半髋关节置换与锁定钢板治疗股骨粗隆间骨折的疗效比较

目的分析半髋关节置换与锁定钢板治疗股骨粗隆间骨折的疗效差异。方法选取股骨粗隆间骨折患者50例,随机采用半髋关节置换与锁定钢板,对两组患者的手术时间,术中出血量,术后并发症发生率,术后卧床时间及术后1年髋关节功能进行比较。结果所有患者随访6~30个月,平均12个月。半髋关节置换组手术时间和术后卧床时间短,术中出血量及术后并发症少,与锁定钢板组比较差异有统计学意义(P<0.05);术后1年Harris评分,两组之间无统计学意义(P>0.05)。结论半髋关节置换较锁定钢板具有操作简单、创伤小、卧床时间短、并发症少的优点。     

Calcar Preservation Arthroplasty for Unstable Intertrochanteric Femoral Fractures in Elderly

Background

The treatment of unstable intertrochanteric fractures in elderly is still controversial. The purpose of this study is to present treatment strategies for unstable intertrochanteric fractures with hemiarthroplasty using standard uncemented collared femoral stems and at the same time preserving the fractured calcar fragment.

Methods

Fifty-four patients aged 75 years or older with unstable intertrochanteric fractures were included in this prospective cohort study. All patients were treated with calcar preserving hemiarthroplasty using cementless collored femoral stems. Fractured calcar fragment was stabilized either by compaction between the implant and femur or fixed with cable grip system. Follow-up evaluations were performed at least 24 months and later. Palmer and Parker mobility score and visual analogue scale (VAS) pain score were assessed. We also analyzed radiographs of the operated hip at each follow-up visit.

Results

The patients were 15 males and 39 females with a mean age of 81.3 years (range, 75 to 93 years). The average operative time was 86.6 minutes. The mean transfused blood units were 1.2 units. The average duration of hospital stay was 5.3 days. The preoperative mean mobility score was 6.20. This score was found to be 4.96 on postoperative third day and 5.90 at 24 months postoperatively. The results of the statistical analysis revealed significant increase in the mobility scores at each follow-up after three days. Radiological interpretation revealed no loosening in the cable-grip systems, and no significant subsidence (> 5 mm) of prosthesis was observed.

Conclusions

Calcar preservation arthroplasty is a good option for elderly patients with severe osteoporosis, frail constitution and the patients who are at higher risk for second operation due to unstable intertrochanteric fractures.     

改良髋关节外侧小切口人工股骨头置换治疗股骨头坏死的效果观察

目的探讨改良髋关节外侧小切口人工股骨头置换术治疗股骨头坏死的临床效果。方法选取该院收治的股骨头坏死患者,依据患者手术方式的不同分为改良组和传统组,传统组患者采用传统人工股骨头置换手术。改良组患者采用改良髋关节外侧小切口人工股骨头置换术。比较分析两组患者手术时间、术中失血量以及术后6个月髋关节Harris功能评分等临床数据。结果与传统人工股骨头置换术患者相比,改良髋关节外侧小切口人工股骨头置换治疗术患者手术时间明显缩短,术中失血量明显减少,术后6个月髋关节Harris功能评分为优者明显增加,差者明显降低,差异有统计学意义（P〈0.05）。结论改良髋关节外侧小切口人工股骨头置换能够有效治疗股骨头坏死,并促进患者术后髋关节功能的恢复。     

Proximal femoral fracture in patients with rheumatoid arthritis

Abstract

Hip fracture occurrence was examined cross-sectionally in Japanese patients with rheumatoid arthritis (RA). Between January 2005 and June 2006 we studied RA outpatients with a past history of hip fractures. Patients included 1 man and 25 women. As 3 women had bilateral hip fractures, the total number was 29. Age at the time of fracture was 72.1 ± 4.5 years. Of the 29 fractures, 22 were cervical and 7 were trochanteric. Four fractures were spontaneous while the others occurred in falls. 24 fractures were associated with oral steroid administration. All 5 fractures unassociated with prednisolone were cervical. Of the 26 patients, 8 were taking bisphosphonate when fracture occurred. Cervical fracture was treated with total hip arthroplasty in 1 patient whose hip showed RA changes. In others whose hip joint lacked RA change, procedures included osteosynthesis in 2 patients with good function over 6 years; and hemiarthroplasty with a bipolar system in 19 displaced fractures, with good function over 4.1 years. Osteosynthesis was performed for all 7 trochanteric fractures. Trabeculae were thin, and fewer transverse trabeculae could be found in specimens from cervical fracture. Hip fracture in RA patients occurred 10 years earlier than in the general population, and many fractures were cervical.     

Total shoulder arthroplasty versus hemiarthroplasty in patients with shoulder osteoarthritis: A meta-analysis of randomized controlled trials

Objectives

Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are treatment choices for end-stage shoulder osteoarthritis. The decision of whether to use TSA or HA is controversial. The objective of this study was to compare the effects of TSA and HA for shoulder osteoarthritis.

Methods

We conducted a search for clinical studies that had been published in any language in December 2012 or before. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and several other databases. Randomized and quasi-randomized controlled clinical studies that evaluated different methods were included. At least two review authors independently performed the study selection, data collection, and data extraction. The software Revman 5.1 was used for the statistical analysis.

Results

This study included 4 clinical trials. Two of the trials were published clinical trials, and the other 2 clinical trials were presented as unpublished abstracts. A total of 146 patients with 153 shoulders were included in the trials. Compared with HA, TSA presents with a higher UCLA shoulder scale (MD 3.10, 95% CI 1.13–5.08) and a higher ASES (MD 10.17, 95% CI 1.40–18.87). There was no significant difference between TSA and HA for revision (RR 0.35, 95% CI 0.10–1.19), WOOS (MD 9.10, 95% CI −2.72 to 20.92), and incidence of instability (RR 0.88, 95% CI 0.19–3.98). HA had a lower operation time (MD 39.00, 95% CI 17.05–60.95).

Conclusion

The available evidence suggests that TSA is more effective than HA for patients with shoulder arthritis.     

人工股骨头置换与股骨近端髓内钉治疗高龄患者股骨粗隆间骨折的对比研究

目的对比分析人工股骨头置换和股骨近端髓内钉（PFN）内固定治疗高龄不稳定型股骨粗隆间骨折的临床疗效,评价两种手术治疗方案的优劣。方法选取2002-5-2008—6我院收治的高龄不稳定型股骨粗隆间骨折患者78例,其中行人工股骨头置换42例,PEN内固定36例。对两组患者的术前合并症、手术时间、术中失血量、输血例数、输血量、负重时间、住院时间、术后并发症等临床指标以及末次随访时患侧髋关节功能Harris评分进行统计学分析。结果随访6～48个月,平均26．5个月。两组患者术前合并症、骨折类型及骨质疏松程度即Singh指数均无明显统计学差异（P〉0．05）,股骨头置换组在手术时间、住院时间、失血量及输血例数上明显多于PFN组（P〈0．05）。两者在负重时间上差异无统计学意义。股骨头置换组术后平均Harris评分为（85．2±12．8）分,与PFN组比较差异无统计学意义。结论PEN内固定与人工股骨头置换术治疗高龄不稳定股骨粗隆间骨折在功能恢复上基本相同,但前者较人工股骨头置换术具有手术及住院时间短、失血量少等优点。     

髋关节成形术治疗老年股骨颈骨折

目的:介绍一种老年人工股骨头置换术的改进方法。方法:2005年3月～2007年3月,采用Gibson人路,保留髋关节囊和旋后肌群,对26例新鲜的老年股骨颈骨折行人工股骨头置换术。结果:26例患者手术时间为45～65分钟,平均53分钟。术中最多出血量为230ml,平均出血量为120ml。所有患者经11个月～24个月随访,平均19个月,术后均未发生远近期髋关节脱位、切口感染及假体松动。术后6、12个月随访时采用髋关节功能评分,分别为92.7分和95.1分。测量双下肢长度患肢比健肢平均长0.4cm。结论:后外侧切口保留关节囊和旋后肌群的人工股骨头置换术,保留了髋关节的外旋力量和关节囊后外侧软组织,重建了髋关节软组织平衡,增加术后髋关节的稳定性,能够更好地恢复髋关节的功能。     

Return to work following shoulder arthroplasty: A systematic review

BACKGROUNDMany patients prioritize the ability to return to work (RTW) after shoulder replacement surgeries such as total shoulder arthroplasty (TSA), reverse TSA (rTSA), and shoulder hemiarthroplasty (HA). Due to satisfactory clinical and functional long-term outcomes, the number of shoulder replacements performed will continue to rise into this next decade. With younger individuals who compose a significant amount of the workforce receiving shoulder replacements, patients will begin to place a higher priority on their ability to RTW following shoulder arthroplasty.AIMTo summarize RTW outcomes following TSA, rTSA, and HA, and analyze the effects of workers’ compensation status on RTW rates and ability.METHODSThis systematic review and analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search regarding RTW following shoulder arthroplasty was performed using four databases (PubMed, Scopus, Embase, and Cochrane Library), and the Reference Citation Analysis (https://www.referencecitationanalysis.com/). All studies in English relevant to shoulder arthroplasty and RTW through January 2021 that had a level of evidence I to IV were included. Nonclinical studies, literature reviews, case reports, and those not reporting on RTW after shoulder arthroplasty were excluded.RESULTSThe majority of patients undergoing TSA, rTSA, or HA were able to RTW between one to four months, depending on work demand stratification. While sedentary or light demand jobs generally have higher rates of RTW, moderate or heavy demand jobs tend to have poorer rates of return. The rates of RTW following TSA (71%-93%) were consistently higher than those reported for HA (69%-82%) and rTSA (56%-65%). Furthermore, workers’ compensation status negatively influenced clinical outcomes following shoulder arthroplasty. Through a pooled means analysis, we proposed guidelines for the average time to RTW after TSA, rTSA, and HA. For TSA, rTSA, and HA, the average time to RTW regardless of work demand stratification was 1.93 ± 3.74 mo, 2.3 ± 2.4 mo, and 2.29 ± 3.66 mo, respectively.CONCLUSIONThe majority of patients are able to RTW following shoulder arthroplasty. Understanding outcomes for rates of RTW following shoulder arthroplasty would assist in managing expectations in clinical practice.     

Digital templating in hip hemiarthroplasty: Is it possible to accurately predict femoral head size from magnification alone?

BackgroundTemplating is an integral part of pre-operative planning in elective hip arthroplasty to achieve favourable long-term outcomes, but its applications in trauma surgery remain limited. When templating from radiographs without a calibration marker, there is always an element of magnification which must be accounted for. Our aim was to establish our institute-specific magnification and to determine whether using this to predict femoral head size in hemiarthroplasty was more accurate than using set magnifications previously reported in the literature.Materials & methodsFifty consecutive patients who underwent hip hemiarthroplasty were retrospectively identified, their pre-operative radiographs reviewed and femoral head measured with templating software. Intra- and inter-observer reliability analyses were performed. Using this value, and two set values of 15% and 21% magnification, we attempted to predict femoral head sizes of our original cohort. The results were compared using paired t-test to ascertain if there was any significant difference in accuracy.ResultsWe established our institute-specific magnification as 17%. Inter- and intra-observer reliability were excellent. However, using this magnification we were only able to correctly predict to within ± one femoral head size in 49% of patients. There was no significant difference in accuracy comparing our institute-specific magnification with other magnifications from the literature.ConclusionWe would not recommend using magnification factor in digital templating software as this could potentially lead to errors in predicting final femoral head size in hip hemiarthroplasty and adversely affect patient outcomes.     

Trends in Medicare physician reimbursement and utilization for proximal humerus fixation and shoulder arthroplasty

BackgroundFixation and arthroplasty remain the mainstays of surgical treatment of degenerative and traumatic shoulder pathology. They also constitute an appreciable sum of Medicare expenditure. With continued concern for declines in Medicare reimbursement across orthopedic surgery, it is important to understand how trends in reimbursement correlate with relative procedure volumes. Our aims were to describe temporal changes in procedure volumes, physician payment, and patient charges for proximal humerus open reduction internal fixation (ORIF) and shoulder arthroplasty.MethodsUsing Medicare's Physician Fee Schedules from 2012 to 2017, we examined procedure volumes, number of unique surgeons performing, actual submitted patient charges, and surgeon payments from 2012 to 2017 for six shoulder procedures: proximal humerus ORIF (CPT-23615), traumatic hemiarthroplasty (HEMI) (CPT-23616), degenerative HEMI (CPT-23470), primary total shoulder arthroplasty (TSA) (CPT-23472), partial TSA revision (humeral or glenoid component, CPT-23473), and total TSA revision (CPT-23474). The reimbursement ratio was calculated by dividing surgeon payment by patient charges. Growth rates of charges and payment were adjusted for inflation using annual consumer price index inflation rates over the same time period.ResultsThe total number of traumatic and degenerative HEMI cases fell over ?60%. Similarly, the number of unique surgeons performing traumatic and degenerative HEMI fell over ?53%. In contrast, the number of TSA procedures rose by +70%, whereas partial and total revision TSA rose by +62% and +88%, respectively. The number of unique surgeons rose +28% and over +73% for primary and revision TSA, respectively. There was a large gap (between 3.4 and 4.4 times) between submitted charges and surgeon payment for all years analyzed. After adjusting for inflation, Medicare payment to surgeons decreased for all types of surgery (?6% to ?9%) other than ORIF, which increased +10%. Submitted patient charges during this period increased +14% and +9.7% for ORIF and revision TSA (total), respectively, but decreased by ?6% for traumatic HEMI. The reimbursement ratio was ≤29% for all procedures analyzed across all years and fell the most for revision TSA (partial and total).ConclusionFrom 2012 to 2017, there was a sharp decline in the use of shoulder HEMI with a correspondingly high increase in TSA. After accounting for inflation, HEMI and TSA showed appreciable declines in surgeon payment over time, whereas ORIF was the only surgery with increased surgeon payment. Revision TSA saw the largest declines in the reimbursement rate. Physicians and health care policy makers must be aware of these trends to ensure both a sustainable payment infrastructure for surgeons as well as to maintain access to care for these procedures.Level of evidenceLevel III; Economic Study