股骨远端C型骨折治疗体会

股骨远端C型骨折多由高能量损伤造成，治疗颇为棘手，易遗留下肢体短缩、骨不愈合及畸形愈合、创伤性关节炎等后遗症。笔者自2002年来共治疗此类损伤16例，均获随访。报告如下。     

短柄股骨假体全髋关节置换术后股骨近端骨改建及有限元分析

目的 通过观察股骨假体周围骨密度改变情况来分析短柄股骨假体全髋关节置换术后股骨近端骨改建情况.方法 纳入自2011-06-2016-06完成的71例全髋关节置换术,35例(37髋)采用短柄股骨假体(短柄组),36例(37髋)采用常规股骨假体(常规组).比较两组术后1年疼痛VAS评分、髋关节功能Harris评分、股骨假体...     

Vancouver B型股骨假体周围骨折的治疗

目的 探讨全髋关节置换术后Vancouver B型股骨假体周围骨折的治疗方法及其临床疗效.方法 收治全髋关节置换术后Vancouver B型股骨假体周围骨折7例,分别采用锁定加压钢板联合钢丝捆扎,生物型或骨水泥型长柄假体翻修联合钢丝捆扎、局部异体松质骨植骨,生物型长柄假体翻修联合钢丝捆扎、局部自体髂骨植骨治疗.结果 平均随访21个月,骨折均愈合,对位、对线好,平均愈合时间为3.5个月.末次随访时Harris评分平均84分,术后无感染、脱位、深静脉血栓等并发症发生.结论 Vancouver B型骨折应积极采取手术治疗,根据不同的骨折类型选择不同的治疗方法能取得较好的临床疗效.     

股骨远端锁定钢板治疗股骨假体周围骨折

目的 探讨应用股骨远端锁定钢板治疗Vncouver B1型股骨假体周围骨折的疗效.方法 对股骨假体周围骨折Vncouver B1型17例,采用切开复位,股骨远端锁定钢板内固定,骨折远端用双侧骨皮质锁定螺钉固定,髓内假体部分用单侧骨皮质锁定螺钉固定,对于骨缺损较大者予以自体髂骨植骨处理.结果 患者均达到骨性愈合,愈合时间3～7个月,平均4.8个月,未出现畸形愈合及骨不连,无假体松动,患者术前术后Harris评分无明显差别.结论 应用股骨远端锁定钢板治疗Vncouver B1型股骨假体周围骨折.简单有效,固定效果好,据骨缺损情况予以植骨,可获得良好临床效果.     

双钢板与单钢板治疗全膝关节置换术后Rorabeck Ⅰ、Ⅱ型股骨远端假体周围骨折的疗效分析

目的 比较双钢板与单钢板内固定治疗全膝关节置换术（total knee arthroplasty,TKA）后Rorabeck Ⅰ、Ⅱ型股骨远端假体周围骨折的疗效。方法 回顾分析2015年1月至2022年6月收治的26例TKA术后股骨远端假体周围骨折病人,根据内固定方式不同分为单钢板组（单钢板固定,16例）与双钢板组（双钢板固定,10例）。比较两组病人一般资料、手术时长、术中出血量、住院时长、术后完全负重时间、并发症及美国特种外科医院（HSS）膝关节评分。结果 两组病人均未见感染、骨不连、内固定失败或假体松动等并发症发生。单钢板组见1例骨折延迟愈合。双钢板组手术时间长于单钢板组,术后完全负重时间早于单钢板组（P＜0.05）。两组术中出血量、住院时长及术后1年随访HSS评分差异无统计学意义（P＞0.05）。结论 对于TKA术后假体稳定的股骨远端假体周围骨折,双钢板固定与单钢板固定相比,能获得与之相当的功能预后及更早的下地时间。     

Vancouver B型股骨假体周围骨折的手术治疗分析

目的 探讨髋关节置换术后股骨假体周围骨折Vancouver B型手术治疗方法的选择.方法 对13 例股骨假体周围骨折Vancouv erB型患者进行手术治疗,3 例B1型行切开复位捆绑带或钢板钢缆螺钉内固定治疗;8 例B2型患者取出股骨假体后骨折复位内固定,然后置入长柄股骨假体;2 例B3型采用结构性异体骨植骨,假体翻...     

全髋置换术后股骨假体周围骨折的治疗

目的分析全髋置换术后假体周围骨折的治疗方法及结果。方法回顾分析2003年1月至2007年12月收治的外伤所致的全髋置换术后假体周围骨折患者12例,男7例,女5例;年龄48～82岁,平均69.7岁。骨折发生于术后1个月～8年,平均3.3年。骨折发生原因：跌伤9例,交通伤2例,不明原因骨折1例。行关节置换术的原发病：股骨头缺血性坏死6例,髋关节退行性骨关节病4例,股骨颈骨折2例。根据Vancouver假体周围骨折分型标准：A型3例,B型7例,C型2例。A型采用保守治疗（外展卧床、牵引）及钢丝捆扎治疗,B型采用锯齿臂环抱内固定器、长柄假体翻修及异体皮质骨植骨治疗,C型应用解剖钢板内固定。结果12例患者均获得随访,随访时间1.5～5.5年,平均2年。除1例患者骨折未愈合外,余患者骨折均愈合,且均未发生感染、内固定断裂等并发症。结论全髋关节置换术后假体周围骨折的治疗棘手,治疗方案需结合骨折部位、原置换假体有无松动、局部骨质量、身体状况而制定。     

全髋关节置换术后股骨假体周围骨折的治疗

目的 探讨人工全髋关节置换术后股骨假体周围骨折的治疗方法及疗效. 方法 回顾性分析2005年7月至2010年6月收治且获得随访的13例人工全髋关节置换术后股骨假体周围骨折,其中男6例,女7例;年龄51 ～ 80岁,平均67岁;骨折按Vancouver分型:B1型3例,B2型5例,B3型3例,C型2例.分别用钢丝或钢缆环扎固定,异体皮质骨板加钢丝环扎;长柄假体翻修;记忆合金环抱器、锁定加压钢板固定.结果 所有患者术后随访9 ～ 30个月,平均16个月.骨折均愈合,时间4～7个月,平均4.8个月.患者无感染、畸形愈合、假体松动脱位、内固定断裂和深静脉血栓形成.根据Harris髋关节功能评分:优7例,良5例,可1例. 结论 全髋关节置换术后假体周围骨折的治疗方案需结合骨折部位、假体有无松动、局部骨质量、身体状况而制定,原则是移位骨折要进行牢固固定、松动假体要进行翻修、严重骨缺损需要植骨处理.     

胫骨近端肿瘤型膝关节假体中长期生存及失败类型

[目的]探讨胫骨近端骨肿瘤切除重建后假体的中长期生存情况和假体失败的原因。[方法]对2001～2013年肿瘤切除、胫骨近端肿瘤型膝关节假体重建或假体翻修的143例患者(165例假体)进行回顾性研究。采用Kaplan-Meier法计算生存曲线及生存率,Log-rank检验行单因素分析,Cox回归进行多因素分析。[结果]所有患者平均随访时间(84.19±47.33)个月。截止最后一次随访,143例患者中,97例无瘤生存,18例带瘤生存,28例死亡,11例截肢。165例假体中,胫骨近端肿瘤型膝关节假体5年生存率80.67%,10年生存率73.82%,其中,国产与进口型假体总生存间差异无统计学意义(P>0.05);假体骨水泥固定与生物固定方式间的生存差异无统计学意义(P>0.05);初治手术假体与翻修手术假体间生存差异无统计学意义(P>0.05);组配型假体与定制型假体生存差异无统计学意义(P>0.05)。根据假体失败的定义标准,共出现假体失败37例。根据ISOLS推荐假体失败类型分类:其中I型失败7例,II型3例,III型3例,IV型14例,V型10例。假体周围感染是最常见导致假体失败的原因,金黄色葡萄球菌为最常见的致病菌。将胫骨近端假体应用设计参数纳入COX多因素分析显示,胫骨侧假体柄长度大于131mm者假体预后较好(P<0.05)。[结论]假体周围感染是导致中期假体失败的最主要原因,应进一步延长随访时间,观察假体远期效果。     

肿瘤型膝关节假体置换术后近期再次手术的原因分析

[目的]分析肿瘤型膝关节假体置换术后近期再次手术的原因,评价不同原因对再手术的影响。[方法]回顾分析西京骨科医院骨与软组织肿瘤科2010年1月²013年6月收治的167例肿瘤型膝关节假体置换术病历资料,其中男106例,女61例;年龄82013年6月收治的167例肿瘤型膝关节假体置换术病历资料,其中男106例,女61例;年龄8⁷2岁,平均25.27岁。骨肿瘤部位:股骨下段95例,胫骨上段72例;骨肿瘤类型:骨肉瘤88例,骨巨细胞瘤67例,Ewing肉瘤6例,软骨肉瘤4例,恶性纤维组织细胞瘤2例。96例恶性肿瘤患者术后行至少一次化疗,化疗药物有顺铂、多柔比星、洛铂、异环磷酰胺、甲氨蝶呤等。假体类型:定制型新轴心式膝关节假体44例,定制型旋转铰链膝关节假体56例,可延长式股骨远端膝关节假体2例,组配式铰链膝关节假体65例。首次手术距再次手术时间472岁,平均25.27岁。骨肿瘤部位:股骨下段95例,胫骨上段72例;骨肿瘤类型:骨肉瘤88例,骨巨细胞瘤67例,Ewing肉瘤6例,软骨肉瘤4例,恶性纤维组织细胞瘤2例。96例恶性肿瘤患者术后行至少一次化疗,化疗药物有顺铂、多柔比星、洛铂、异环磷酰胺、甲氨蝶呤等。假体类型:定制型新轴心式膝关节假体44例,定制型旋转铰链膝关节假体56例,可延长式股骨远端膝关节假体2例,组配式铰链膝关节假体65例。首次手术距再次手术时间4⁵5个月,平均35.6个月;首次手术时长8055个月,平均35.6个月;首次手术时长80²75 min,平均178.58 min;首次手术术中失血量450275 min,平均178.58 min;首次手术术中失血量450¹ 000 ml,平均681.67 ml;首次手术术后第1 d引流量901 000 ml,平均681.67 ml;首次手术术后第1 d引流量90²70 ml,平均175.75 ml。[结果]167例病例中34例进行了再次手术,占20.36%。再次手术的原因有:术后假体周围感染14例,占8.38%;局部肿瘤复发9例,占5.39%;假体松动8例,占4.79%;假体断裂3例,占1.80%。72例胫骨近端病例中,既往手术中行腓肠肌肌瓣转移术的57例,术后发生假体周围感染2例,占3.51%;未行腓肠肌肌瓣转移术的15例,术后发生假体周围感染6例,占40.00%。34例行再次手术的病例中,定制型新轴心式膝关节假体10例,定制型旋转铰链膝关节假体14例,组配式铰链膝关节假体10例。通过x2检验,发现化疗病例和未化疗病例在感染发生率方面差异存在统计学意义(P=0.026);行腓肠肌肌瓣转移术病例与未行该术病例在感染发生率方面差异存在统计学意义(P<0.005)。通过t检验发现感染病例和非感染病例在既往手术时间、术中失血量及术后第1 d伤口引流量方面差异无统计学意义(P=0.457、P=0.339、P=0.385)。[结论]导致肿瘤型膝关节假体置换术后近期再次手术的主要原因是术后假体周围感染,而化疗的应用、软组织覆盖的缺失等与感染的发生有密切的关系。     

髋关节置换术后股骨假体周围骨折的临床治疗分析

目的总结人工髋关节置换术后股骨假体周围骨折的病因及其治疗方法。 方法回顾性分析自2011年1月至2017年1月于中山大学孙逸仙纪念医院治疗的并于术中、术后出现股骨假体周围骨折患者,排除初次手术前已经出现骨折的患者,共纳入男5例,女8例,平均年龄为(68±19)岁(34～93岁),初次置换病因：股骨颈骨折6例;股骨头缺血坏死5例,强直性脊柱炎1例,类风湿性关节炎1例。初次置换时股骨假体固定方式：骨水泥固定5例,其余8例病人为生物型假体。假体周围骨折病因包括7例有明确外伤史(不慎跌伤或车祸)、6例为翻修术中骨折。根据Vancouver分型,A_G型3例,A_L型1例,B2型4例,B3型3例,C型2例。翻修时骨折固定方式：5例采用大粗隆再结合装置加钢缆固定,7例使用钢板钢缆固定,1例病人使用异体皮质骨板加钢丝固定。在各类分型中,2例C型股骨假体周围骨折使用钢板钢缆固定骨折端,其余11例股骨假体均不稳定,仅1例使用骨水泥重新固定初次置换假体,余10例使用全涂层假体。通过Harris评分对患髋进行功能评价,X线或CT观察骨折愈合。采用Mann-Whitney检验对比术前、术后髋关节Harris评分、疼痛视觉模拟(VAS)评分。 结果平均随访时间(29±19)月,平均骨折愈合时间为(4.5±1.1)月。Harris评分由术前13.0(4.0,25.0)提高至末次87.0(82.3,93.3)分,(Z ＝－4.34,P <0.05)。异体皮质骨板病例在末次随访时显示与宿主骨融合,所有病人末次随访均未见假体松动、脱位及感染。 结论根据不同分型选择相应的骨折复位与固定方式,钢板钢缆组合有效提高了稳定性;对于骨量不足病人可以考虑使用异体皮质骨固定以增加患者骨量。     

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。     

髋表面置换股骨侧假体外翻位植入后股骨近端应力变化的有限元分析

目的 探讨髋表面置换股骨侧假体外翻位植入后股骨近端的应力变化,并寻求最佳外翻植入角度.方法 建立正常股骨近端髋表面置换股骨侧假体(Wright假体)三维模型,其中股骨假体按解剖颈干角(本文选用股骨模型的生理解剖颈干角为135°)、外翻5°、10°、15°植入,加载关节合力及相关肌肉的肌力负荷,分析假体植入前后股骨近端的应力分布变化,并对股骨近端假体周围区域骨质应力分布进行分区量化研究.结果 股骨假体轻度外翻植入降低了股骨头颈交界处上方(2、8区)的应力,5°外翻植入股骨头上方假体杯下缘(1、7区)应力遮挡最小,股骨颈下方(4、10区)应力分布更接近正常股骨.结论 外翻5°植入假体股骨近端应力更接近正常股骨,降低了股骨颈骨折和假体松动的危险.     

股骨上段有限元几何模型的建立与分析

目的建立股骨骨结构三维有限元模型并对其进行分析以指导临床工作。方法在Mimics10.1中直接读取符合Dicom 3.0标准的股骨原始CT数据,经阈值设定、区域增长及形态学操作等生成股骨初始3D模型,后期结合有限元软件ANSYS12.1生成最终的三维有限元网格模型,然后在ANSYS12.1中分别对应用Mimics得到的模型进行分析。结果应用Mimics10.1和Ansys12.1软件建立股骨有限元模型,外形逼真、计算精确。结论 Mimics10.1软件能直接与Ansys12.1软件进行对接,并能根据CT值直接赋值使股骨上段三维有限元模型的建立更加快捷、精确。     

Revision arthroplasty in periprosthetic fractures of the proximal femur

Objective

Hip revision arthroplasty of a loose stem in the case of Vancouver type B2 and B3 periprosthetic fractures and cerclage wiring of the femoral shaft.

Indications

Vancouver type B2 and B3 periprosthetic fractures of the proximal femur.

Contraindications

Periprosthetic joint infection. Interprosthetic femoral fractures between the ends of hip and knee prosthetic stems that require total replacement of the femur.

Surgical technique

Extended posterolateral approach to the tip of the fracture. Exposure along the septum intermusculare laterale with ligation of the perforating vessels below the fracture. Longitudinal osteotomy of the proximal fragment above the linea aspera using an oscillating saw under cooling. Ventral proximal osteotomy at the corner of the vasto-gluteal sling after short muscular incision using an osteotome chisel. Opening of the proximal fragment with lifting up of the bony flap like a transfemoral approach. Removal of the loosened prosthetic stem and possibly the cement. Preparation of the distal fixation zone of the modular cementless revision stem in the isthmus of the femur distal of the fracture. Implantation of the distal component of the modular cementless revision stem. Use of additional distal interlocking screws in cases of destroyed isthmus with a fixation zone of less than 3 cm for the distal prosthetic component. Trial reposition after combination with the proximal trial component in situ. Assembly with the original proximal component in situ. Reposition with the original proximal component. Wound closure.

Postoperative management

Thrombosis prophylaxis, physiotherapy, gait training with partial loading of the limb at 10 kg for a period of 6 weeks with hip flexion limited to 70°. Then, free range of movement and increased loading by 10 kg per week.

Results

In all, 23 patients with periprosthetic fractures of Vancouver type B2 (15 patients) and type B3 (eight patients)—in 15 women and eight men in the age range of 70.7?±?12.2 (42–88) years—were followed up for at least 5 years. All fractures healed with a mean time of 14.4?±?5.3 weeks. No cases of subsidence of the stem were observed and, according to the classification of Engh et al. concerning the biological fixation of the stem, there was bony ingrowth fixation in 21 cases and two cases of stable fibrous fixation. One dislocation occurred and there were no cases of intraoperative fracture. The Harris Hip Score rose continually following the operations: from a 3-month postoperative score of 65.0?±?16.8 points, it rose to 86.9?±?16.2 points after 24 months and to 89.0?±?14.3 points after 5 years. According to the classification of Beals and Tower, all results were rated as excellent, i.e., the prefracture functional status was restored in all cases.     

Structure-mechanical analysis of various fixation constructs for basicervical fractures of the proximal femur and clinical implications; finite element analysis

ObjectiveThis present study was conducted to determine the structural-mechanical stability of various fixation constructs through finite element (FE) analysis following simulation of a basicervical fracture and to introduce the clinical implications.Materials and MethodsWe simulated fracture models by using a right synthetic femur (SAWBONES®). We imported the implant models into ANSYS® for placement in an optimal position. Five assembly models were constructed: (1) multiple cancellous screws (MCS), (2) FNS (femoral neck system®), (3) dynamic hip screw (DHS), (4) DHS with anti-rotation 7.0 screw (DHS + screw), and PFNA-II (Proximal Femoral Nail Antirotation-II®). The femur model's distal end was completely fixed and 7° abducted. We set the force vector at a 3° angle laterally and 15° posteriorly from the vertical ground. Analysis was done using Ansys® software with von Mises stress (VMS) in megapascals (MPa) and displacement (mm)ResultsThe displacements of the proximal femur were 10.25 mm for MCS, 9.66 mm for DHS, 9.44 mm for DHS + screw, 9.86 mm for FNS, and 9.31 mm for PFNA-II. The maximum implant VMS was 148.94 MPa for MCS, 414.66 MPa for DHS, 385.59 MPa for DSH + screw, 464.07 MPa for FNS, and 505.07 MPa for PFNA-II. The maximum VMS at the fracture site was 621.13 MPa for MCS, 464.14 MPa for DHS, 64.51 MPa for DHS + screw, 344.54 MPa for FNS, and 647.49 MPa for PFNA-II. The maximum VMS at the fracture site was in the superior area with the high point around the posterior screw in the MCS, anterosuperior corner in the DHS, the posteroinferior site of the FNS, and posterosuperior site around the entry point in the PFNA-II. In the DHS + screw, the stresses were distributed evenly and disappeared at the maximum VMS fracture site.ConclusionBased on the fracture site and implant's stress distribution, the model receiving the optimal load was a DHS + screw construct, and the FNS implant could be applied to anatomically reduced fractures without comminution. Considering the high-stress concentration around the entry point, a PFNA-II fixation has a high probability of head-neck fragment rotational instability.     

Treatment of proximal femur fractures associated with total hip arthroplasty

The authors reviewed seven cases of proximal femur fractures with ipsilateral total hip arthroplasty between April 1985 and July 1987. All patients had ORIF with Odgen plates and Parham bands. Early mobilization of the patients avoided prolonged bedrest with its inherent morbidity. The morbidity of a revision of the total hip arthroplasty was also avoided. There were no problems with healing of the fractures sites and no evidence of devascularization related to Parham band utilization. All seven type A fractures went to clinical and radiographic union by 4 months and all seven were asymptomatic. The authors recommend the use of Ogden plates and Parham bands for type A fractures. Their clinical data suggest that this method is an effective treatment modality that produces a decrease in morbidity with satisfactory results.     

Survival after pathological fractures of the proximal femur

We report on the survival of 145 patients presenting to a single centre with a pathological metastatic fracture of the proximal femur. The single surviving patient had a follow-up of 17.7 years. Mean survival for the 144 patients who died was 332 days (range 2 to 3053 days), being longest for those with myeloma (662 days), lymphoma (> 633 days) and breast tumours (477 days) and lowest for lung tumours (110 days). The most common sites for the primary tumour were breast (36%), prostate (23%) and lung (17%). 47% of fractures were intracapsular, 28% trochanteric and 25% subtrochanteric. 99% of the fractures were treated surgically with a mean hospital stay of 19 days. The commonest fracture healing complication was further fracture of the femur around or immediately below the implant which occurred after 9/144 (6.2%) of operations. The difference in survival of patients related to the primary tumour site is of relevance in planning surgical treatment and discussing prognosis with patients.     

多臂环抱型锁式接骨器治疗股骨假体周围骨折

随着社会人口的老龄化和人工关节置换年龄的年轻化,假体周围骨折的发生率在不断增高。由于假体的存在,使得再次手术固定较为困难。既往常采用非手术治疗或钢丝钢缆环扎、异体皮质骨板等材料固定,手术较为复杂,骨折不愈合或再移位的发生率高。我院自2001年12月～2005年3月采用多臂环抱型锁式接骨器治疗7例股骨假体周围骨折患者,取得了较为满意的效果。     

Clinical and finite element analysis of a modular femoral prosthesis consisting of a head and stem component in the treatment of pertrochanteric fractures

OBJECTIVE: To determine the biomechanical characteristics and potential clinical efficacy of a cementless modular femoral prosthesis consisting of a variable head (50 to 80 millimeters) and stem (length 120 to 280 millimeters, diameter 10 to 20 millimeters) component in patients with pertrochanteric femoral fracture. DESIGN: Finite element analysis (FEA) of different lengths and diameters of prosthesis components and first clinical prospective study in pertrochanteric femoral fracture. METHOD: Using a 3D-CAD program, a model of femoral cortical bone with a pertrochanteric fracture was created and combined with a model of the prosthesis. This model was transferred into an FEA program. After applying a torsion-bending load of 2,000 N (25 degrees, 45 degrees) on the prosthesis, stress distribution in the cortical bone was determined for different lengths (160 to 240 millimeters) and diameters (10 and 12 millimeters) of stem. PATIENTS: Twenty-eight patients with pertrochanteric fractures (very unstable or osteoarthritis) were treated with a modular hip arthroplasty. Complications, fracture healing, and results at first follow-up (average 13 months) were determined. RESULTS: FEA analysis indicated that reduction in stress was less when a prosthesis with a short stem was used. Shear stress in the interface bone/prosthesis was not affected by stem length. Prostheses with thin stems produced higher sheer stresses than those with thick stems. Results of FEA were used as the basis for clinical application of the device. None of the patients died, and all patients were able to walk, although some needed a cane or walker after surgery. There was no increase in thigh pain compared with reported pretrauma levels. Radiographs showed subsidence of up to 5 millimeters in 20 percent of patients. However, all but one prosthesis was stable at follow-up. Fracture healing was achieved in all patients. CONCLUSIONS: If proximal fixation of a femoral uncemented stem cannot be achieved, stem diameter should provide maximum cortical contact to reduce sheer stress. Longer stems do not necessarily provide additional stability. By using this prosthesis and selection method, a good outcome at first follow-up was observed.