全髋置换并发严重血管损伤

为了探讨全髋关节置换术中发生严重血管损伤的机制及其诊治策略,作者对１９７８年－１９９３年施行全髋置换术的７２１例患者进行了调查,其中发生严重血管损伤者３例,发生率为０．４２％。其中１例为摘除中心型脱位的髋臼假体时,骨水泥团块的锐缘割破髂外静脉;１例为髋臼前半区内安放螺丝钉时气钻打洞刺伤外静脉;另１例为切除关节囊瘢痕组织时切破股动脉。作者对并发严重血管损伤的肌制及临床处理进行了分析和讨论。作者认为,     

Irreducible traumatic posterior dislocations of the hip

Posterior dislocation is the most common form of traumatic dislocation of the hip. It is usually the result of severe force applied to the flexed knee of a sitting occupant of a car involved in a high-speed accident. Closed reduction is usually successful; however, failed or irreducible dislocations occur in 3–16% of patients and may be complete or incomplete. We discuss three patients in whom closed reduction was unsuccessful, each with a different cause: buttonhole tear of the posterior capsule, interposition of the piriformis muscle, and dislodgement of an osteocartilaginous fragment into the hip joint.     

Transient osteoporosis of the Hip: a densitometric study

Summary Three new cases of transient osteoporosis of the hip are reported. Diagnosis was achieved by plain radiographs, bone scintiscan, magnetic resonance imaging and X-ray absorptiometry of proximal femurs. The densitometry showed at the Ward's triangle a mean reduction of bone mineral density in the affected side of 36%. All subjects were treated with i.v. clodronate for ten consecutive days with a complete recovery of femoral density within 4 months. X-ray absorptiometry allows a quantification of the demineralization process and can be useful in the long term evaluation of this entity.     

Risk infection factors in the total hip replacement

Infection is a complication that occurs in a considerable percentage of hip prostheses replacements, being in many cases necessary to retire them, which generates important health and economical problems. Objectives: To know the distribution of infection and its risk factors in total hip replacement. Material and methods: A four year prospective study was developed in the rehabilitation and orthopedic center of La Paz Hospital. A total of 873 patients were included. Patients were controlled by means of active epidemiological surveillance until the day of discharge, listing up their characteristics at admission and risk factors during their stay. A multivariant study was carried out to determine risk factors. Results: Patients, average age was 63 years, 3.4% of them suffered from diabetes and there were no inmunocompromised patients. The percentage of wound infection during the four years was 6%, being reduced to 1.2% in the last year. The risk factors found in the multivariant study were: incorrect prophylaxis (OR: 3.85), wrong scaring (OR: 14.06), suffering more than one intervention (OR: 7.31) and a hospitalization period longer than 30 days (OR: 2.84). Conclusion: We think that special attention in the care of the surgical wound, as well as the correct use of prophylaxis, can significantly collaborate to the reduction of infection.     

Introduction

The number of femoral fractures after hip arthroplasty has increased proportionally to the number of hip arthroplasties. Eleven university-orthopaedic centers in eastern France co-operated to review 250 femoral fractures in relation to hip prothesis. This is the largest published review. The aims of this retrospective study were:

The epidemiology of fragility fractures: Is there a role for bone quality?

Fragility fractures, particularly those of the hip, vertebrae, and distal forearm, constitute a major public health problem. The two ultimate determinants of fracture are bone strength and propensity to trauma. Bone strength depends not only upon bone mass but also upon a variety of qualitative aspects of bone structure. These include its architecture, the amount of fatigue damage it has sustained, and changes in its bulk material properties, indices that are collectively subsumed into the term bone quality Fragility fractures show differences in their patterns of incidence by age, sex, ethnic group, geographic area, and season. Many of these differences are currently unexplained, and disorders of bone quality might contribute to them. There are two fracture sites at which evidence implicates bone quality more directly—the spine and proximal femur. Many vertebral compression fractures follow minimal trauma, and controlled studies suggest that vertebral microarchitecture contributes to fracture risk independently of vertebral bone mass. At the hip, observational studies have pointed to a role for disordered trabecular architecture, accumulation of microfractures (fatigue damage), and the accumulation of osteoid. The extent to which these phenomena act independently of bone mass, however, remains uncertain.Presented at the NIA Workshop on Aging and Bone Quality, September 3–4, 1992, Bethesda, Maryland     

Blood loss in the minimally invasive posterior approach to total hip arthroplasty: a comparative study

AIMS: Our primary aim was to evaluate whether there is really less bleeding in patients for whom the minimally invasive posterior approach is used in comparison with the direct lateral approach for primary total hip arthroplasty. Our secondary aim was to evaluate the clinical functional results after six months as well as the postoperative radiographic result. METHODS: In a comparative non-random prospective study, 76 adult patients underwent elective total hip arthroplasty using one of two approaches. The minimally invasive posterior approach (34 cases; mini-incision group) was compared with the standard direct lateral approach (42 cases; control group). RESULTS: Lower total estimated bleeding (means of 1083.5 ml versus 1682.3 ml; p < 0.001) and lower intraoperative bleeding (means of 745.6 ml versus 1282.8 ml; p < 0.001) were found in the mini-incision group. There was, however, no difference in the volume of blood drained after the operation (means of 340 ml and 399 ml; p = 0.77). There was also a difference between the two groups regarding the need for allogenic transfusion (8.8% in the mini-incision group versus 28.6%, p = 0.02). We observed a better clinical result in the mini-incision group (p = 0.002) despite the lack of difference between the two groups in relation to the radiographic result. DISCUSSION: Our results draw attention to the possibility that other authors may have underestimated blood losses when using minimally invasive approaches. CONCLUSION: The minimally invasive approach gave rise to a positive final impression with regard to lower blood loss.     

Anterior shoulder instability: a review of pathoanatomy, diagnosis and treatment

The glenohumeral joint is inherently predisposed to instability by its bony architecture. The incidence of traumatic shoulder instability is 1.7% in the general population. Associated injuries to the capsulolabral structures of the glenohumeral joint have been described and may play a role in predicting recurrent instability. Advanced imaging, computed tomography or MRI may be necessary to adequately evaluate for associated glenohumeral pathology. Treatment algorithms have traditionally included a period of non-operative management in all patients, however young athletic patients may often benefit from early operative treatment. Various open and arthroscopic surgical options exist to address anterior glenohumeral instability. Bony injuries including bony Bankart lesions and Hills Sachs lesion have been implicated in failed surgical management using techniques that address only the soft tissues. An individualized treatment approach, based upon the patient’s injury pattern and expectations, will likely lead to the most successful outcome.     

Management of long-standing mandibular dislocation

Long-standing dislocation of the temporomandibular joint (TMJ) is rare. The management of this disorder is still controversial. This paper presents the authors’ experience of managing long-standing dislocation of the TMJ, and their attempt to develop guidelines for the management of this problem. They also show magnetic resonance images of two patients with long-standing dislocation of the TMJ.