一期人工全髋关节置换治疗中老年Pipkin Ⅳ型股骨头骨折

目的探讨一期人工全髋关节置换治疗中老年Pipkin Ⅳ型股骨头骨折的效果。方法对12例无坐骨神经损伤中老年Pipkin Ⅳ型股骨头骨折患者采用髋臼骨折复位钢板内固定、一期人工全髋关节置换术治疗。结果患者均获随访,时间12~36（22±3.8）个月。无假体松动、关节脱位及深部感染等并发症发生。根据Harris评分标准：优7例（94分±2.8分）,良5例（86分±2.3分）。结论采用髋臼骨折复位钢板内固定、一期人工全髋关节置换术治疗中老年Pipkin Ⅳ型股骨头骨折手术简单,临床效果显著。     

Dynamic internal fixation of the periprosthetic femoral fractures after total hip arthroplasty

Periprosthetic fractures of the femur after total hip arthroplasty are a big orthopaedic problem, particularly in elderly patients and quite a challenge for orthopaedic surgeons. There is no universal method in treating these fractures. Rigid plates fixation can be limited and aggravated especially in the proximal part of the femur where the endoprosthesis stem does not allow for an undisturbed fixation of both femur cortexes by means of screws. Mitkovic's dynamic internal fixator is an original implant allowing for an undisturbed fixation of both femur cortexes regardless of the presence of the endoprosthesis stem. Fixation is made possible by means of movable clamps and a convergent possibility to place screws. A dynamic internal fixator can fix all types of periprosthetic femoral fractures. The paper shows the early experience in fixating periprosthetic femoral fractures after total hip arthroplasty in 14 patients, average age 69.7. According to Vancouver classification, 3 patients had the type A fracture, 9 patients had the type B fracture, and 2 patients had the type C fracture. All fractures were fixed by Mitkovic's dynamic internal fixator. The fracture occurred 2-12 years after primary total hip arthroplasty. The follow-up of the operated patients was 12 months. The method is less invasive than the methods described in books. Mechanical complications are not likely to appear due to the fracture dynamics along the femoral shaft axis, which is made possible by this implant. Our initial experience in femur fracture fixation after hip arthroplasty ahows that it is modern and effective dynamic implant which will contribute significantly to the improving of the treatment of these often very complicated fractures.     

Hip arthroplasty for failed treatment of proximal femoral fractures

Failed treatment of an intertrochanteric fracture typically leads to profound functional disability and pain. Salvage treatment with hip arthroplasty may be considered. The aim of this study was to evaluate the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture. Twenty-one patients were treated in our hospital with hip arthroplasty for failed treatment of intertrochanteric hip fracture. There were sixteen women and five men with a mean age of 75.8 years (range 61–85 years). Fourteen patients had failure of a previous nail fixation procedure, five had failure of a plate fixation, one of hip screws fixation and one of Ender nail fixation. In 19 out of 21 patients we performed a total hip arthroplasty—14 cases used modular implants with long-stems and five cases used a standard straight stem. In 2 of 21 cases we used a bipolar hemiarthroplasty. A statistically significant improvement was found comparing pre and postoperative conditions (p < 0.05). Our experience confirms that total hip arthroplasty is a satisfactory salvage procedure after failed treatment of an intertrochanteric fracture in elderly patients with few serious orthopaedic complications and acceptable clinical outcomes.     

Hip fractures: failure of fixation and outcome of salvage arthroplasty

Between 1999 and 2005, we treated 41 patients with a total hip arthroplasty for failed fixation of a hip fracture. This study had three purposes: (1) to determine the reason/s for fixation failure (2) to record difficulties/complications encountered in converting to a salvage arthroplasty and (3) to compare the outcome of these patients (Group 1) with a matched group of patients who underwent a primary hip arthroplasty (Group 2). Failure to achieve a good reduction and optimal screw placement was evident in 80% of cases of failed fixation. A high incidence of complications was recorded in the perioperative period during conversion to a salvage arthroplasty. Functional outcome was statistically inferior in Group1; this group also had a higher incidence of complications. Radiographs at 2 years postoperatively showed evidence of femoral stem loosening in 16% of the salvage group compared with 3% in the primary hip arthroplasty group.     

全髋关节置换假体柄周围骨折的治疗

目的 :回顾性研究全髋关节置换假体柄周围骨折的治疗及预防。方法 :将本院近年收治的全髋置换假体柄周围骨折的 8例病例按Vancouver分类方法进行分类 ,其中A1型 3例 ,B1型 3例 ,B2型 1例 ,B3型 1例 ,分别用钢丝环扎固定 ,异体皮质骨板加钢丝环扎 ;骨水泥长柄假体翻修。结果 :术后随访 8～ 18个月 ,骨折愈合 ,假体固定可靠。结论 :全髋关节置换术后假体柄周围骨折用Vancouver分类方法分类 ,简单、适用。采用异体皮质骨板与钢丝环扎固定骨折 ,治疗假体柄周围骨折 ,不仅固定可靠而且能促进骨折愈合、恢复骨量。     

Hip arthroplasty after extracapsular hip fracture: a matched pair cohort analysis

Eighteen patients with a prior intertrochanteric or basicervical hip fracture had a total or bipolar hip arthroplasty. The clinical and radiographic results of these patients were compared to a control group of patients (matched for age, gender, associated diagnoses, and length of follow-up) who had a primary total hip arthroplasty. There was a significant increase in intraoperative blood loss, operative time, and number of units of blood transfused in the fracture group compared to the primary arthroplasty group. The mean preoperative Harris hip scores were not significantly different between the two groups, but the postoperative scores were significantly lower for the fracture group (p < .001). There was no notable difference in the rates of radiographic loosening or heterotopic ossification between the two groups. The results of this study suggest that patients should be counseled preoperatively that the functional outcome of hip arthroplasty after internal fixation of extracapsular hip fractures is decreased compared to control patients with a primary total hip arthroplasty.     

Cementless acetabular reconstruction after acetabular fracture.

BACKGROUND: Total hip arthroplasty in patients with posttraumatic arthritis has produced results inferior to those in patients with nontraumatic arthritis. The use of cementless acetabular reconstruction, however, has not been extensively studied in this clinical context. Our purpose was to compare the intermediate-term results of total hip arthroplasty with a cementless acetabular component in patients with posttraumatic arthritis with those of the same procedure in patients with nontraumatic arthritis. We also compared the results of arthroplasty in patients who had had prior operative treatment of their acetabular fracture with those in patients who had had prior closed treatment of their acetabular fracture. METHODS: Thirty total hip arthroplasties were performed with use of a cementless hemispheric, fiber-metal-mesh-coated acetabular component for the treatment of posttraumatic osteoarthritis after acetabular fracture. The median interval between the fracture and the arthroplasty was thirty-seven months (range, eight to 444 months). The average age at the time of the arthroplasty was fifty-one years (range, twenty-six to eighty-six years), and the average duration of follow-up was sixty-three months (range, twenty-four to 140 months). Fifteen patients had had prior open reduction and internal fixation of their acetabular fracture (open-reduction group), and fifteen patients had had closed treatment of the acetabular fracture (closed-treatment group). The results of these thirty hip reconstructions were compared with the intermediate-term results of 204 consecutive primary total hip arthroplasties with cementless acetabular reconstruction in patients with nontraumatic arthritis. RESULTS: Operative time (p < 0.001), blood loss (p < 0.001), and perioperative transfusion requirements (p < 0.001) were greater in the patients with posttraumatic arthritis than they were in the patients with nontraumatic arthritis. Of the patients with posttraumatic arthritis, those who had had open reduction and internal fixation of their acetabular fracture had a significantly longer index procedure (p = 0.01), greater blood loss (p = 0.008), and a higher transfusion requirement (p = 0.049) than those in whom the fracture had been treated by closed methods. Eight of the fifteen patients with a previous open reduction and internal fixation required an elevated acetabular liner compared with one of the fifteen patients who had been treated by closed means (p = 0.005). Two of the fifteen patients with a previous open reduction and internal fixation required bone-grafting of acetabular defects compared with seven of the fifteen patients treated by closed means (p = 0.04). The thirty patients treated for posttraumatic arthritis had an average preoperative Harris hip score of 41 points, which increased to 88 points at the time of follow-up; there was no significant difference between the open-reduction and closed-treatment groups (p = 0.39). Twenty-seven patients (90%) had a good or excellent result. There were no dislocations or deep infections. The Kaplan-Meier ten-year survival rate, with revision or radiographic loosening as the end point, was 97%. These results were similar to those of the patients who underwent primary total hip arthroplasty for nontraumatic arthritis. CONCLUSIONS: The intermediate-term clinical results of total hip arthroplasty with cementless acetabular reconstruction for posttraumatic osteoarthritis after acetabular fracture were similar to those after the same procedure for nontraumatic arthritis, regardless of whether the acetabular fracture had been internally fixed initially. However, total hip arthroplasty after acetabular fracture was a longer procedure with greater blood loss, especially in patients with previous open reduction and internal fixation. Previous open reduction and internal fixation predisposed the hip to more intraoperative instability but less bone deficiency.     

Total hip arthroplasty in patients with below-knee amputations

We present a unique small group of 5 patients with below-knee amputation who underwent total hip arthroplasty after a displaced subcapital fracture of the femur. Three patients were operated on after failed fixation of the fracture, and 2 were operated on as a primary procedure. All 5 patients resumed their prefracture level of activity and mobilization with no deterioration during follow-up (average, 69 months [range, 22-98]). These encouraging results call for use of total hip arthroplasty or hemiarthroplasty as the primary treatment modalities of patients with displaced subcapital femoral head fracture in an extremity with below-knee amputation.     

Interprosthetic fracture of the femoral shaft

Experience in the management of a complication of ipsilateral hip and knee arthroplasty is described. The cases of four female patients who sustained a femoral shaft fracture after ipsilateral hip and knee arthroplasty are reported. All fractures were treated operatively, and in all cases internal fixation devices failed. This complication of multiple joint arthroplasty presents a difficult management problem. Rigid fixation has a high failure rate for this type of fracture. Surface knee arthroplasty provides a better opportunity for internal fixation than a knee arthroplasty with a stemmed femoral component.     

老年移位髋臼骨折手术治疗策略及疗效

目的探讨切开复位内固定术和一期全髋关节置换术治疗老年髋臼骨折的临床疗效并进行比较研究。方法1998～2005年间共收治45位年龄超过60岁的髋臼骨折患者，其中21例行切开复位内固定，10例行一期全髋关节置换术。手术距受伤时间不到2周，平均7d。术后常规给予抗凝药预防深静脉血栓形成，按康复计划进行恢复性功能锻炼，定期随访行髋关节功能Harris评分。结果本组随访1．5～7年，平均4年；最后随访时，切开复位内固定组Harris评分为69～84分，平均79分，优良率为57％，伴有较高的创伤性关节炎、异位骨化、股骨头骨坏死发生率；全髋关节置换术组患者的Harris评分为75～90分，平均84分，优良率为80％，仅有髋臼杯轻度移动（〈4mm），无假体松动、深部感染等并发症。结论全髋关节置换术治疗老年移位髋臼骨折可以取得比切开复位内固定更好的稳定性，术后恢复快、功能质量高，并发症少，是一种较好的选择。     

髋关节置换术中及术后股骨干骨折使用捆绑带固定的临床研究

目的 探讨人工全髋关节置换术中及术后股骨干骨折使用捆绑带固定的治疗方法及临床疗效.方法 回顾性分析1999年8月至2007年9月由同一术者连续进行的人工全髋关节置换术(包括翻修手术)2186例,发生术中及术后股骨干骨折22例,其中术中骨折12例,术后外伤骨折10例.男性10例,女性12例,初次置换术9例,翻修术13例.Vancouver骨折分型为B1型骨折15例,B2型骨折7例,并且均为斜形骨折.处理方法为切开骨折复位,根据骨折长度和范围采用2～5根钛制捆绑带环形捆扎,其中13例选用2根,7例选用3根,1例选用4根,1例选用5根.同时根据术中原假体稳定性决定是否更换,其中15例B1型骨折和1例B2型骨折患者术中未予更换股骨柄假体,另外6例B2型骨折患者因股骨假体松动给予更换同类型的加长柄假体.结果 所有患者术后平均18周(12～ 20周)时X线片显示骨折愈合.术后随访4～11年(平均6.5年),髋关节Harris评分80～ 95分(平均90分),髋关节活动度105°～135°(平均120°).股骨假体固定良好,无下沉,无明显透亮线及松动迹象.结论 全髋关节置换术中及术后发生股骨干斜形骨折时可采用捆绑带固定,如果股骨柄假体稳定及分型为B1型骨折时不更换原假体,如果假体柄不稳定分型为B2型时直接更换同类型的加长柄假体,可获得骨折处的坚强固定和股骨柄假体良好的初始稳定性,中长期随访临床效果满意.     

Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient

Nine elderly patients were treated by salvage hip arthroplasty following failed internal fixation of an intertrochanteric or subtrochanteric hip fracture. The mean age at time of fracture was 79 years (range 67–94 years). The mean interval from initial fracture fixation to conversion arthroplasty was 7 months (range 5 days to 19 months). One 84-year-old patient died 6 weeks postoperatively from a pulmonary infection. The remaining eight patients were assessed clinically and roentgenographically after a mean follow-up period of 41 months (range 4–85 months). The functional results, rated according to the Merle d'Aubigné hip rating scale, were excellent in one patient, very good in four patients, good in two patients, and fair in one patient. Serial roentgenographic analysis showed new bone formation around the extramedullary part of the femoral component in all these patients and bone remodelling of the diaphyseal part of the femur in all patients. The preservation of the functional continuity of the abduction apparatus during surgery and the early walking with full unrestricted weight-bearing made possible by the arthroplasty are considered to be the major contributing factors to these results.     

微创直接前方入路髋关节置换术治疗股骨颈骨折合并阿尔茨海默病的短期疗效观察

目的探讨采用微创直接前方入路(DAA)行髋关节置换术治疗股骨颈骨折合并阿尔茨海默病的短期疗效。方法回顾性分析自2015-01—2016-10采用微创DAA行髋关节置换术治疗15例股骨颈骨折合并阿尔茨海默病的临床资料。术后复查X线片观察假体位置及假体松动情况。采用髋关节功能Harris评分评估术后髋关节功能。结果所有患者均获得随访3~24个月,平均10.4个月。术后无切口感染、重要神经、血管等组织结构损伤,无关节假体早期脱位、松动及下肢深静脉血栓形成等并发症。末次随访疗效按照髋关节功能Harris评分评定:平均92(78~98)分;优13例,良2例。结论采用微创DAA行髋关节置换术治疗新鲜股骨颈骨折合并阿尔茨海默病具有创伤小、患者术后恢复快、安全性好、保留髋关节周围肌群正常张力、减少术后早期关节假体脱位等优点,可安全有效应用于股骨颈骨折合并阿尔茨海默病的治疗。     

Reduced survival for uncemented compared to cemented total hip arthroplasty after operatively treated acetabular fractures

BackgroundPost traumatic arthritis and avascular necrosis of the femoral head are common complications after operatively treated acetabular fractures. This may cause severe disabilities for the patient, necessitating a total hip arthroplasty. Even though an arthroplasty may provide good symptomatic relief, the long-term results are more uncertain and no consensus exists according to preferred prosthetic designs. With this cohort study, we aimed to investigate the medium to long term arthroplasty survival and clinical results of total hip arthroplasty after operatively treated acetabular fractures.MethodsWe included 52 patients treated with a secondary total hip arthroplasty at a median of 2.4 (0.1–14.1) years after an operatively treated acetabular fracture. The median age was 54 (11–82) years. Cemented arthroplasty was used for 33 patients, 10 patients had an uncemented arthroplasty and 9 patients received a hybrid arthroplasty. Average follow up was 8.0 (SD 5.0) years.ResultsTen-year revision free arthroplasty survival was 79%. Uncemented arthroplasties had a significantly worse 10-year survival of 57%. Arthroplasties performed at a centre without a pelvic fracture service also had a significantly worse 10-years survival of 51%. Cox regression showed similar results with an 8-fold increase in risk of revision for both uncemented arthroplasties and operations performed at a non-pelvic trauma centre.ConclusionTotal hip arthroplasty secondary to an operatively treated acetabular fracture provides good symptomatic relief. These patients are, however, complex cases and are probably best treated at specialist centres with both pelvic trauma surgeons and arthroplasty surgeons proficient in complex revisions present.     

Satisfactory results of Stanmore total hip arthroplasty after failed osteosynthesis of the femoral neck

Treatment of fractures of the femoral neck by closed reduction and internal fixation results in a high incidence of complications, and often requires secondary total hip arthroplasty. We retrospectively studied 31 patients who underwent a Stanmore (Howmedica) total hip arthroplasty performed five months (median) after osteosynthesis. The most common indications were: failure of fixation (n = 14), osteonecrosis (n = 9) and secondary osteoarthritis (n = 6). Eight patients had a maximum follow-up of 12 months; the median follow-up was 30 months in the remaining group of 23 patients. Although one patient had radiographical signs of femoral loosening, none of the patients studied needed revision of the total hip arthroplasty. Using the Merle d'Aubigné scoring system, we found excellent results in 94% of the cases. Despite the short-term follow-up and the small number of patients, we conclude that the Stanmore THA was a satisfactory salvage procedure after failure of internal fixation for femoral neck fracture.     

同侧髋臼骨折合并股骨颈骨折行一期全髋关节置换术的临床研究

目的探讨同侧髋臼骨折合并股骨颈骨折行一期全髋关节置换（THA）的手术方法及其疗效。方法2003年7月至2006年3月,对5例同侧髋臼骨折合并股骨颈骨折的患者行一期THA,均采用生物型人工髋关节,强调髋臼重建结构的稳定性,随访21～54个月（平均34．4个月）;手术距受伤时间5～42d（平均18．6d）。3例2周内手术者,尽可能解剖复位内固定,2例超过4周手术者,在骨折畸形愈合的基础上,不剥离骨痂,给予结构性植骨并重塑髋臼。结果按HHS评分为87．6分,其中优2例,良2例,可1例,随访期间未发生感染、松动和异位骨化等并发症。结论对同侧髋臼骨折合并股骨颈骨折的患者行一期THA,能取得较好疗效,避免切开复位内固定引起的治疗周期长,高并发症,疗效差,甚至短期再次行THA等缺点;重视髋臼结构的稳定性和有翻修经验的医师参与是提高手术疗效的关键。     

Short-term outcomes of total hip arthroplasty after complications of open reduction internal fixation for hip fracture

Failed open reduction internal fixation (ORIF) of the proximal femur can render patients severely disabled. This study analyzed the short-term functional results and complications of total hip arthroplasty (THA) for complications of ORIF after hip fracture. A retrospective arthroplasty database review identified 36 patients treated with a THA for complications of ORIF of the hip. These patients were matched to a cohort of 36 patients who underwent primary unilateral THA for osteoarthritis. Study results indicate that THA for failed ORIF of the hip is a successful procedure despite concerns of increased intraoperative difficulty and risk of fracture.     

人工全髋关节置换术治疗老年股骨颈骨折

目的探讨人工全髋关节置换术治疗老年股骨颈骨折的临床疗效。方法对52例应用人工全髋关节置换术治疗老年股骨颈骨折患者临床资料进行回顾性分析,并对骨水泥固定16例与未用骨水泥固定18例的临床疗效进行比较。结果随访时间1-10年,平均5年6个月。根据Harris髋关节评分标准,骨水泥组疗效：优11例,良8例,尚可4例,差2例;非骨水泥组疗效：优11例,良10例,尚可5例,差1例。结论人工全髋关节置换术是老年股骨颈骨折的理想治疗方法．府用骨水泥固定与非骨水泥方法．两者疗效并无显著善异．     

Treatment Results of a Periprosthetic Femoral Fracture Case Series: Treatment Method for Vancouver Type B2 Fractures Can Be Customized

Background

Currently, an algorithmic approach for deciding treatment options according to the Vancouver classification is widely used for treatment of periprosthetic femoral fractures after hip arthroplasty. However, this treatment algorithm based on the Vancouver classification lacks consideration of patient physiology and surgeon''s experience (judgment), which are also important for deciding treatment options. The purpose of this study was to assess the treatment results and discuss the treatment options using a case series.

Methods

Eighteen consecutive cases with periprosthetic femoral fractures after total hip arthroplasty and hemiarthroplasty were retrospectively reviewed. A locking compression plate system was used for osteosynthesis during the study period. The fracture type was determined by the Vancouver classification. The treatment algorithm based on the Vancouver classification was generally applied, but was modified in some cases according to the surgeon''s judgment. The reasons for modification of the treatment algorithm were investigated. Mobility status, ambulatory status, and social status were assessed before the fracture and at the latest follow-up. Radiological results including bony union and stem stability were also evaluated.

Results

Thirteen cases were treated by osteosynthesis, two by revision arthroplasty and three by conservative treatment. Four cases of type B2 fractures with a loose stem, in which revision arthroplasty is recommended according to the Vancouver classification, were treated by other options. Of these, three were treated by osteosynthesis and one was treated conservatively. The reasons why the three cases were treated by osteosynthesis were technical difficulty associated with performance of revision arthroplasty owing to severe central migration of an Austin-Moore implant in one case and subsequent severe hip contracture and low activity in two cases. The reasons for the conservative treatment in the remaining case were low activity, low-grade pain, previous wiring around the fracture and light weight. All patients obtained primary bony union and almost fully regained their prior activities.

Conclusions

We suggest reaching a decision regarding treatment methods of periprosthetic femoral fractures by following the algorithmic approach of the Vancouver classification in addition to the assessment of each patient''s hip joint pathology, physical status and activity, especially for type B2 fractures. The customized treatments demonstrated favorable overall results.     

Treatment of displaced intracapsular hip fractures with total hip arthroplasty: comparison of primary arthroplasty with early salvage arthroplasty after failed internal fixation

BACKGROUND: Closed reduction and internal fixation is the preferred initial treatment for young active patients who sustain a displaced intracapsular hip fracture. However, there is a paucity of information on the outcome in patients in whom this procedure fails and who subsequently require revision to a total hip arthroplasty. The purpose of this study was to compare a group of patients with a displaced intracapsular fracture who required early salvage total hip arthroplasty following failure of internal fixation within the first year after fracture with a group treated with primary total joint replacement for treatment of the same type of fracture. METHODS: With use of a matched-pairs case-control design, a group of 107 patients, between the ages of sixty and eighty years, who required an early salvage total hip arthroplasty with cement following failed reduction and internal fixation of a displaced intracapsular hip fracture (Group I) was compared with an age and gender-matched group of patients who had undergone total hip arthroplasty with cement as the primary procedure for the treatment of such a fracture (Group II). RESULTS: During the first year after the arthroplasty, there were fifty-two early complications in thirty-nine patients in Group I and twenty-two complications in fourteen patients in Group II (p < 0.05). There were significantly more superficial infections and dislocations in Group I (p < 0.05). The rate of revision beyond one year was greater and the overall prosthetic survival rate at both five and ten years postoperatively was significantly worse in Group I (log-rank test, p < 0.05). The functional outcomes at one year and at the time of final follow-up were also significantly worse in Group I. CONCLUSIONS: Reduction and internal fixation will continue to be used as the primary treatment of displaced intracapsular fractures in many younger patients because of the benefits of preservation of the normal hip joint. However, patients should be counseled that if this method of treatment is unsuccessful and requires revision to a total hip arthroplasty with cement, the risk of early complications is higher and hip function may be poorer than if the arthroplasty had been performed as a primary procedure.