股骨颈骨折全髋关节置换术后股骨近端形态变化

目的:观察全髋关节置换(THA)治疗股骨颈骨折及股骨头坏死术后股骨近端形态改变,分析是否存在差异及其表现形式.方法:2014年1月至12月同一手术组连续股骨颈骨折和股骨头坏死行THA治疗的病例进行对比分析,其中股骨颈骨折患者22例,男11例,女11例,年龄44~83岁,平均(66.18±11.47)岁;股骨头坏死患者23例,男12例,女11例,年龄19~68岁,平均(51.91±11.76)岁.测量THA术后股骨高度,Offset,截骨位置和调整方式,进行统计分析.结果:全部患者获得测量,行THA治疗后,股骨颈骨折病例较股骨头坏死病例有更低的股骨高度,更小的Offset,更低的截骨位置,并发现了3种低位截骨后的调整方式.结论:股骨颈骨折行THA手术,有产生低截骨、较小Offset的可能,因低位截骨而进行的调整可能会对近远期疗效产生不良影响.     

股骨颈骨折人工髋关节置换的偏心距调整

高龄股骨颈骨折用人工关节置换治疗越来越普遍[1],其优点是能够使患者早期离床,避免因长期卧床带来的一系列并发症。下地后能有一个良好的关节功能是临床医师的追求,功能优劣与关节的软组织平衡直接相关。在髋关节软组织平衡中,偏心距(offset)是否符合生理解剖非常重要[2]。总结2004年1月-2005年12月,30例(由同一组手术医师操作)股骨颈骨折人工髋关节置换术的病例,均经过术前偏心距测量、术中偏心距调整及术后功能的康复,获得满意疗效。1资料与方法1.1一般资料30例股骨颈骨折患者接受了人工髋关节置换术,男12例,女18例;年龄62~90岁,平均73.8…     

Cardiovascular collapse after femoral prosthesis surgery for acute hip fracture

Purpose

Prosthetic revision of hip fractures may result in embolization of tissue products leading to death. In this report, from cases reported to the Anaesthesia Advisory Committee to the Chief Coroner of Ontario, emphasis is placed on the immediate resuscitative procedures which may offset a fatal outcome.

Clinical features

Two elderly patients are reported in whom hip fractures necessitated primary prosthetic hip repair. The first patient, with a history of limited cardiac reserve and syncope, suffered a subcapital hip fracture. Under general anaesthesia, a Moore’s prosthesis was inserted. The anaesthetic penod remained relatively stable until surgical teaming of the femoral canal. Bradycardia. hypotension and cyanosis developed and quickly proceeded to a fatal cardiac anest. Autopsy demonstrated diffuse pulmonary embolism of fat and thrombus. The second patient suffered a fracture around the stem of a previously inserted femoral prosthesis. Under general anaesthesia, a new cemented hip prosthesis was inserted, following which hypotension occurred. This was supported with small doses of ephednne, ventilation was controlled with oxygen and the procedure was quickly terminated. Despite addition of a dopamme infusion, cardiac arrest and death followed. Autopsy disclosed massive fat and bone marrow embolization.

Conclusion

The combination of hip fracture, activated clotting factors and borderline cardiopulmonary function presents a risk of death from embolization of tissue products released during the placement of a cemented hip prosthesis. While the outcome of this catastrophe is generally poor, all practitioner’s should be prepared to immediately institute resuscitative procedures to manage the accompanying cardiovascular collapse.     

Early mortality after elective hip surgery

Specimens of the joint surfaces of the tibia from patients with OA and RA were examined for bone mineralization, bone formation, osteoid tissue and bone resorption. Judging from the appearance of the osteoblasts in OA the sclerotic changes are mainly focal with relatively little osteogenesis. No osteoclasia was seen, in the sclerotic areas. Breakdown of the mineralized cartilage is followed by the development of cysts with highly cellular connective tissue with high osteoblastic activity and osteoclasia. Osteoid tissue is relatively sparse. The changes in RA are more diffuse with a more active osteoblastic activity and widespread zones of osteoid tissue as well as resorption by osteoclasts. It appears as if the increased uptake of ⁸³Sr in OA is more dependent on the occurrence of relatively inert osteosclerosis than on a rapid turnover of the bone tissue.     

全髋关节置换术治疗高龄患者股骨颈骨折

目的探讨高龄患者股骨颈骨折全髋关节置换术(THA)的疗效。方法采用THA治疗58例高龄患者股骨颈骨折,分析其疗效及并发症。结果 经2．5～6年(平均4．3年)随访,按Harris评分标准：优良率93．1％(54／58);术后并发症主要为深静脉栓主塞6例(10．3％),异位骨化3例。结论THA适应证取决于患者手术耐受性、患者的预期寿命及社会生活需求,年龄不宜作为影响手术选择的决定性因素。     

Function after primary hemiarthroplasty and secondary total hip arthroplasty in femoral neck fracture

Four to 12 years after primary treatment of femoral neck fracture with hemiarthroplasty in a group of Finnish patients and secondary total hip arthroplasty as a salvage procedure for healing complication after orimary osteosynthesis in a group of Swedish patients, function was classified and the Nottingham Health Profile questionnaire was applied. The two groups were comparable with regard to age, sex, and social status. The patients with secondary total hip arthroplasty used walking aids to a lesser extent than the patients with hemiarthroplasty and experienced less problems in several aspects of life. Walking ability was considered unchanged, compared to prefracture, to a larger extent in the secondary total hip arthroplasty group. Thus, secondary total hip arthroplasty in patients with healing complication following primary osteosynthesis gives better long-term functional capacity than that obtained with a primary hemiarthroplasty.     

Hemarthrosis after femoral neck fracture fixation

In 34 femoral neck fractures, CT was performed within 1-32 days after internal fixation. All the cases except one showed an increased distance between the femoral neck and the anterior aspect of the joint capsule as compared with the intact side, indicating varying degrees of hip joint effusion and/or synovitis. Hip joint aspiration in 11 patients revealed increased intracapsular pressure varying between 10 and 112 mmHg and volumes of aspirated joint effusion up to 23 ml. Pain relief and increased joint motion after drainage of the intracapsular effusion was observed in 3 patients whose postoperative mobilization was facilitated.     

Hemarthrosis after femoral neck fracture fixation

In 34 femoral neck fractures, CT was performed within 1-32 days after internal fixation. All the cases except one showed an increased distance between the femoral neck and the anterior aspect of the joint capsule as compared with the intact side, indicating varying degrees of hip joint effusion and/or synovitis. Hip joint aspiration in 11 patients revealed increased intracapsular pressure varying between 10 and 112 mmHg and volumes of aspirated joint effusion up to 23 ml. Pain relief and increased joint motion after drainage of the intracapsular effusion was observed in 3 patients whose postoperative mobilization was facilitated.     

老年股骨颈骨折患者行全髋关节置换术后体重的变化

目的了解老年股骨颈骨折患者行全髋关节置换术(THA)术后体重的变化。 方法回顾性分析2013年1月至2016年6月在聊城市第二人民医院关节外科接受单侧初次THA的股骨颈骨折患者。以BMI为分组依据,18.5 kg/m²≤BMI<24.0 kg/m²为体重正常组,24.0 kg/m²≤BMI<28.0 kg/m²为超重组,BMI≥28.0 kg/m²为肥胖组。采用Kaplan-Meier法分析比较THA后人体质量指数(BMI)减少超过5%的时间间隔。 结果共有78例患者纳入本研究,体重正常组28例患者、超重组46例患者、肥胖组4例患者,3组患者之间的年龄、性别构成差异无统计学意义,P>0.05。3组患者在THA术后人体质量指数减少超过5%的中位时间分别为52个月(43, 69)个月、48个月(40,67)个月、47个月(41,60)个月,行log-rank检验,差异没有统计学意义(χ²＝4.72,P>0.05)。 结论体重正常组、超重组、肥胖组患者在THA术后BMI减少超过5%的中位时间基本一致。     

Early mortality and morbidity after total hip arthroplasty in patients with femoral neck fracture

Background and purpose — Early postoperative mortality is relatively high after total hip arthroplasty (THA) that has been performed due to femoral neck fracture. However, this has rarely been investigated after adjustment for medical comorbidity and comparison with the mortality in an age-matched population. We therefore assessed early mortality in hip fracture patients treated with a THA, in the setting of a nationwide matched cohort study.

Patients and methods — 24,699 patients who underwent THA due to a femoral neck fracture between 1992 and 2012 were matched with 118,518 controls. Kaplan-Meier survival analysis was used to calculate cumulative unadjusted survival, and Cox regression models were fitted to compute hazard ratios (HRs) and 95% confidence intervals (CIs), with adjustment for age, sex, comorbidity, and socioeconomic background.

Results — 90-day survival was 96.3% (95% CI: 96.0–96.5) for THA cases and 98.7% (95% CI: 98.6–98.8) for control individuals, giving an adjusted HR of 2.2 (95% CI: 2.0–2.4) for THA cases compared to control individuals. Comorbidity burden increased in THA cases over time, but the adjusted risk of death within 90 days did not differ statistically significantly between the time periods investigated (1992–1998, 1999–2005, and 2006–2012). A Charlson comorbidity index of 3 or more, an American Society of Anesthesiologists (ASA) grade of 3 and above, male sex, an age of 80 years and above, an income below the first quartile, and a lower level of education were all associated with an increased risk of 90-day mortality.

Interpretation — The adjusted early mortality in femoral neck fracture patients who underwent THA was about double that in a matched control population. Patients with femoral neck fracture but with no substantial comorbidity and an age of less than 80 years appear to have a low risk of early death. Patients older than 80 years and those with a Charlson comorbidity index of more than 2 have a high risk of early death, and such patients would perhaps benefit from treatment strategies other than THA, but this should be investigated further.     

Fracture-dislocation of the hip with ipsilateral femoral neck fracture

. Fracture-dislocation of the hip associated with fracture of the femoral neck and intrapelvic intrusion of the femoral head is a rare injury. In this case we performed open reduction for the femoral neck fracture, and external fixation for the pelvic fracture by Judet-Meyers method. As a result the patient has not complained of pain, although he developed arthrokleisis due to ectopic ossification around the femoral head, as well as femoral head necrosis. Résumé. Nous rapportons un cas de fracture-luxation de la tête fémorale avec migration dans le bassin chez un homme de 25 ans. La réduction a été réalisée par fixation vis-plaque, le patient ne présente actuellement aucune douleur, pas d'arthrose de la hanche, ni de nécrose de la tête fémorale, mais il a une petite raideur due à des ossifications péri-articulaires de sa hanche. Cinq ans après, le patient est resté asymptomatique.     

股骨颈骨折后股骨头坏死

简要叙述股骨颈骨折后股骨头坏死的早期诊断和坏死预测等的最新进展。为使骨折后骨坏死尽量减少，早期手术和关节穿刺减压，避免髋关节放置在伸直及内旋位是必要的，建议屈曲位牵引。应用Gd-DTPA增强MRI T1脂肪浸润扫描，可预测股骨头坏死的可能性。建议将股骨头坏死分为静息型骨坏死和临床型骨坏死．     

Cost of infection after surgery for intracapsular fracture of the femoral neck

Introduction

We investigated the financial and human costs of postoperative infection for intracapsular fracture of the femoral neck at a district general hospital in the UK.

Methods

Data on postoperative infections after surgical treatment for intracapsular fracture of the femoral neck were collected prospectively from June 2005 to April 2009. Infected patients were pairwise-matched (1:2 ratio) with a non-infected group of patients from a database on hip fractures. Costs of additional surgery, duration of hospital stay, and opportunity costs were calculated using Primary Care Trust (PCT) tariffs and PCT-specific data.

Results

A total of 525 patients were treated with total hip replacement (n=110) or hip hemiarthroplasty (n=415). Seventeen patients (3.2%) were identified as having a surgical-site infection. Eight (1.5%) deep infections and nine (1.7%) superficial infections were documented. Compared with the non-infected group, duration of hospital stay and the prevalence of mortality doubled. Repeat surgery and the costs associated with hospital admission were increased significantly in the infected group. Mean financial loss associated with an infected patient was £7,726, whereas an uninfected patient brought £153 of profit to the hospital. When opportunity costs were considered, an infected patient represented £24,397 of lost income.

Conclusions

Postoperative infection after surgical treatment for intracapsular fracture of the femoral neck has a significant negative impact on duration of hospital stay and financial costs, and demonstrates a trend towards an increase in the prevalence of mortality.     

Periprosthetic femoral fracture after total hip arthroplast

Periprosthetic femoral fractures represent a significant complication in total hip arthroplasty. based on originand treatment considerations, these fractures are best considered on the basis of the proximal region, and middle region below the lesser trochanter, and distal region at the prosthetic tip and beyond. Proximal-region fractures are usually wired and treated conservatively. Middle-region fractures may require prosthetic revision in addition to fracture fixation.Distal-region fractures are most difficult and may need advanced techniques, such as distal prosthetic fixation and allograft femoral plates.     

Pre-operative and postoperative scintimetry after femoral neck fracture

In 22 patients with femoral neck fractures 99mTc-MDP scintimetry was performed before operation and again shortly after operation; in 17 of these patients the investigation was repeated after four months. Six patients with increased uptake in the femoral head before operation and eight with decreased uptake had similar results at the first postoperative investigation. Of eight patients with an intermediate uptake before operation, two showed increased and six decreased femoral head uptake after operation. It is concluded that for the patients in the group with intermediate femoral head uptake before operation, the operative procedure probably influenced the postoperative blood supply of the femoral head.     

Hip joint pressure after femoral neck fracture

The hip joint pressure in 40 patients with intracapsular femoral neck fractures was measured on the fracture table prior to surgery. All but 1 patient had pressures well below 20 mmHg with the hip unreduced. When the hip was extended and internally rotated, the pressure rose to values exceeding the normal arteriolar pressure in most patients, with a peak pressure of 135 mmHg. In nine of 22 Garden IV fractures, the pressure remained low despite extension and inward rotation. Injection of contrast medium in three of these hips indicated a rupture of the joint capsule. The pressure response to extension and internal rotation was less marked in fractures older than 72 hours.

The findings do not support the hypothesis that a hip-joint tamponade is a common etiologic factor for the development of femoral head necrosis following fracture. However, prolonged reduction maneuvers with the hip joint in extension and internal rotation can create intracapsular pressures high enough to temporarily jeopardize the circulation of the femoral head.     

Bone and muscle mass after femoral neck fracture

The cortical bone mineral density (BMD), bone volume, bone mass and muscle volume of the thigh, and the BMD of the distal femur and proximal tibia were measured quantified by quantitative computed tomography (QCT) after an operation for a displaced femoral neck fracture. Twenty patients were randomized to osteosynthesis or total hip arthroplasty (THA). Both legs were scanned after 18 months, and the operated side was compared with the healthy side. Clinical assessment was performed with a Harris hip score. A reference group of 9 patients, who had undergone THA because of arthrosis, was chosen. In the fracture patients, we found a 9% decrease in bone mass and muscle volume of the middle femur. The BMD of the distal femur and proximal tibia showed a more marked osteopenia. There was no difference in these parameters between the two groups. In the reference group of operated arthrosis patients, we did not find any differences between sides postoperatively. After the operation, the fracture patients had a lower Harris score than the arthrosis patients, and this was most pronounced among those who had undergone osteosynthesis. The finding of a marked osteopenia after a femoral neck fracture, irrespective of treatment, but no bone loss after THA because of arthrosis, implies that patients with a femoral neck fracture are more sensitive to osteopenia, and that the bone loss is not proportional to the operative trauma. caused by the disuse and the posttraumatic effect on the bone caused by the operation. Also, the magnitude of the operative trauma may play a role in the development of the osteopenia. Thus, a displaced femoral neck fracture, treated with osteosynthesis or total hip arthroplasty (THA), offers a possibility to distinguish between the osteopenia caused by the fracture and the role of the operation, since the degree of the operative trauma is different. The aim of this study was to investigate whether or not the bone loss after a displaced femoral neck fracture depends on the mode of treatment.