人工髋关节置换术治疗内固定失败的髋部骨折

目的探讨挽救性人工髋关节置换术的疗效。方法1995年1月至2007年12月，对11例髋部骨折内固定治疗失败的患者（股骨颈骨折7例，股骨粗隆问骨折4例）进行回顾性研究，分析其内固定治疗失败的原因，总结这11例患者行人工髋关节置换术的疗效。结果髋部骨折内固定治疗失败的主要原因是复位不良、内固定技术错误。10例患者获平均12个月（2～27个月）随访。无感染、脱位、假体松动下沉及假体周围骨折等并发症发生。10例患者髋关节功能均有改善，Harris评分由术前平均34.5分提高到术后84.2分。结论骨折复位不良、错误的内固定技术是髋部骨折治疗失败的重要原因。进行挽救性的人工髋关节置换手术对恢复患者髋关节功能临床疗效满意。     

股骨颈骨折内固定术失败原因分析及其治疗对策

目的探讨空心螺钉及股骨近端解剖板内固定治疗股骨颈骨折失败的原因,评价改行全髋关节置换术后的疗效。方法对23例股骨颈骨折内固定失败后行全髋关节置换术,根据术前、术后X线片及髋关节功能恢复情况,评价治疗效果。结果术后随访6~13个月,平均9个月,髋关节功能根据Harris评分标准:优20例,良3例。结论全髋关节置换术能有效挽救股骨颈骨折内固定失败后髋关节功能,解除疼痛,恢复下肢功能。     

关节置换治疗股骨粗隆间骨折内固定失败的疗效观察

目的观察人工髋关节置换治疗股骨粗隆间骨折内固定失败患者的临床疗效。方法对2007年6月至2013年6月收治的21例股骨粗隆间骨折内固定失败的患者采用人工髋关节置换,并随访其疗效。本组21例21髋,其中20例采用全髋关节置换,1例采用人工双动股骨头置换。年龄40~79岁,平均62.8岁。无一例术中发生不良反应,术后均在2~3 d下床活动,无肺炎、褥疮等并发症发生。结果随访时间5~48个月,平均15.6个月。本组病例均伤口愈合良好,未发生假体下沉、松动现象,部分患者假体长度未超过远端螺钉孔,但无应力骨折发生。术后早期脱位1例,复位并行前方松解后未再次脱位。术后行走功能恢复正常(Harris评分平均术前43.2分,术后84.5分)。结论人工关节置换治疗股骨粗隆间骨折内固定失败患者,可早期下地功能锻炼,减少卧床时间及并发症的发生,有利于早期功能恢复,远期疗效需要进一步观察。     

股骨近端重建结合生物长柄人工关节治疗老年股骨粗隆间骨折内固定失败

目的探讨股骨近端重建结合生物长柄人工髋关节置换的手术要点及临床疗效。方法自2011-01—2015-06采用股骨近端重建结合生物长柄人工髋关节置换治疗股骨粗隆间骨折内固定失败6例。结果所有患者手术时间平均156(90~225)min,术中出血量平均883(400~1700)ml,住院期间均无伤口感染、关节脱位、坠积性肺炎、褥疮、下肢深静脉栓塞、神经损伤等并发症发生。6例均获得平均17(4~51)个月随访,均无明显髋部疼痛,随访期间未发生假体周围感染、人工关节松动、假体周围骨折等并发症。髋关节功能Harris评分:术前平均21(8~46)分,术后平均87.42(85.15~90.75)分。放射学评估:见6例假体在位,无假体松动、下沉存在。结论股骨近端重建结合生物长柄人工髋关节置换术是治疗股骨粗隆间骨折内固定失败的有效术式,股骨近端重建是恢复髋关节良好功能的重要因素。     

锁定接骨板治疗外侧壁粉碎的股骨转子间骨折

目的完整的外侧壁对股骨转子间骨折内固定术后的稳定性有着重要意义。本文旨在探讨采用锁定接骨板治疗外侧壁粉碎的股骨转子间骨折的疗效。方法回顾2009年12月至2013年6月以来南京大学医学院附属鼓楼医院收治的股骨转子间骨折患者,术前CT证实为外侧壁粉碎的AO/ASIF A3型骨折、接受锁定接骨板内固定手术治疗且随访超过18个月者共24例,其中男15例,女9例;年龄48~79岁(平均63.5岁)。术中在牵引床辅助下行骨折复位内固定手术治疗,14例采用对侧股骨远端外侧锁定加压接骨板倒置固定,10例采用股骨近端外侧锁定加压接骨板固定。术后定期随访并行髋关节功能评分。结果 24例患者中,手术骨折复位优良率为91.7%。术后3个月时骨折全部愈合。平均随访时间26.4个月(18~44个月),末次随访时髋关节功能评分(harris hip score,HHS)62~86分,平均71.4分。无复位丢失、内固定失败等。结论采用锁定接骨板治疗外侧壁粉碎的股骨转子间骨折,可获得满意的临床疗效。     

髋关节置换术治疗老年髋部骨折内固定失败的中期疗效观察

目的评价髋关节置换术治疗老年髋部骨折内固定失败的中期临床效果。方法回顾性分析2010年1月至2016年8月,在西南医科大学附属医院接受髋关节置换术治疗的老年髋部骨折内固定失败的41例患者资料,其中男19例,女22例;髋部骨折类型:股骨颈骨折24例,股骨转子间骨折17例。受伤原因:摔伤24例,交通车祸伤12例,坠落伤5例。内固定方式:空心螺钉内固定19例,股骨近端防旋髓内钉内固定18例,股骨近端钢板内固定4例。初次内固定术时年龄51~85岁,平均68.6岁。内固定失败原因:股骨头坏死24例,骨折不愈合内固定移位切出12例,创伤性关节炎5例。从内固定术到髋关节置换术时间为6~38个月,平均为15.4个月。髋关节置换术前患髋Harris评分为21~48分,平均(35.4±6.5)分。采用生物型全髋关节置换术21例,骨水泥型全髋关节置换术13例,非骨水泥型半髋置换术3例,骨水泥型半髋置换术4例;其中采用标准股骨柄27例,加长型股骨柄14例。结果 1例患者术后3d死亡,1例出现切口浅表感染,经再次清创缝合后愈合。36例患者获随访,随访时间1.5~6.0年,平均为3.8年。末次随访时患髋Harris评分为51~96分,平均(82.6±4.3)分。有1例出现假体周围骨折并再次手术;1例出现假体松动下沉,患髋中度疼痛。结论髋关节置换术是治疗老年髋部骨折内固定失败后的一种有效挽救关节功能的治疗方式,中期并发症少,临床效果满意。     

股骨近端锁定钢板治疗老年股骨转子间骨折术后并发症原因分析及防治对策

[目的]总结分析股骨近端锁定钢板治疗老年股骨转子间骨折术后并发症发生的原因,探讨其防治对策。[方法]回顾性分析本院2009年1月~2015年12月采用股骨近端锁定钢板治疗且获得随访的112例老年股骨转子间骨折患者资料,男49例,女63例;年龄60~91岁,平均70.23岁。记录并发症的发生率及末次随访时髋关节Harris功能评分。对术后出现并发症的患者进行分析,探讨其发生的原因及防治的方法。[结果]所有患者获得11~72个月的随访,平均36个月。末次随访Harris评分为32~91分,平均78.86分。112例患者中23例术后出现并发症,发生率为20.54%,其中髋内翻7例,内固定物断裂10例,近端螺钉突出并切割股骨头颈3例,骨折延期愈合3例。10例内固定物断裂者其中9例行二次翻修手术:内固定加植骨4例,人工髋关节置换5例;另1例患者放弃再次翻修手术。[结论]适应证选择不当是导致术后并发症的主要原因,而不稳定骨折、严重骨质疏松及骨折复位不良都将增加失败的发生率;内固定失败者,结合患者年龄、股骨近端骨质情况及髋关节功能行再次内固定加植骨或人工关节置换治疗可获得满意的临床结果。     

髋关节置换术治疗股骨近端防旋髓内钉内固定失败

目的探讨股骨近端防旋髓内钉(PFNA)内固定治疗股骨转子间骨折失败的原因及其行髋关节置换的疗效。方法 10例老年股骨转子间骨折患者经PFNA内固定治疗失败后行股骨头置换7例,全髋关节置换3例。术后12个月采用Harris评分标准评价疗效。结果 9例随访12～24个月,1例随访6个月时死亡。无切口感染、假体松动、关节脱位、假体周围骨折等并发症发生。术后12个月髋关节Harris评分72～91分,优6例,良2例,可1例。结论 PFNA内固定失败后,行股骨头置换或全髋关节置换临床疗效满意。     

老年股骨转子间骨折内固定失败后的二次手术治疗

目的 探讨老年股骨转子间骨折内固定失败的原因及二次手术治疗方法. 方法 2002年8月至2010年3月共收治22例老年股骨转子间骨折内固定失败患者,男13例,女9例;年龄66～87岁,平均74.6岁.原始骨折根据改良Evans分型:ⅠB型1例,ⅡA型5例,ⅡB型7例,Ⅲ型8例,逆转子间骨折1例.首次内固定方式:动力髋螺钉(DHS)9例,动力髁螺钉(DCS)4例,锁定钢板2例,股骨近端髓内钉(PFN)2例,Gamma钉5例.内固定失败时间平均为5.6个月(1.4～8.0个月).二次手术改行髋关节置换术8例,应用PFN 3例,股骨近端防旋交锁髓内钉7例,DHS 1例,DCS 3例.结果 内固定失败原因:螺钉松脱或折断7例,头颈钉切割2例,髋内翻7例,骨折再移位3例,骨折不愈合2例,股骨头坏死1例.22例患者术后获8 ～26个月(平均13.7个月)随访.末次随访时髋关节Harris评分由术前平均22分(11 ～36分)提高至85分(72 ～93分).再次内固定患者骨折均获骨性愈合,愈合时间平均为5.9个月(4 ～7个月). 结论 老年股骨转子间骨折内固定失败多因内固定方式选择不当、技术应用失误等因素所致.根据股骨转子部后内侧结构的稳定性、骨折愈合状况及骨质疏松程度等,合理选择内固定更换或髋关节置换术治疗,老年股骨转子间骨折内固定失败后仍可获得良好疗效.     

股骨近端锁定钢板内固定治疗股骨转子下骨折

目的分析应用股骨近端锁定钢板内固定治疗股骨转子下骨折的疗效。方法对22例闭合复位不满意的股骨转子下骨折患者采用有限切开骨折复位结合股骨近端锁定钢板内固定治疗。结果患者均获得随访,时间8～22个月。骨折愈合时间为3～10个月。术后6个月按髋关节Harris评分评定疗效:优13例,良5例,可3例,差l例。结论对于闭合复位不满意的股骨转子下骨折,有限切开复位股骨近端锁定钢板内固定治疗,能够较好地恢复肢体功能,是一种可行的治疗方法。     

55岁以下成年移位股骨颈骨折内固定术后失败的研究分析

目的:回顾性研究年龄55岁以下成年患者移位股骨颈骨折内固定治疗失败病例以提高对其治疗的重视。方法:2007年1月至2010年6月治疗55岁以下移位股骨颈骨折内固定术后失败患者18例,男13例,女5例;年龄27～55岁,平均(48.0±6.0)岁;空心钉治疗17例,髓内钉治疗1例。入院时诊断为股骨头坏死16例,骨不连合并股骨头坏死2例。结果:18例患者内固定术后至手术失败时间8～32个月,平均23个月。复位内固定术后Garden指数不佳;入院时髋关节Harris评分33～80分,平均(56.0±12.5)分。8例股骨头坏死病例和2例骨不连合并股骨头坏死病例接受了全髋关节置换术,5例股骨头坏死病例接受了表面髋关节置换术,3例虽然影像学有股骨头坏死征象但临床症状不明显,接受了保守治疗。所有行髋关节表面置换和全髋关节置换的病例术后随访12～53个月,平均34个月,术后Harris评分(94.0±3.0)分(89～96分)。结论:股骨头坏死是55岁以下成年移位股骨颈骨折闭合复位内固定术后常见并发症,必须提高对青壮年股骨颈骨折闭合复位内固定治疗的重视。     

Displaced femoral neck fracture: comparison of primary total hip replacement with secondary replacement after failed internal fixation: a 2-year follow-up of 84 patients

INTRODUCTION: Recent randomized controlled trials have shown that for the active and lucid elderly patient with a displaced femoral neck fracture, a primary total hip replacement (THR) is superior to internal fixation (IF) regarding the need for secondary surgery, hip function and health-related quality of life (HRQoL). Despite the high failure rate for IF, the method is still recommended for this patient cohort by some authors. One argument is that if IF fails, there is always the possibility of performing a secondary salvage THR. The main aim of our study was to determine whether a primary THR, as compared to a secondary THR after failed IF, gives a better outcome after 2 years. METHODS: We compared outcome for 43 patients with a primary THR to the outcome for 41 patients who were treated with a secondary THR after failed IF. All patients (mean age 80 years) were lucid and had a displaced femoral neck fracture. Hip function (Charnley score) and health-related quality of life (HRQoL, EQ5D) were assessed 2 years after the THR procedure. RESULTS: Hip function was better in the primary THR group: the mean Charnley score was 15/18 as compared to 13/18 in the secondary THR group (p < 0.001). The patients with failed IF who later underwent a secondary THR experienced a more pronounced decrease in HRQoL (EQ-5D index score) during the first year of treatment compared to patients in the primary THR group, with a difference of 0.25 in the EQ-5D index score at the 4-month follow-up (p = 0.02). INTERPRETATION: We found that a secondary THR after failed IF results in inferior hip function compared to a primary THR for a displaced femoral neck fracture in the active and lucid elderly patient. Moreover, the patients with failed IF had to undergo at least one re-operation and experienced a significant reduction in HRQoL before the salvage THR.     

股骨颈骨折内固定失败Ⅱ期行髋关节置换的早期疗效

目的:研究青壮年股骨颈骨折患者内固定失败后Ⅱ期行髋关节置换的早期临床疗效。方法:2008年6月至2010年6月,对24例股骨颈骨折内固定术后股骨头坏死患者行全髋关节置换术,其中男12例,女12例;年龄18～58岁,平均42.9岁。术后行X线检查,并根据Harris评分标准评价临床疗效。结果:23例获得随访,平均随访时间34.4个月(25～48个月),1例术后并发髋关节脱位,未发现髋关节感染、松动或假体周围骨折等并发症。Harris评分为90.9±4.3,优18例,良4例,可1例。结论:Ⅱ期全髋关节置换治疗股骨颈骨折内固定术后并发股骨头坏死,术中手术难度增加,但可以获得良好的早期疗效。     

髋关节置换术治疗老年髋部骨折内固定失败

目的 评价采用髋关节置换术治疗老年髋部骨折内固定失败的临床效果.方法 回顾性分析2003年7月至2011年6月,采用髋关节置换术治疗老年髋部骨折内固定失败并获得完整随访资料者22例,男12例,女10例;行髋关节置换术的年龄为65～82岁,平均72岁;从骨折到行髋关节置换的时间为8～71个月,平均41个月.骨折内固定方法是多枚螺钉12例,滑动髋螺钉6例,股骨近端髓内钉2例,股骨近端钢板2例.失败原因是拉力螺钉切出股骨头7例,骨折不愈合6例,股骨头缺血性坏死5例,创伤性骨关节炎4例.术前患髋Harris评分平均37分(32～45分),采用非骨水泥型全髋置换l1例,骨水泥型全髋置换4例,非骨水泥型半髋置换4例,骨水泥型半髋置换3例.标准柄股骨假体1 5例,长柄股骨假体7例.结果 22例均获随访,随访时间1～5年,平均2.5年.末次随访时Harris评分平均88分(84～95分),优7例,良11例,可3例,差1例,优良率81.8％.无假体松动和下沉.结论 髋关节置换术是治疗老年髋部骨折内固定失败后的一种有效挽救关节功能的选择.     

股骨转子间骨折术后内固定失效的再次内固定治疗

目的 评价股骨转子问骨折术后内固定失效行再次内固定加自体髂骨植骨术的疗效. 方法回顺性研究2000年1月至2008年3月间收治的股骨转子问骨折术后内固定失效、骨折不愈合病例31例,其中25例接受切开复位重新内固定加自体髂骨植骨术.一期失效的内固定种类包括动力髋螺钉12例,髁钢板3例,角钢板1例,带锁髓内针3例和空心钉6例.根据遗留骨质状况以及骨折类型选择更换的内固定物,包括股骨近端髓内钉12例,动力髁螺钉7例,动力髋螺钉4例和角钢板2例.所有患者均行自体髂骨植骨. 结果随访时间6-84个月,平均24个月.平均手术时间200 min(120～240 rain),平均出血量1500 mL(800～3000 mL).术中和术后无严重并发症发生.骨折愈合24例,愈合率为96.0%(24/25).25例患者术后髋关节Harris评分平均87分(35～100分),优良率为76.0%.随访患者X线片测量颈十角平均120.(110°～140°),无股骨头缺血坏死表现及髋关节退行性改变. 结论对于股骨转子间骨折术后内固定失效的患者,股骨近端只要存在可固定的骨质,患者的髋关节无严重损害,再次内固定加植骨治疗能够获得满意的临床结果.     

Displaced femoral neck fracture: comparison of primary total hip replacement with secondary replacement after failed internal fixation: A 2-year follow-up of 84 patients

Introduction?Recent randomized controlled trials have shown that for the active and lucid elderly patient with a displaced femoral neck fracture, a primary total hip replacement (THR) is superior to internal fixation (IF) regarding the need for secondary surgery, hip function and health-related quality of life (HRQoL). Despite the high failure rate for IF, the method is still recommended for this patient cohort by some authors. One argument is that if IF fails, there is always the possibility of performing a secondary salvage THR. The main aim of our study was to determine whether a primary THR, as compared to a secondary THR after failed IF, gives a better outcome after 2 years.

Methods?We compared outcome for 43 patients with a primary THR to the outcome for 41 patients who were treated with a secondary THR after failed IF. All patients (mean age 80 years) were lucid and had a displaced femoral neck fracture. Hip function (Charnley score) and health-related quality of life (HRQoL, EQ5D) were assessed 2 years after the THR procedure.

Results?Hip function was better in the primary THR group: the mean Charnley score was 15/18 as compared to 13/18 in the secondary THR group (p < 0.001). The patients with failed IF who later underwent a secondary THR experienced a more pronounced decrease in HRQoL (EQ-5D index score) during the first year of treatment compared to patients in the primary THR group, with a difference of 0.25 in the EQ-5D index score at the 4-month follow-up (p = 0.02).

Interpretation?We found that a secondary THR after failed IF results in inferior hip function compared to a primary THR for a displaced femoral neck fracture in the active and lucid elderly patient. Moreover, the patients with failed IF had to undergo at least one re-operation and experienced a significant reduction in HRQoL before the salvage THR     

人工关节置换治疗股骨颈骨折内固定失败的疗效观察

目的:观察人工髋关节置换治疗股骨颈骨折内固定失败患者的临床疗效.方法:自2007年6月至2014年1月采用人工髋关节置换治疗29例股骨颈骨折内固定失败的患者,其中男12例,女17例;年龄43~83岁,平均60.3岁;左髋16例,右髋13例.内固定距关节置换时间3~48个月,平均23.3个月.结果:29例患者中,直接生物杯固定20例,植骨修复缺损后生物杯固定7例,植骨修复缺损钛网杯固定后骨水泥臼杯固定2例;股骨柄生物型柄13例,骨水泥柄16例.无术中并发症发生,手术时间(115±38) min,术中出血量(420±175) ml,术后引流量(240±119) ml,术中输血量(200±220) ml,术中补液量(2 200±400) ml,术后输血量(300±200)ml,术后早期脱位1例.术后随访时间5~24个月,平均14.7个月,均愈合良好,未发生假体下沉、松动、脱位等现象.Harris评分由术前的51.1±7.5提高到末次随访88.5±6.4.结论:人工关节置换治疗股骨颈骨折内固定失败患者,可早期下地功能锻炼,减少卧床时间及并发症的发生,有利于早期功能恢复,远期疗效需要进一步观察.     

The Use of Standard Cemented Femoral Stems in Total Hip Replacement After Failed Internal Fixation of Intertrochanteric Femoral Fractures

BackgroundTotal hip replacement (THR) after failed internal fixation of intertrochanteric femoral fractures is challenging. The aim of this study is to show the reliability of using standard cemented femoral stems in this operation.MethodsThis work included 107 THRs performed in 107 patients after failed treatment of intertrochanteric femoral fractures. The etiology of failure included 67 cases of failure of fixation, 16 cases of nonunion, 15 cases of avascular necrosis, and 9 cases of post-traumatic osteoarthritis. There were 48 males and 59 females. The mean age was 66 years (range 58-81). Failed dynamic hip screws were removed at the time of THR, and the screw holes were blocked with cement. All cases had cemented standard stem femoral prostheses.ResultsAt an average 7.4 years with a minimum of 5 years of follow-up, 102 cases had good clinical and radiological outcomes and 5 cases had fair outcomes. One patient was infected and required 2 stages of revision arthroplasty. Two cases had intraoperative proximal femoral crack, and were treated by cerclage wires. Two patients had early postoperative dislocations. No patients had late periprosthetic femoral fractures or implant loosening.ConclusionStandard cemented femoral stems are reliable and cost-effective prostheses in such cases. It is not necessary to bypass the distal screw hole by doubling the femoral canal diameter as long as the bone holes are covered by cement.     

Total endoprosthetic management of the hip joint after failed osteosynthesis of para-articular hip fracture

OBJECTIVE: Treatment of fractures of the proximal femur by open reduction and internal fixation is prone to complications and frequently requiring secondary joint replacement. The aim of the present study was to examine the results of total hip arthroplasty as a salvage procedure for failed internal fixation of femoral or acetabular fractures. PATIENTS AND METHODS: We retrospectively studied 145 patients who had undergone 146 total hip arthroplasties for failed internal fixation of femoral (n = 135) or acetabular fractures (n = 11). Mean follow-up time after insertion of the hip endoprosthesis was 7.1 years (1.5-14.7 years). Patient evaluation included a history, clinical examination, and standard radiographs. RESULTS: Twenty-eight patients had died, and 18 patients were lost to follow-up. Kaplan-Meier analysis with revision of the implants as the end-point demonstrated 85 percent survival after ten years. Using the Merle d'Aubigné rating system, we found good or excellent results in 85 percent of the cases. However, only 73.9 percent of the patients were satisfied with their result, and 40.9 percent still showed a positive Trendelenburg gait at follow-up. The perioperative mortality was 2.7 percent. Surgery-related femoral fractures or fissures were observed in 18 cases, and deep infections in four. CONCLUSIONS: In comparison with data of patients who had undergone primary total hip arthroplasty for osteoarthritis in our department, the results reported here after secondary hip replacement are clearly inferior. Nonetheless, alloarthroplasty of the hip still is the most effective procedure after failed internal fixation for acetabular or proximal femoral fractures.