术,应为首选措施。     

人工股骨头置换与全髋关节置换术治疗股骨颈骨折

目的了解、评价人工股骨头置换与全髋关节置换术治疗股骨颈骨折的价值和选择。方法从１９９０年１月～１９９６年１２月住院治疗的股骨颈骨折病例中,选择年龄、性别、随访时间均相仿的人工股骨头置换术患者５４例,全髋置换术患者６０例,进行回顾性分析。结果发现两种术式的住院时间相仿,早期并发症均较低;人工股骨头置换组的中、远期并发症、再手术率较高,全髋置换组手术创伤。假体费用较大,随访功能优良率较高。结论全髋置换术适合于５５岁以上、有移位的头下型患者,人工股骨头置换术适合高龄或全身情况较差者。     

Femoral implant neck fracture following total hip arthroplasty. A report of three cases

Femoral neck fracture following total hip arthroplasty (THA) is an infrequent complication. Of 1808 T-28 and TR-28 THA performed at our clinic, 32 fractures of the femoral stem occurred, but none through the femoral neck. Two femoral neck fractures ten years following Trapezoidal-28 THA have recently been referred to our clinic. A separation of the head and neck of a Dual Lock prosthesis at two years was also referred. Failure of these implants suggests that significant forces are encountered in this region of a femoral component. Newer modular implant designs must consider these loads.     

Results of operative therapy of periprosthetic femur shaft fractures in total hip endoprostheses

Periprosthetic femoral shaft fracture represents an uncommon but potentially devastating complication associated with total hip arthroplasty. The treatment should result in complete union of the fracture and at the same time guarantee stability of the implant. 15 patients treated between 1992 to 1998 were analysed. Clinical and radiographic follow-up averaged 30 months (6-79 months) in 13 cases. Two patients died regardless of the fracture. The method of treatment depended on the intraoperative stability of the prosthesis and in addition on the fracture type (Bethea). In 5 cases of intraoperative stability of the prosthesis plate fixation was performed. Plate fixation was complicated by fixation failure combined with a recurrent fracture in two cases leading to shift to a long stem prosthesis. Ten cases of fractures associated with loose stems were treated with a new prosthesis using a long stem system. In these cases an uncomplicated healing of the fracture was achieved with adequate stability in radiographic examinations. The average Harris score was 70 (26-93). For fractures near the femoral stem or in case of implant loosening we recommend the shift to a long stem prosthesis. Also in fractures distally from the femoral stem tip we prefer now long stem implants rather than plate fixation to avoid large exposure of the femoral shaft and resultant complications.     

Press-fit hemiarthroplasty for elderly with femoral neck fracture: high complication rates in operations performed by younger surgeons

Press-fit un-cemented hemiarthroplasty used in the treatment of elderly osteoporotic patients with femoral neck fracture requires technical skills in order to avoid iatrogenic complications. This study was performed in order to correlate the complication rate and the grade of the operating surgeon (middle-grade residents as compared to consultants). In this comparative retrospective study, 75 consecutive patients (mean age 80.5 years) were treated for displaced intra-capsular fracture of the neck of the femur with a hydroxy-apatite-coated (HAC) Furlong bipolar hip press-fit hemiarthroplasty. Residents performed the operation without supervision in 50 cases and in the remaining 25 patients, senior colleagues (consultants) performed the operation. The following complications were encountered; ten intra-operative and two postoperative pertrochanteric proximal femoral fractures, two cases of prosthetic loosening, one case of deep wound infection and one case of dislocation of the prosthesis. Re-operation rate was 9% revision (two for loosening, two for early postoperative pertrochanteric fracture and one for infection and one for dislocation). The complications, the intra-operative blood loss and operative time was higher in the hands of junior surgeons. Furlong HAC prosthesis hemiarthoplasty in the elderly was found to be associated with significant technical problems in the hands of junior as compared to the senior colleagues. Inadequate or overzealous reaming of the greater trochanter in order to accommodate the lateral fin of the Furlong press-fit prosthesis in our experience was the main reason for the high incidence of pertrochanteric fractures in this series. Unlike younger patients, osteoporotic patients have a lower threshold for pertochanteric fracture when press-fit prosthesis is used. Training the junior surgeons, the change of design of the press-fit prosthesis and the availability of a wide range of sizes are helpful hints reducing the complication rate. We suggest changing the current design when used in elderly.     

高龄股骨颈骨折髋关节置换术的比较

目的　比较全髋关节置换术与半髋关节置换术治疗高龄股骨颈骨折的疗效和手术方式的选择。方法　 1990年 8月～ 1999年 8月对 110例 70～ 10 6岁股骨颈骨折患者采用人工髋关节置换术治疗 ,有 96例 (半髋关节置换组 44例 ,全髋关节置换组 5 2例 )获得随访 ,随访时间 15～ 112个月 ,平均 5 1个月。结果　半髋关节置换组优良者 38例 ,占 86 .4% ;全髋关节置换组优良者 48例 ,占 92 .3%。全髋关节置换组手术时间较半髋关节置换组平均长 2 0分钟 ,出血量多 12 0 ml,引流量多 140 ml。扶双拐下地时间、住院时间和住院费用无明显差别。结论　对高龄股骨颈骨折患者 ,年龄相对较轻 ,身体状况较好者选择全髋关节置换术 ;年龄相对较大 ,身体状况较差者选择半髋关节置换术 ,术后效果均较满意     

Femoral stem dislodgement during bipolar hemiarthroplasty dislocation

Bipolar hemiarthroplasty remains a treatment option for displaced femoral neck fractures in elderly patients without pre-existing hip disease. Implant-related complications associated with this procedure include acetabular erosion, dislocation, disassembly of the modular components, polyethylene debris-induced osteolysis, metallosis from outer cup impingement, and femoral component loosening. This article presents a case of a patient in whom the polished collarless tapered femoral stem dislodged out of the cement mantle during traumatic bipolar hemiarthroplasty dislocation, 28 days after the index procedure. This complication, associated with bipolar hemiarthroplasty dislocation, was adequately managed by driving the stem back to the original cement mantle, followed by reduction of bipolar component dislocation and placing bone cement over the shoulder of the femoral stem to prevent a new dislodgement episode. Although rare, dislodgement of cemented polished collarless tapered stems from the cement mantle has been recently reported either during dislocation or, more frequently, as a complication of reduction of a dislocated total hip arthroplasty. However, its occurrence in association with bipolar hemiarthroplasty dislocation was not found to have been reported in the literature. The occurrence of femoral stem dislodgement during bipolar hemiarthroplasty dislocation should be considered as a possible complication of such a procedure and may be prevented by routinely placing bone cement over the shoulder of the femoral implant.     

Fractures of the femoral neck treated with a bipolar endoprosthesis

Seventy-five patients with 77 bipolar hip endoprostheses were reexamined and had roentgenograms taken at an average of 51 months postoperatively. The average age of the patients was 77 years. All prostheses had been inserted due to intracapsular fractures of the femoral neck. Three prostheses had been revised to a total hip arthroplasty at the time of follow-up examination. Radiologically, three cases of protrusion and ten cases with a radiolucent zone greater than 2 mm around the femoral stem were found. Functionally, the result was excellent or good in about 75% of the active ambulators. As acetabular erosion and protrusion appears to have been reduced to some extent, a bipolar hip prosthesis is found to be a good alternative to conventional hemiarthroplasty in elderly patients with a fracture of the femoral neck.     

Analysis of outcomes for surgically treated hip fractures in patients undergoing chronic hemodialysis

BACKGROUND: Hip fractures in patients with end-stage renal disease are associated with frequent complications. This study analyzed clinical outcomes for patients on chronic hemodialysis who sustained hip fractures and were treated with a variety of fracture repair methods. METHODS: Twenty-nine patients with thirty-two hip fractures were analyzed in three groups. Group 1 consisted of eleven hips in eleven patients with an intertrochanteric fracture that was treated with internal fixation; Group 2, thirteen hips in ten patients with a femoral neck fracture that was treated with screw fixation; and Group 3, eight hips in eight patients with a femoral neck fracture that was treated with hemiarthroplasty. The outcomes and early and late complications were recorded for each group. Survivorship analysis was performed, and the mortality and complication rates for the groups were compared. RESULTS: In Group 1, eight complications occurred in six hips and nonunion developed in five hips. In Group 2, sixteen complications developed in eleven hips. Union was achieved in two of the thirteen hips, nine hips had nonunion, and two hips had osteonecrosis develop. In Group 3, only one hip had early complications, there were no late complications, and three patients died. The mean duration of follow-up was twenty-three months, and the overall mortality rate was 45%. There were no significant differences among the groups with respect to the cumulative survival proportions. Regression analysis of age, sex, and total hemodialysis duration in relation to mortality risk revealed that only age had a significant influence on mortality (p = 0.019). CONCLUSIONS: Surgical treatment of hip fractures in patients with end-stage renal disease who are on chronic hemodialysis is associated with frequent complications and a high mortality rate. Osteosynthesis is an acceptable option for treating intertrochanteric fractures and nondisplaced femoral neck fractures, but displaced femoral neck fractures should be treated with hemiarthroplasty.     

Operative treatment of hip fractures in patients receiving hemodialysis

Fifteen hips in 13 patients with hip fracture were treated in patients receiving hemodialysis for chronic renal failure. There were four intertrochanteric and 11 femoral neck fractures. 10 of the 11 femoral neck fractures and one of the four intertrochanteric fractures were treated with cemented bipolar hemiarthroplasty. Two intertrochanteric fractures fixed with sliding compression screws. External fixation was used for stabilization in two patients who had femoral neck and intertrochanteric fractures. Two intertrochanteric fractures that were treated with sliding hip screw showed radiological union postoperatively at the 6th month. Of the 11 hemiarthroplasty, four hips developed aseptic loosening (36%). According to Harris hip score grading system, three (37.5%) poor, two (25%) fair, two (25%) good and one (12.5%) case had excellent outcome in the hemiarthroplasty group. The survival of dialysis patients with a hip fracture is markedly reduced. Initial treatment of hemiarthroplasty allows early mobilization and prevents revision surgery.     

Hydroxyapatite-coated total hip prostheses. Two-year clinical and roentgenographic results of 100 cases

Studies of implant fixation have shown that hydroxyapatite (HA) coatings provide early and strong fixation to bone. This is a report of 100 consecutive cases of total hip arthroplasties, using HA coating, which were mainly for osteoarthrosis, avascular necrosis, or revision for failed implants. The average prospective follow-up period was two years. Titanium femoral components had a proximal HA coating, usually with an HA-coated screw cup. For both HA-coated components, the average Harris hip score was 96 points after one year and 98 after two years. Analysis of data shows that the incidence of pain was low immediately after surgery and at 4% one year postoperatively. There was no difference between the results of primary cases and revisions after the one-year interval. On roentgenographic examination, there was a rapid bony integration of implants with bone apposition on the coating within six months, accompanied by specific patterns of remodeling. No radiolucent line formation was detected around HA-coated implant parts. There were no revisions for loose implants. After two years, 97% of the patients had positive roentgenographic evidence of femoral ingrowth compared to 55% for HA-coated acetabular cups, with a statistical significance between bone ingrowth and clinical results. Implant fixation using HA coatings is a reliable procedure for good bony fixation and clinical results.     

Subcapital femoral neck fracture after closed reduction and internal fixation of an intertrochanteric hip fracture: a case report and review of the literature.

A subcapital femoral neck fracture in a healed intertrochanteric fracture treated by an open reduction and internal fixation is a rare, but catastrophic, event. We present the case of an 86-year-old woman, a community ambulator, who sustained a displaced right intertrochanteric hip fracture during a fall. She was treated with closed reduction and internal fixation with a dynamic compression hip screw and side plate. Four months later, she was noted to have a displaced subcapital femoral neck fracture and underwent hip screw and side plate hardware removal and cemented bipolar hemiarthroplasty. Both postoperative recoveries were uncomplicated, and she was discharged to a rehabilitation facility able to ambulate with minimal assistance. This devastating complication in patients with osteoporosis may be prevented by deeper placement of the dynamic hip compression lag screw to within 5 mm to 8 mm of the subchondral bone, which may decrease the stress forces in the subcapital femoral neck.