股骨转子间骨折内固定失败后人工全髋关节置换术治疗的安全性及有效性分析
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摘要
目的分析股骨转子间骨折内固定失败后行人工全髋关节置换术的安全性和有效性。方法 2007年1月—2016年1月,采用人工全髋关节置换术治疗32例(33髋)股骨转子间骨折内固定失败患者。男15例,女17例;年龄65～87岁,平均74.0岁。股骨转子间骨折类型:Evans-JensenⅡ型3髋、Ⅲ型10髋、Ⅳ型8髋、Ⅴ型12髋。内固定类型:动力髋螺钉18髋,股骨近端防旋髓内钉9髋,锁定钢板5髋,空心螺钉1髋。内固定失败原因:骨折移位及不愈合21例,创伤性关节炎6例,骨折不愈合及感染3例,股骨头缺血性坏死2例。内固定术至人工全髋关节置换术时间2～48个月,中位时间20个月。记录手术时间、术中出血量、术后引流量以及术后输血、手术相关并发症发生情况,以评价其安全性;采用Harris评分、疼痛视觉模拟评分(VAS)、膝关节活动度(range of motion,ROM)、双下肢长度差值,评价术后功能恢复情况;随访X线片,观察假体生存情况。结果手术时间55～135 min,平均92 min;术中出血360～620 mL,平均480 mL;术后引流量220～520 mL,平均350 mL。术中2髋发生股骨近端裂纹骨折;术后10例患者输血,1例发生脑梗死,2髋发生关节脱位,1髋扭伤导致大转子再次骨折,1例死于心肌梗死。术后29例(30髋)获随访,随访时间2～10年,平均4.9年。末次随访时,3例感染患者感染未复发;X线片未见假体松动、下沉及断裂;髋关节Harris评分、VAS评分、ROM、双下肢长度差值均较术前明显改善(P<0.05)。结论人工全髋关节置换术是股骨转子间骨折内固定失败的有效补救治疗方法,但围术期风险和并发症发生率较高。术前应充分评估和精细化、个体化管理,使患者安全度过围术期。
Objective To evaluate the safety and efficacy of total hip arthroplasty(THA) following failed internal fixation of intertrochanteric fractures. Methods Between January 2007 and January 2016, THAs were performed in32 patients(33 hips) for failed internal fixation of intertrochanteric fractures. There were 15 males and 17 females, with mean age of 74.0 years old(range, 65-87 years). There were 3 hips of Evans-Jensen type Ⅱ, 10 hips of type Ⅲ, 8 hips of type Ⅳ, and 12 hips of type Ⅴ. The fractures were fixed with dynamic hip screw in 18 hips, proximal femoral nail antirotation in 9 hips, locking plate in 5 hips, and hollow screw in 1 hip. The internal fixation failure caused by fracture displacement and nonunion in 22 patients, traumatic arthritis in 6 patients, fracture nonunion and infection in 3 patients,and avascular necrosis of the femoral head in 2 patients. The mean interval from initial fracture fixation to THA was 20 months(range, 2-48 months). The safety evaluation indicators included operation time, amount of operative bleeding and postoperative drainage, blood transfusion, and perioperative complications. The efficacy indexes included the hip Harris score, the range of motion(ROM), visual analogue scale(VAS) score, and the length difference between both legs; the X-ray films were taken to assess the prosthesis survival condition. Results The average operation time was 92 minutes(range, 55–135 minutes). The average amount of operative bleeding and postoperative drainage were 480 mL(range,360-620 mL) and 350 mL(range, 220-520 mL), respectively. Intraoperative proximal femur fissure fracture occurred in2 hips. After operation, 10 cases received allogeneic blood transfusion, 1 case occurred cerebral infarction, 2 hips experienced dislocation, 1 hip occurred greater trochanter re-fracture and dislocation because of spraining, and 1 case died of myocardial infarction. Twenty-nine patients(30 hips) were followed up 2-10 years(mean, 4.9 years). At last follow-up,there was no infection recurrence in 3 infected hips, and there was no prosthesis loosening, subsidence, or rupture in all cases. The Harris score, ROM, VAS score, and the length difference between both legs were significantly superior to preoperative ones(P<0.05). Conclusion THA is an effective salvage procedure after failed internal fixation of intertrochanteric fracture. But its perioperative risks and complications are pretty high. Adequate preoperative evaluation,elaborate and individualized perioperative management are keys to make sure the patient can safely survive the perioperative period.
Objective To evaluate the safety and efficacy of total hip arthroplasty(THA) following failed internal fixation of intertrochanteric fractures. Methods Between January 2007 and January 2016, THAs were performed in32 patients(33 hips) for failed internal fixation of intertrochanteric fractures. There were 15 males and 17 females, with mean age of 74.0 years old(range, 65-87 years). There were 3 hips of Evans-Jensen type Ⅱ, 10 hips of type Ⅲ, 8 hips of type Ⅳ, and 12 hips of type Ⅴ. The fractures were fixed with dynamic hip screw in 18 hips, proximal femoral nail antirotation in 9 hips, locking plate in 5 hips, and hollow screw in 1 hip. The internal fixation failure caused by fracture displacement and nonunion in 22 patients, traumatic arthritis in 6 patients, fracture nonunion and infection in 3 patients,and avascular necrosis of the femoral head in 2 patients. The mean interval from initial fracture fixation to THA was 20 months(range, 2-48 months). The safety evaluation indicators included operation time, amount of operative bleeding and postoperative drainage, blood transfusion, and perioperative complications. The efficacy indexes included the hip Harris score, the range of motion(ROM), visual analogue scale(VAS) score, and the length difference between both legs; the X-ray films were taken to assess the prosthesis survival condition. Results The average operation time was 92 minutes(range, 55–135 minutes). The average amount of operative bleeding and postoperative drainage were 480 mL(range,360-620 mL) and 350 mL(range, 220-520 mL), respectively. Intraoperative proximal femur fissure fracture occurred in2 hips. After operation, 10 cases received allogeneic blood transfusion, 1 case occurred cerebral infarction, 2 hips experienced dislocation, 1 hip occurred greater trochanter re-fracture and dislocation because of spraining, and 1 case died of myocardial infarction. Twenty-nine patients(30 hips) were followed up 2-10 years(mean, 4.9 years). At last follow-up,there was no infection recurrence in 3 infected hips, and there was no prosthesis loosening, subsidence, or rupture in all cases. The Harris score, ROM, VAS score, and the length difference between both legs were significantly superior to preoperative ones(P<0.05). Conclusion THA is an effective salvage procedure after failed internal fixation of intertrochanteric fracture. But its perioperative risks and complications are pretty high. Adequate preoperative evaluation,elaborate and individualized perioperative management are keys to make sure the patient can safely survive the perioperative period.
引文
1 Socci AR, Casemyr NE, Leslie MP, et al. Implant options for the treatment of intertrochanteric fractures of the hip:rationale,evidence, and recommendations. Bone Joint J, 2017, 99-B(1):128-133.
2 Lee SH, Chen IJ, Li YH, et al. Incidence of second hip fractures and associated mortality in Taiwan:A nationwide population-based study of 95,484 patients during 2006-2010. Acta Orthop Traumatol Turc, 2016, 50(4):437-442.
3 Desteli E, Imren Y, Erdogan M, et al. Quality of life following treatment of trochanteric fractures with proximal femoral nail versus cementless bipolar hemiarthroplasty in elderly. Clin Invest Med, 2015, 38(2):E63-E72.
4 Arslan A, Utkan A, Koca TT. Results of a compression pin alongwith trochanteric external fixation in management of high risk elderly intertrochanteric fractures. Indian J Orthop, 2016,50(6):636-640.
5 Teague DC, Ertl WJ, Hickerson L, et al. What is new in orthopaedic trauma. J Bone Joint Surg(Am),2016, 98(13):1142-1149.
6 Matre K, Havelin LI, Gjertsen JE, et al. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures.A study of 2716 patients in Norwegian Hip Fracture Register.Injury, 2013, 44(6):735-742.
7 Ovesen O, Andersen M, Poulsen T, et al. The trochanteric gamma nail versus the dynamic hip screw:a prospective randomized study.One-year follow-up of 146 intertrochanteric fractures. Hip Int,2006,16(4):293-298.
8 Yuan BJ, Abdel MP, Cross WW, et al. Hip arthroplasty after surgical treatment of intertrochanteric hip fractures. J Arthroplasty, 2017, 32(11):3438-3444.
9 Winemaker M,Gamble P, Petruccelli D, et al. Short-term outcomes of total hip arthroplasty after complications of open reduction internal fixation for hip fracture. J Arthroplasty, 2006,21(5):682-688.
10 Srivastav S, Mittal V, Agarwal S. Total hip arthroplasty following failed fixation of proximal hip fractures. Indian J Orthop, 2008,42(3):279-286.
11 Tsai SW, Chen CF, Wu PK, et al. Does implant selection impact postoperative complications following hip arthroplasty for failed intertrochanteric fractures? A retrospective comparative study Artif Organs, 2016, 40(8):798-804.
12 Lee YK, Kim JT, Alkitaini AA, et al. Conversion hip arthroplasty in failed fixation of intertrochanteric fracture:A propensity score matching study. J Arthroplasty, 2017, 32(5):1593-1598.
13周宗科,翁习生,曲铁兵,等.中国髋、膝关节置换术加速康复-围术期管理策略识专家共识.中华骨与关节外科杂志,2016, 9(1):1-9.
14 Floren M, Lester DK. Durability of implant fixation after lessinvasive total hip arthroplasty. J Arthroplasty, 2006,21(6):783-790.
15 Cho CH, Yoon SH, Kim SY. Better functional outcome of salvage THA than bipolar hemiarthroplasty for failed intertrochanteric femur fracture fixation. Orthopedics, 2010, 33(10):721-726.
16 Chen DW, Lin CL, Hu CC, et al. Biomechanical consideration of total hip arthroplasty following failed fixation of femoral intertrochanteric fractures-a finite element analysis. Med Eng Phys,2013, 35(5):569-575.
17 Greidanus NV, Masri BA, Garbuz DS, et al. Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty. J Bone Joint Surg(Am), 2007, 89(7):1409-1416.
18 Mabry TM, Prpa B, Haidukewych GJ, et al. Long-term results of total hip arthroplasty for femoral neck fracture nonunion. J Bone Joint Surg(Am), 2004, 86-A(10):2263-2267.
19 Chen YT, Chen WM, Lee KS, et al. Diaphyseal locking hip arthroplasty for treatment of failed fixation of intertrochanteric hip fractures. J Arthroplasty, 2008,23(2):241-246.
20 Pui CM, Bostrom MP, Westrich GH, et al. Increased complicationrate following conversion total hip arthroplasty after cephalomedullary fixation for intertrochanteric hip fractures:a multicenter study. J Arthroplasty, 2013, 28(8 Suppl):45-47.
21 Wang D, Li LL, Wang HY, et al. Long-term results of cementless total hip arthroplasty with subtrochanteric shortening osteotomy in Crowe type IV developmental dysplasia. J Arthroplasty, 2016,32(4):1211-1219.
22 White TO, Dougall TW. Arthroplasty of the hip. Leg length is not important. J Bone Joint Surg(Br), 2002, 84(3):335-338.
23孙菁阳,周勇刚,高志森,等.人工全髋关节置换术治疗CroweⅣ型髋关节发育不良术中应用粗隆下截骨的相关研究.中国修复重建外科杂志,2018, 32(2):152-156.
24朱建辛,王跃,庞健,等.人工全髋关节置换术治疗重度成人髋关节发育不良疗效分析.中国修复重建外科杂志,2014, 28(3):335-338.
2 Lee SH, Chen IJ, Li YH, et al. Incidence of second hip fractures and associated mortality in Taiwan:A nationwide population-based study of 95,484 patients during 2006-2010. Acta Orthop Traumatol Turc, 2016, 50(4):437-442.
3 Desteli E, Imren Y, Erdogan M, et al. Quality of life following treatment of trochanteric fractures with proximal femoral nail versus cementless bipolar hemiarthroplasty in elderly. Clin Invest Med, 2015, 38(2):E63-E72.
4 Arslan A, Utkan A, Koca TT. Results of a compression pin alongwith trochanteric external fixation in management of high risk elderly intertrochanteric fractures. Indian J Orthop, 2016,50(6):636-640.
5 Teague DC, Ertl WJ, Hickerson L, et al. What is new in orthopaedic trauma. J Bone Joint Surg(Am),2016, 98(13):1142-1149.
6 Matre K, Havelin LI, Gjertsen JE, et al. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures.A study of 2716 patients in Norwegian Hip Fracture Register.Injury, 2013, 44(6):735-742.
7 Ovesen O, Andersen M, Poulsen T, et al. The trochanteric gamma nail versus the dynamic hip screw:a prospective randomized study.One-year follow-up of 146 intertrochanteric fractures. Hip Int,2006,16(4):293-298.
8 Yuan BJ, Abdel MP, Cross WW, et al. Hip arthroplasty after surgical treatment of intertrochanteric hip fractures. J Arthroplasty, 2017, 32(11):3438-3444.
9 Winemaker M,Gamble P, Petruccelli D, et al. Short-term outcomes of total hip arthroplasty after complications of open reduction internal fixation for hip fracture. J Arthroplasty, 2006,21(5):682-688.
10 Srivastav S, Mittal V, Agarwal S. Total hip arthroplasty following failed fixation of proximal hip fractures. Indian J Orthop, 2008,42(3):279-286.
11 Tsai SW, Chen CF, Wu PK, et al. Does implant selection impact postoperative complications following hip arthroplasty for failed intertrochanteric fractures? A retrospective comparative study Artif Organs, 2016, 40(8):798-804.
12 Lee YK, Kim JT, Alkitaini AA, et al. Conversion hip arthroplasty in failed fixation of intertrochanteric fracture:A propensity score matching study. J Arthroplasty, 2017, 32(5):1593-1598.
13周宗科,翁习生,曲铁兵,等.中国髋、膝关节置换术加速康复-围术期管理策略识专家共识.中华骨与关节外科杂志,2016, 9(1):1-9.
14 Floren M, Lester DK. Durability of implant fixation after lessinvasive total hip arthroplasty. J Arthroplasty, 2006,21(6):783-790.
15 Cho CH, Yoon SH, Kim SY. Better functional outcome of salvage THA than bipolar hemiarthroplasty for failed intertrochanteric femur fracture fixation. Orthopedics, 2010, 33(10):721-726.
16 Chen DW, Lin CL, Hu CC, et al. Biomechanical consideration of total hip arthroplasty following failed fixation of femoral intertrochanteric fractures-a finite element analysis. Med Eng Phys,2013, 35(5):569-575.
17 Greidanus NV, Masri BA, Garbuz DS, et al. Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty. J Bone Joint Surg(Am), 2007, 89(7):1409-1416.
18 Mabry TM, Prpa B, Haidukewych GJ, et al. Long-term results of total hip arthroplasty for femoral neck fracture nonunion. J Bone Joint Surg(Am), 2004, 86-A(10):2263-2267.
19 Chen YT, Chen WM, Lee KS, et al. Diaphyseal locking hip arthroplasty for treatment of failed fixation of intertrochanteric hip fractures. J Arthroplasty, 2008,23(2):241-246.
20 Pui CM, Bostrom MP, Westrich GH, et al. Increased complicationrate following conversion total hip arthroplasty after cephalomedullary fixation for intertrochanteric hip fractures:a multicenter study. J Arthroplasty, 2013, 28(8 Suppl):45-47.
21 Wang D, Li LL, Wang HY, et al. Long-term results of cementless total hip arthroplasty with subtrochanteric shortening osteotomy in Crowe type IV developmental dysplasia. J Arthroplasty, 2016,32(4):1211-1219.
22 White TO, Dougall TW. Arthroplasty of the hip. Leg length is not important. J Bone Joint Surg(Br), 2002, 84(3):335-338.
23孙菁阳,周勇刚,高志森,等.人工全髋关节置换术治疗CroweⅣ型髋关节发育不良术中应用粗隆下截骨的相关研究.中国修复重建外科杂志,2018, 32(2):152-156.
24朱建辛,王跃,庞健,等.人工全髋关节置换术治疗重度成人髋关节发育不良疗效分析.中国修复重建外科杂志,2014, 28(3):335-338.
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