髋部手术围手术期隐性失血的研究进展

髋部骨折的患者术前、术后均存在隐性失血,且常影响患者伤口的愈合,使感染概率增加,康复锻炼时间延长,影响术后疗效.同时,机体失血量的增加激发了血液的凝血机制,促进了深静脉血栓形成的发生,出血和深静脉血栓已成为髋部手术高风险的主要原因.止血非常重要,抗凝亦不容忽视,因此,如何有效地处理术后抗凝和止血这一突出矛盾或从中寻找一个最佳的平衡点已成为髋部骨折治疗的棘手问题.     

The effect of clopidogrel and aspirin on blood loss in hip fracture surgery

Introduction

Anti-platelet drugs are commonly used for primary and secondary prevention of thrombo-embolic events and following invasive coronary interventions. Their effect on surgery-related blood loss and perioperative complications is unclear, and the management of trauma patients treated by anti-platelets is controversial. The anti-platelet effect is over in nearly 10 days. Notably, delay of surgical intervention for hip fracture repair for >48 h has been reported to increase perioperative complications and mortality.

Patients and methods

Intra-operative and perioperative blood loss, the amount of transfused blood and surgery-related complications of 44 patients on uninterrupted clopidogrel treatment were compared with 44 matched controls not on clopidogrel (either on aspirin alone or not on any anti-platelets).

Results

The mean perioperative blood loss was 899 ± 496 ml for patients not on clopidogrel, 1091 ± 654 ml for patients on clopidogrel (p = 0.005) and 1312 ± 686 ml for those on combined clopidogrel and aspirin (p = 0.0003 vs. all others). Increased blood loss was also associated with a shorter time to operation (p = 0.0012) and prolonged surgical time (p = 0.0002). There were no cases of mortality in the early postoperative period.

Conclusions

Patients receiving anti-platelet drugs can safely undergo hip fracture surgery without delay, regardless of greater perioperative blood loss and possible thrombo-embolic/postoperative bleeding events.     

The hidden blood loss in proximal femur fractures is sizeable and significant

BackgroundPatients sustaining hip fractures experience blood loss as a direct result the fracture independent of surgery. The objective of this study was to quantify the expected non-surgical blood loss for proximal femur fractures using hemoglobin values.MethodsA retrospective chart review of patients at a level 1 trauma center sustaining proximal femur fractures between October 2015 and January 2018 was performed. Patients were ≥30 years of age, had sustained intertrochanteric, subtrochanteric, or femoral neck fractures and had hemoglobin values documented at admission and after 12 h but before surgery. Patients with concomitant fractures, other hemorrhagic injuries, or blood transfusions before their second hemoglobin result were excluded. A multivariate linear regression model was constructed to evaluate the predictive ability of age, sex, BMI, number of comorbidities, fracture type, anticoagulation/antiplatelet therapy, admission hemoglobin, timing of surgical intervention and changes in electrolyte levels on subsequent hemoglobin values. Hemoglobin changes were compared between intertrochanteric, subtrochanteric, and femoral neck fractures and anticoagulant therapy types with Welch’s tests.Results119 patients were included. The mean age was 80.9 ± 10.81 years. Nearly 53% of subjects were using anticoagulation therapy. The mean drop in hemoglobin was 1.4 ± 1.03 g/dL. The multivariate linear regression model had statistically significant predictive ability (R = 0.91, p < 0.001). Independent predictors of hemoglobin decrease were number of comorbid conditions (p = 0.02), admission hemoglobin reading (p < 0.001), fracture type (p = 0.02), and time from admission to surgery (p = 0.03). Intertrochanteric fractures demonstrated the largest hemoglobin drops. Anticoagulation therapy had no effect on subsequent hemoglobin.ConclusionProximal femur fractures cause a significant amount of blood loss prior to surgical intervention. Patients at particular risk include those with comorbidities, intertrochanteric fractures, low admission hemoglobin values, and increased time to surgery. The identification of demographic, fracture type, and treatment characteristics may help surgeons identify patients at the greatest risk for blood loss, and provide more effective perioperative care.     

骨质疏松性椎体压缩性骨折椎体后凸成形术后隐性失血及其影响

目的：探讨骨质疏松性椎体压缩性骨折在椎体后凸成形术后隐性失血及相关危险因素。方法：对2015年3月至2017年12月收治的153例骨质疏松性椎体压缩性骨折并接受椎体后凸成形术患者的临床资料进行回顾性分析,其中男55例,女98例;年龄68~87（78.6±11.4）岁。收集患者手术前后红细胞比容用于计算隐性失血量,通过多元线性回归模型分析患者的性别、年龄、体重指数、骨密度、是否合并糖尿病和高血压、手术方式（单侧或双侧）、手术时间、手术节段及数量、椎体丢失高度及恢复高度比因素对于隐性失血的影响。结果：术后隐性失血量为（287.7±68.5）ml。多元线性回归分析显示糖尿病病史（β=2.405,P=0.012）,手术方式（β=3.042,P<0.001）,手术时间（β=2.043,P=0.038）,手术节段（β=1.993,P=0.043）及数量（β=0.374,P<0.001）,椎体高度丢失（β=2.785,P=0.003）及恢复比例（β=7.301,P<0.001）与隐性失血相关。结论：骨质疏松性椎体压缩性骨折椎体后凸成形术存在一定程度的隐性失血,糖尿病病史、手术方式、手术时间、手术节段及数量、椎体高度丢失及恢复比例为隐性失血的危险因素。     

股骨转子间骨折围手术期隐性失血的比较研究

 目的 探讨围手术期不同内固定方式、不同时段隐性失血量的差异。方法 回顾性分析2008 年1 月至2012 年1 月应用动力髋螺钉(DHS)、股骨近端短重建钉(IMHS)和经皮加压钢板(PCCP)治疗AO/OTA 31-A1、31-A2 型股骨转子间骨折患者的围手术期临床资料, 其中DHS 组35 例, IMHS 组55 例, PCCP组38 例。比较不同内固定方式及不同时间段(术后第1 天、第2~3 天、第4~5天)的隐性失血量。结果 三种手术方式治疗股骨转子间骨折术后平均总隐性失血量是平均显性失血量的7 倍以上。PCCP、IMHS、DHS 组组间总隐性失血量比较, 差异均有统计学意义;而IMHS 组与DHS 组比较, 差异无统计学意义。对于阶段性隐性失血量, 在DHS 组三个时间段比较, 差异无统计学意义;在IMHS 组及PCCP 组, 术后第4~5 天与第1 天、第2~3 天比较差异均有统计学意义;而术后第1 天与第2~3 天比较差异无统计学意义。对于各组三个时间段阶段性隐性失血量/总隐性失血量比例, 术后第4~5 天与术后第1天、第2~3天比较, 差异均有统计学意义, 而术后第1 天与第2~3 天比较差异无统计学意义。结论 股骨转子间骨折围手术期隐性失血量远大于术中显性失血量。PCCP 组的总隐性失血量明显少于IMHS 组和DHS 组, 而IMHS 组与DHS 组的总隐性失血量相似。隐性失血主要发生在手术后的前3 d, 故术后前3 d应密切监测患者的血红蛋白变化, 及时评估患者的失血情况。     

The appropriateness of blood transfusion following primary total hip replacement

INTRODUCTION

A significant proportion of all red cell transfusions are given to patients undergoing elective orthopaedic surgery. Concern over transfusion safety and cost, coupled with evidence showing that restrictive transfusion policies benefit patients, prompted us to audit our blood prescribing practice at Gloucestershire Hospitals NHS Foundation Trust in order to assess the appropriateness of every transfusion episode following elective primary total hip replacement.

METHODS

All patients undergoing a primary total hip replacement in our department over a six-month period were included in the study. Data were collected retrospectively using case note examination and transfusion service data. Standards were dictated by the British Orthopaedic Association guidelines on blood conservation in elective orthopaedic surgery.

RESULTS

Twenty-seven per cent of patients (39/143) were transfused. Forty-six per cent of these (18/39) were transfused inappropriately and twenty-three per cent (9/39) appropriately. Thirteen per cent (5/39) had a valid indication for transfusion but were over-transfused and in eighteen per cent (7/39) the quality of documentation did not allow an assessment to be made. Fifty-two per cent of patients who had surgical drains (29/56) were transfused. Reaudit following staff education and amendments to the local transfusion policy did not demonstrate a reduction in transfusion rates.

CONCLUSIONS

This audit showed that significant potential exists for reducing transfusion rates based on optimising prescribing practice alone. It also demonstrated that changing local practice based on audit data can be challenging.     

Investigation of perioperative hidden blood loss of unstable intertrochanteric fracture in the elderly treated with different intramedullary fixations

ObjectiveOur aim was to investigate perioperative hidden blood loss (PHBL) of unstable intertrochanteric fracture (UIF) in the elderly treated with different intramedullary fixations.Patients and methods120 consecutive elderly patients with UIF treated by intramedullary nails between January 2013 and September 2016 were enrolled in the retrospective study, including 52 patients (mean age 79.6 ± 6.3) for the Third generation Gamma Nail (TGN), 51 patients (mean age 79.3 ± 7.4) for the Proximal Femoral Nail Anti-rotation (PFNA), 17 patients (mean age 76.2 ± 5.8) for the Intertrochanteric Antegrade Nail (InterTan). The PHBL and total blood loss (TBL) were calculated based on the haematocrit change from admission to 72 h after the operation. The differences of perioperative visible blood loss (PVBL), PHBL, and TBL among TGN, PFNA, and InterTan were compared. The statistical analysis was made using One-way ANOVA for comparison among groups, and Mann-Whitney U test was conducted to a direct comparison between two procedures.ResultsThe mean TBL of all patients was 911.3 mL (range, 446.8-1697.3 mL), whereas the mean PHBL was 771.8 mL (range, 331.5–1756.5 mL), being about 84.5% of TBL. The PVBL in the TGN group was 201.4 ± 101 mL, the TBL was 871.3 ± 196.1 mL, the PHBL was 709.4 ± 181 mL. In the PFNA group, the PVBL was 147.3 ± 81.6 mL, the TBL was 892.6 ± 234.8 mL, and the PHBL was 787.7 ± 250.9 mL. The InterTan group had a PVBL of 246.5 ± 89.7 mL, the TBL was 1086.1 ± 198.1 mL where the PHBL was 910 ± 167.9 mL. The patients in the InterTan group had the largest amount of PHBL and TBL among three groups (P < 0.01), there was no difference between TGN and PFNA group (P = 0.2141).ConclusionsElderly patients with UIF treated by intramedullary fixations always have a significant amount of PHBL, which is much greater than that observed intra-operatively. Regular perioperative measurements of full blood count are necessary to avoid anaemia. InterTan nail is associated with a significantly higher PHBL than that of TGN and PFNA, which needs to be monitored carefully in usual clinical practice.     

Predictors of bone loss after hip fracture

Although accelerated bone mineral density (BMD) loss follows hip fracture, little is known about factors associated with this loss. We examined potential predictors of BMD loss in a cohort of community-dwelling women who had sustained hip fracture and who were followed for 1 year after fracture. BMD was measured at the femoral neck, intertrochanteric region, and total body, during hospitalization and 2, 6, and 12 months later. Demographic, health, lifestyle, clinical, surgical, and functional characteristics at baseline, and postfracture activity were evaluated for associations with baseline BMD and BMD 1 year later. To examine possible BMD-dependent effects, high and low baseline BMD groups were defined. None of the studied factors consistently predicted either baseline BMD or BMD at 1 year after fracture, among women with either high or low baseline BMD. Baseline BMD was the only factor that substantially and consistently predicted change, explaining 70% to 90% of variation. These results suggest that BMD will not be preserved by general rehabilitative measures and that prompt, specific intervention to minimize bone loss after hip fracture is an essential element of clinical management of the hip fracture patient.     

腰椎椎间融合术后隐性失血的研究进展

腰椎椎间融合术是目前治疗腰椎疾病最常用的术式之一,但术后隐性失血量大,占总失血量的1/3甚至1/2以上,如不注意监测与治疗,则易引起贫血、延长卧床时间,从而增加感染的机会。本文就腰椎融合术后隐性失血可能发生的机制、影响因素、隐性出血量的计算、治疗方法进行综述,使术者对进行腰椎融合术的患者隐性失血量有一个正确的认识和评估,从而减少并发症的发生,对帮助患者顺利度过围手术期有着重要意义。     

Blood transfusions and hip fracture mortality - A retrospective cohort study

BackgroundHip fractures are associated with serious morbidity and mortality. Low haemoglobin at presentation has been shown to be associated with increased mortality in hip fracture patients. This comorbid patient group commonly receives packed red cell blood transfusions during their hospital admission, the impact of which is less clear.Aims and objectivesWe aim to assess the rate, appropriateness and impact of blood transfusions on one-year mortality in hip fracture patients. We also aim to assess the impact of patients taking anticoagulant medications at presentation on the rates of blood transfusions in this patient group.MethodsA retrospective cohort study of 324 consecutive hip fracture patients. Data was collected from the national hip fracture database, electronic patient records and PACS.Results75 patients received a blood transfusion. Receiving a blood transfusion increased absolute risk of one-year mortality by 2.466 (p < 0.05). Adjusted for age, sex, comorbidities, residence prior to admission and time from presentation to surgery increased the risk of one-year mortality was 2.790 (p < 0.05).28% of patients who went on to receive a transfusion had a haemoglobin of less than 100 g/L at presentation. 94.6% of transfused patients had a pre-transfusion haemoglobin of less than 90 g/L. There was no increased risk of requiring a blood transfusion if anticoagulant medication was being taken at presentation.ConclusionReceiving a blood transfusion during an admission for hip fracture carried an increased risk of one-year mortality of almost two and a half times. With appropriate preoperative optimisation, taking an anticoagulant medication at presentation did not increase the risk of requiring a transfusion. Most blood transfusions were administered appropriately using thresholds. Just over a quarter of patients who received a transfusion had an admission haemoglobin of less than 100 g/L, showing it as a poor predictor of blood transfusion requirement during admission.     

Recovery after hip fracture

OBJECTIVES: The aim was to monitor the inhospital progress of 170 patients sustaining proximal femoral fractures. The extent of delay in discharge was recorded and what effect this prolonged hospitalisation had on nosocomial infection rates. SETTING: A regional trauma centre. DESIGN: A prospective observational study. PATIENTS AND PARTICIPANTS: All consecutive patients sustaining proximal femoral fracture over 60 years of age. INTERVENTION: The same clinician monitored each patient throughout their inhospital stay. Factors recorded included nosocomial infection acquired and when, mobility scores, loss of independence, delay in discharge amongst others. MAIN OUTCOME: Delay in discharge, incidence of nosocomial infection and mobility scores. RESULTS: Nosocomial infection occurred in 58% of patients (99 patients) when discharge was delayed beyond 8 days (after surgery). Eighty-five per cent of patients (145 patients) achieved their maximum mobility score by the 8th, and 95% (162 patients) by the 10th postoperative day. CONCLUSIONS: Patients with proximal femoral fracture derive no benefit from acute hospital admission of more than 8 days and the majority acquire nosocomial infection after this.     

Survival after hip fracture

Although it is known that overall mortality is increased after hip fracture, the influence of hip fracture risk factors on the subsequent mortality and cause of death has not been well studied. The objective of this study was to establish the survival after hip fracture in women and to assess the impact of comorbidity on mortality. We identified a complete population-based set of 2,245 incident hip fracture cases and 4,035 randomly selected population-based controls among women 50–81 years old in Sweden and followed these subjects for an average of 5 years through the Swedish National Inpatient and Cause-of-Death Registers. Information on factors related to hip fracture was obtained through linkage to hospital discharge data and through a mailed questionnaire. We studied excess mortality of hip fracture patients compared to controls using survival curves and proportional hazard regression models. During follow-up, 896 hip fracture patients (40%) and 516 (13%) controls died. The relative risk (RR) of death, adjusted for age and previous hospitalization for serious disease, was 2.3 (95% CI 2.0–2.5). Although the highest mortality risks were in the 1st 6 months post-fracture, RRs for fractures versus controls were increased for at least 6 years. Increased mortality was apparent both in those with evidence of comorbidity and those without. Hip fracture patients have a substantially increased risk of death that persists for at least 6 years post-fracture. The relative excess mortality is independent of comorbidity and known hip fracture risk factors.The authors represent the Swedish Hip Fracture Study Group, whose members include Akke Alberts, John A. Baron, Thomas Dolk, Bahman Y. Farahmand, Olof Johnell, Lena Lindén, Sverker Ljunghall, Karl Michaëlsson, Gunnar Brobert, Karl-Göran Thorngren, Mats Thorslund, Carl Zetterberg and Lena Zidén.     

PVP治疗骨质疏松性椎体压缩性骨折过程中隐性失血及其危险因素分析

目的：探讨经皮椎体成形术（percutaneous vertebroplasty,PVP）治疗过程中出现隐性失血（hidden blood loss,HBL）的影响因素。方法：对2016年3月至2017年12月接受经皮椎体成形术治疗的125例（男55例,女70例）骨质疏松性椎体压缩性骨折的（osteoporotic vertebral compression fractures,OVCFs）临床资料进行回顾性分析。术前均行腰椎正侧位、双斜位及动力位X线片,腰椎CT、MRI及双能X射线骨密度仪（DXA）检查明确诊断。其中胸椎10例,胸腰椎89例,腰椎26例。单节段87例,双节段29例,3节段9例。67例患者椎体压缩高度比例<1/3,41例在1/3~2/3,17例>2/3。术前与术后3 d行血常规检查,分析HBL情况并探索其危险因素。结果：125例患者隐性失血为（317±156）ml。经过多重线性回归分析发现糖尿病病史（P=0.011）、手术节段（P=0.036）、节段数量（P<0.001）、椎体高度丢失率（P=0.002）、椎体高度恢复率（P<0.001）和骨水泥渗漏率（P=0.003）与隐性失血呈正相关。同时,发现椎体高度丢失率高者失血量较椎体高度丢失率低者多,椎体高度恢复良好者失血量较椎体高度恢复不良者多,水泥泄漏也是增加隐性失血的重要因素。然而,骨密度（P=0.814）,高血压病史（P=0.055）与隐性失血无显著相关性。结论：OVCFs患者经过PVP治疗后隐性失血量较大,需要引起关注;同时糖尿病病史、手术节段、节段数量、骨水泥渗漏率、椎体高度丢失率和椎体高度恢复率是增加隐性失血量的危险因素。     

The effect of tranexamic acid on hidden bleeding in older intertrochanteric fracture patients treated with PFNA

ObjectiveTo investigate the effect of tranexamic acid (TXA) on hidden bleeding in older intertrochanteric fracture patients treated with intramedullary nails.MethodBetween January 2016 and January 2017, 100 cases of intertrochanteric fractures eligible for the study were treated with proximal femoral nail antirotation (PFNA) in our hospital. All patients were divided into two groups of 50 patients each: the TXA group and a blank control group. In the TXA group, all patients received TXA at a dose of 10 mg/kg⁻¹ intravenously, 10 min preoperatively and 5 h postoperatively. The control group did not receive TXA. We recorded the volume of intraoperative blood loss and postoperative drainage, and the need for postoperative blood transfusion and transfusion volume for all patients. Blood routine examination was performed on the day of surgery and 2 days postoperatively. We calculated the total blood loss and hidden blood loss in the two groups separately according to the Gross equation. All patients underwent deep vein ultrasound of the lower limbs preoperatively and 1 week postoperatively to detect thrombosis.ResultsCompared with controls, patients in the TXA group had lower: overt bleeding (50.59 ml; p = .012), total blood loss (181.58 ml; p = .005), hidden blood loss (130.64 ml; p = .037), volume of blood transfusion (110.0 ml; p = .019), and 20% lower transfusion rate compared with the control group. Patients receiving short-nail fixation had significantly lower hidden blood loss compared with patients receiving long-nail fixation (p < .05). However, we found no statistically significant difference in the incidence of deep vein thrombosis in the lower limbs between the two groups (p = .938).ConclusionTXA significantly reduced hidden blood loss in older intertrochanteric fracture patients treated with intramedullary nails without an increased risk of thrombosis in lower limb deep veins.     

老年股骨颈骨折与股骨转子间骨折围手术期失血量的临床对比研究

目的通过老年股骨颈骨折与股骨转子间骨折患者围手术期失血量的比较,为临床老年髋部骨折围手术期血液管理提供科学依据。 方法回顾性收集2018年7月至2020年4月间中国科学技术大学附属第一医院骨科收治的因低能量损伤导致的老年髋部骨折患者,共纳入69例。按照骨折类型分为股骨颈骨折组和股骨转子间骨折组,比较两组患者年龄、性别、骨折解剖部位以及术前合并症等基本信息,比较两组患者围手术期隐性失血量、显性失血量和总失血量。 结果股骨颈骨折组患者的平均年龄为（78±8）岁（男性10例,女性35例）,股骨转子间骨折患者的平均年龄为（75±10）岁（男性12例,女性12例）。两组患者术前隐性失血量[股骨颈骨折组：（238.33±97.82）ml ;股骨转子间骨折组：（344.80±130.01）ml,P<0.05]、围手术期隐性失血量[股骨颈骨折组：（314.46±130.30）ml;股骨转子间骨折组：（459.73±173.34）ml,P<0.05]、显性失血量[股骨颈骨折组：（77.78±27.29）ml;股骨转子间骨折组：（160.42±51.03）ml,P<0.05]和总失血量[股骨颈骨折组：（392.24±133.62）ml;股骨转子间骨折组：（620.15±171.11）ml,P<0.05]差异均具有统计学意义,股骨转子间骨折组均高于股骨颈骨折患者组。股骨转子间骨折组（半髋关节置换和PFNA内固定术）较股骨颈骨折组（全髋关节置换和半髋关节置换术）均有较多的显性失血量、术后隐性失血量、围手术期隐性失血量和总失血量（均P<0.05）。但两组内不同手术方式比较,差异无统计学意义。 结论老年股骨转子间骨折患者较股骨颈骨折患者有更多的围手术期隐性失血量、显性失血量和总失血量,在临床诊治中,尤其需要更加重视老年股骨转子间骨折患者的围手术期血液管理。     

全髋关节及全膝关节置换术后隐性失血的临床影响

目的探讨人工全髋关节置换术（THA）和人工全膝关节置换术（TKA）术后隐性失血的相关机制及对临床的影响.方法2001年3月至2005年5月,行THA 61例,其中男22例,女39例;年龄61～79岁,平均68岁.同期行TKA73例,其中男23例,女50例;年龄65～77岁,平均73岁.所有病例均为初次行单侧关节置换的患者,24h补液总量不超过2000ml.通过Gross方程,根据身高、体重和手术前后的红细胞压积（Hct）计算所有患者的总失血量,减去显性失血部分后即得隐性失血.结果THA组的总失血量平均为1520ml,隐性失血量为482 ml（32%）;TKA组的总失血量平均为1508 ml,隐性失血量为776 ml（52%）,两组的隐性失血量比较差异有统计学意义（P＜0.01）.TKA组中使用引流血回输患者的总失血量平均为1625 ml,隐性失血量为774ml（48%）;未使用引流血回输患者的总失血量平均为1345 ml,隐性失血量为783 ml（58%）,两组的隐性失血量相比差异无统计学意义;THA与TKA肥胖组和非肥胖组的隐性失血量相比差异均无统计学意义.结论TKA隐性失血远较THA高,且使用引流血回输仍不能完全满足机体恢复体循环的需要,应特别注意及时补充血容量.对隐性失血的正确认识有助于提高临床评估能力,帮助关节置换患者度过围手术期.     

Randomised trial of blood transfusion versus a restrictive transfusion policy after hip fracture surgery

Background

Debate exists as to what should be the transfusion threshold for patients with anaemia after hip fracture surgery.

Methods

A total of 200 patients aged 60 years and above with a haemoglobin level of between 8.0 and 9.5 g dl⁻¹ after hip fracture surgery were randomised to receive a transfusion to raise the haemoglobin to at least 10.0 g dl⁻¹ or not to have a transfusion unless definite symptoms of anaemia became apparent. Patients were followed up for 1 year.

Results

There was no statistically significant difference in the outcomes of mortality, hospital stay, regain of mobility or complications between the two groups.

Conclusions

This study confirms other recent research studies which found that reducing the transfusion threshold to 8.0 g dl⁻¹ appears to be a safe practice for this group of patients.     

人工髋关节置换术后股骨假体周围骨折的治疗体会

目的总结人工髋关节置换术后股骨假体周围骨折治疗的经验和体会。方法 2002年1月至2008年1月治疗人工髋关节置换术后股骨假体周围骨折的患者21例,19例患者采用手术治疗,按照Vancouver分型标准进行分类,选择不同的手术方式进行治疗,包括：锁定加压接骨板固定,钢缆固定,同时结合异体骨板固定,关节翻修术等。结果术后随访2～6年,平均5年,所有患者骨折均获得骨性愈合,骨折平均愈合时间为6个月（4～9个月）,在最后随访时均有比较好的髋关节功能,Harris评分平均86分（78～92分）。结论按照股骨假体周围骨折的类型,选用合适的治疗方法,全面术前计划,可以取得比较满意的治疗效果。     

髋部骨密度与髋部骨折风险的相关性分析

目的探讨不同年龄，不同性别髋部骨折患者的髋部骨密度值与髋部骨折风险的相关性。方法抽取髋部骨折98例，50岁以上85例，其中男性33例，女性52例，股骨颈骨折占44例，粗隆间骨折41例。按照骨质疏松诊断标准共分为2组：T〈-2．0（骨折组），T〉-2．0（骨折组），按性别、年龄、身高、体重与骨折组按1：1配对，以T〈-2．0（非骨折组），T〉-2．0（非骨折组）分别作为对照组。结果年龄50岁以上非暴力髋部骨折患者，T〈-2．0（骨折组）和T〈-2．0（非骨折组）做对照研究，骨折组的骨密度值要低于非骨折组，对骨折风险预测有显著性差异。男性和女性之间做对照研究，有明显的统计学意义。年龄50岁以上非暴力髋部骨折患者，T〉-2．0（骨折组）和T〉-2．0（非骨折组）做对照研究，骨折组的骨密度值要低于非骨折组，对骨折风险预测有显著性差异。男性和女性之间做对照研究，有明显的统计学意义。年龄50岁以下的患者为13例，其中男性11例，女性2例，均为年轻的受暴力致伤的患者，骨密度值检测对骨折风险评估没有显著性差异。结论（1）对于非暴力髋部骨折，低BMD与髋部骨折有明显的相关性，且呈指数级相关。（2）骨折危险性的评估没有明确的BMD阈值。（3）骨折患者与非骨折患者BMD有相互重叠。（4）女性自50岁左右髋部骨折的发生率要高于男性。（5）小于50岁的较年轻患者BMD和骨折危险性的相关性不明确。     

氨甲环酸的不同给药方式对减少初次全髋关节置换术后隐性出血的病例对照研究

目的 :比较氨甲环酸不同给药方式对减少全髋关节置换术后隐性失血的临床疗效。方法 :自2010年2月至2015年7月收治股骨头坏死患者68例,均接受初次人工全髋关节置换术,术前按照随机分组原则分为静脉应用组(A组)和局部应用组(B组)。A组男19例,女15例,平均年龄(62.0±6.4)岁,血红蛋白(121.33±8.15)g/L,红细胞比容(0.470±0.039)L/L;B组男18例,女16例,平均年龄(64.0±7.5)岁,血红蛋白(125.28±9.37)g/L,红细胞比容(0.490±0.041)L/L。手术切口采用统一的后外侧入路并按照常规手术方式手术,假体选择生物型假体。通过不同途径给予氨甲环酸控制术中及术后出血。静脉应用组:于术前10 min给予10 mg/kg氨甲环酸溶于150 ml生理盐水中静脉滴注。局部应用组(B组):将3 g氨甲环酸溶于120 ml的生理盐水中并分成3等份,用2块纱布浸入40 ml氨甲环酸溶液,分别填塞于在髋臼锉刨削好髋臼壁和股骨侧扩髓之后的髓腔内,持续5 min。剩余40 ml在切口关闭之前注射入关节腔内,放置引流管并将引流管夹闭3 h后开放。术后72 h检测并比较两组患者血红蛋白、红细胞比容等血液学指标,计算总失血量、显性失血量和隐性失血量、输血例数,比较两组患者的术后凝血功能。结果:术后A组手术前后血红蛋白差值(32.34±7.42)g/L,总失血量(833.6±81.4)ml,隐性失血量(276.3±57.9)ml,红细胞比容(10.1±1.4)L/L;B组手术前后血红蛋白差值(28.2±6.1)g/L,总失血量(792.5±61.8)ml,隐性失血量(297.5±50.3)ml,红细胞比容(9.2±1.2)L/L,两组比较差异无统计学意义。术后A组PT(12.78±2.03)s,APTT(34.27±3.91)s,INR 32.34±7.42;B组PT(13.17±2.19)s,APTT(32.36±3.18)s,INR 28.24±6.14,两组差异无统计学意义。超声检查证实两组患者均无下肢深静脉血栓形成。A组术中出血明显少于B组。结论:静脉应用氨甲环酸与局部应用氨甲环酸能同样有效地减少初次全髋关节置换术后总失血量和隐性失血量,减少术后输血率,并没有增加下肢静脉血栓的风险。