半髋与全髋关节置换术治疗老年股骨颈骨折的比较研究
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摘要
目的通过对采用半髋和全髋关节置换术治疗的老年股骨颈骨折的患者进行随访研究,评估影像学结果及临床疗效,探讨适合老年股骨颈骨折的最佳手术方法。
方法选取1998年1月至2008年1月在苏州大学附属第一医院骨科采用单极股骨头假体(unipolar prosthesis, UP)或双极股骨头假体(bipolar prosthesis,BP)行半髋关节置换术(hemiarthroplasty,HA)和采用全髋关节置换术(total hip arthroplasty,THA)治疗的老年移位股骨颈骨折的患者进行随访研究。共获得病例145例145髋,其中采用UP置换患者40例40髋,BP置换患者44例44髋,THA组患者61例61髋。UP置换组中,男13例,女27例,年龄67～93岁,平均80岁;BP置换组中,男9例,女35例,年龄65～97岁,平均81岁,THA组中,男18例,女43例,年龄65～80岁,平均72岁。其中HA组选用锥形多孔表涂设计等现代股骨柄行生物学固定40例,选用国产仿Austin Moore、Thompson ,以及Bateman等老式股骨柄分别行骨水泥和生物学固定15例和29例。THA组选用老式柄行骨水泥固定30例,生物学固定11例,选用锥形柄等现代股骨柄行生物学固定20例。(1)临床疗效方面:分别从手术时间,术中失血量,住院时间及术后并发症等方面进行比较,并采用Harris评分标准对患者进行定期功能评分;(2)影像学方面,采用Labelle法对髋臼软骨磨损程度进行测量,并采用Kwok法对人工股骨头—髋臼匹配度进行测量,从而对影响髋臼软骨磨损的因素进行分析;假体松动方面,骨水泥型股骨假体松动的测量采用Harris标准,髋臼假体松动测量依据Delee标准进行测量,而生物型股骨假体松动采用Engh标准,髋臼假体根据Kawamura标准进行测量。
结果所有患者术中及术后均无严重并发症发生。术后平均随访5.4年,随访期间失访27例,非手术原因死亡15例。共有103例获得完整随访资料,其中UP组24例,BP组26例,THA组53例。在手术时间、失血量及住院时间上相比较,HA组内无明显差异,而THA组则显著长于HA组。而在临床疗效方面,三组患者术后1年时Harris评分结果显示THA组优于HA组,HA组内结果显示BP组优于UP组。随访至术后5年,HA组Harris评分较术后1年显著下降,而THA组则无明显变化。影像学方面,HA组患者X线片显示:髋臼软骨总体磨损率为50%(25/50),其中UP和BP组的磨损率分别为83%(20/24)和19%(5/26),BP组显著低于UP组;所有患者假体总体肯定松动率为36.7%(38/103),髋臼假体2例,均为骨水泥固定型,股骨假体38例,其中老式柄骨水泥固定者11例,老式柄生物学固定者27例。5年总体翻修率为13%,其中UP和BP的翻修率分别为37.5%(9/24)和12%(3/26),而THA组较前两组显著降低,仅为3.8%(2/53)。
结论1.人工髋关节置换术治疗老年移位股骨颈骨折疗效显著。老年股骨颈骨折(GardenⅢ～Ⅳ型)一期行人工髋关节置换术,可避免内固定手术带来的骨折不愈合、股骨头缺血坏死及长期卧床引起的一系列并发症,大大提高了病人的生活质量,利于病人早期恢复。2. THA可以作为治疗老年股骨颈骨折的首选方法,以便获得更好的功能及避免翻修,而对于少数身体条件较差,运动量较小的高龄患者,可考虑选择BP置换,重建髋关节功能。3.在固定方式选择上,采用骨水泥固定的老式股骨柄及采用生物学固定的现代股骨柄比行生物学固定的老式股骨柄松动率更低,疗效更为理想。
Objective: To investigate the best operation mothed for the femoral neck fracture in the elderly by following-up the old patients with femoral neck fracture who were treated by HA and THA and analysising its radiographic examination and clinical results.
Methods: Follow-up the old patients with femoral neck fracture who were operated with UP,BP and THA in the first hospital affiliated to the suzhou university from January 1998 to January 2008. We all get 145 cases,in which 40 cases operated with unipolar prosthesis hemiarthroplasty,44 cases operated with bipolar prosthesis hemiarthroplasty and 61cases with total hip arthroplasty. In the UP group,there are 13 males and 27 females, and age from 67 to 93(average 80); In the BP group,there are 9 males and 35 females ,age from 65 to 97(average 81); In the THA group,there are 18 males and 43 females age from 65 to 80(average 72).In the HA group, there are 40 cases operated with contemporary prothesis with biologic fixtion , 29 cases operated with old prothesis like Austin Moore、Thompson and Bateman with cement fixtion and 15 cases with biologic fixtion .In the THA group,there are 15 cases operated with old prothesis with cement fixtion and 29 cases with biologic fixtion , and 20 cases with contemporary prothesis with biologic fixtion. clinical results include the operation time,blood loss in the operation,the in-hospital time ,complications after the operation and the Harris score. radiographic results : mesure the acetabular cartilage degenerates by Labell method and analysis the factors which may hasten the process.and mesure the lossement of implantation with Harris standard and so on.
Results: There were no severe complications in and after the operation.we followed-up all the cases for average 5.4 years,in which 27 cases losed visits ,and 15 cases dead for other reasons not related to the operation.103 cases were followed-up with complete results:24 cases with UP,26 cases with BP and 53 cases with THA.There were no differences in the operation time、blood loss in operation and the in-hospital time in the HA group.Wheras it shows obvious diffences between the THA group and the HA group. The Harris score 1 year after operation showed THA group is better than HA group ,and BP group is better than UP group. The Harris score of HA group decrease abselotely,while the THA group keeps well in the next 5 years after the operation.The HA group’s X ray film shows: The rate of cartilago acetabularis abrasion is 50%(25/50), and 83%(20/24)of the BP group shows better than 19%(5/26)of the UP group. The lossening rate of all cases is 36.7%(38/103)including 2 acetabular components and 38 femur prothesises.The old femur prothesises with cement fixtion was 11 cases and with biologic fixtion was 27 cases.The whole reoperation rate was 13%,37.5%(9/24) in the UP group and 12%(3/26)in the BP group,while the THA group is absolutely lower than the former groups with only 3.8%(2/53).
Conclusion: 1 Athroplasty shows obvious clinical results in the treatment of the displaced femoral neck fracture of the old patients.Primary athroplasty in the treatment of displaced femoral neck fracture in the elderly could avoid fracture nonunion after internal fixation and femoral head nacrosis so that it could improve the patients’life quality and prompt their recovery time. 2 We advise that THA can be the primary method in the treatment of the displaced femoral neck of the old patients because they could help get better function and avoid complications like reoperation and so on.while for the patients with poor health and less movement we advise BP as the primary treatment method. 3 Old stem with cement fixtion and contemporary stem with biologic fixtion shows better results in the lossement rate than old stem with biologic fixtion.
方法选取1998年1月至2008年1月在苏州大学附属第一医院骨科采用单极股骨头假体(unipolar prosthesis, UP)或双极股骨头假体(bipolar prosthesis,BP)行半髋关节置换术(hemiarthroplasty,HA)和采用全髋关节置换术(total hip arthroplasty,THA)治疗的老年移位股骨颈骨折的患者进行随访研究。共获得病例145例145髋,其中采用UP置换患者40例40髋,BP置换患者44例44髋,THA组患者61例61髋。UP置换组中,男13例,女27例,年龄67～93岁,平均80岁;BP置换组中,男9例,女35例,年龄65～97岁,平均81岁,THA组中,男18例,女43例,年龄65～80岁,平均72岁。其中HA组选用锥形多孔表涂设计等现代股骨柄行生物学固定40例,选用国产仿Austin Moore、Thompson ,以及Bateman等老式股骨柄分别行骨水泥和生物学固定15例和29例。THA组选用老式柄行骨水泥固定30例,生物学固定11例,选用锥形柄等现代股骨柄行生物学固定20例。(1)临床疗效方面:分别从手术时间,术中失血量,住院时间及术后并发症等方面进行比较,并采用Harris评分标准对患者进行定期功能评分;(2)影像学方面,采用Labelle法对髋臼软骨磨损程度进行测量,并采用Kwok法对人工股骨头—髋臼匹配度进行测量,从而对影响髋臼软骨磨损的因素进行分析;假体松动方面,骨水泥型股骨假体松动的测量采用Harris标准,髋臼假体松动测量依据Delee标准进行测量,而生物型股骨假体松动采用Engh标准,髋臼假体根据Kawamura标准进行测量。
结果所有患者术中及术后均无严重并发症发生。术后平均随访5.4年,随访期间失访27例,非手术原因死亡15例。共有103例获得完整随访资料,其中UP组24例,BP组26例,THA组53例。在手术时间、失血量及住院时间上相比较,HA组内无明显差异,而THA组则显著长于HA组。而在临床疗效方面,三组患者术后1年时Harris评分结果显示THA组优于HA组,HA组内结果显示BP组优于UP组。随访至术后5年,HA组Harris评分较术后1年显著下降,而THA组则无明显变化。影像学方面,HA组患者X线片显示:髋臼软骨总体磨损率为50%(25/50),其中UP和BP组的磨损率分别为83%(20/24)和19%(5/26),BP组显著低于UP组;所有患者假体总体肯定松动率为36.7%(38/103),髋臼假体2例,均为骨水泥固定型,股骨假体38例,其中老式柄骨水泥固定者11例,老式柄生物学固定者27例。5年总体翻修率为13%,其中UP和BP的翻修率分别为37.5%(9/24)和12%(3/26),而THA组较前两组显著降低,仅为3.8%(2/53)。
结论1.人工髋关节置换术治疗老年移位股骨颈骨折疗效显著。老年股骨颈骨折(GardenⅢ～Ⅳ型)一期行人工髋关节置换术,可避免内固定手术带来的骨折不愈合、股骨头缺血坏死及长期卧床引起的一系列并发症,大大提高了病人的生活质量,利于病人早期恢复。2. THA可以作为治疗老年股骨颈骨折的首选方法,以便获得更好的功能及避免翻修,而对于少数身体条件较差,运动量较小的高龄患者,可考虑选择BP置换,重建髋关节功能。3.在固定方式选择上,采用骨水泥固定的老式股骨柄及采用生物学固定的现代股骨柄比行生物学固定的老式股骨柄松动率更低,疗效更为理想。
Objective: To investigate the best operation mothed for the femoral neck fracture in the elderly by following-up the old patients with femoral neck fracture who were treated by HA and THA and analysising its radiographic examination and clinical results.
Methods: Follow-up the old patients with femoral neck fracture who were operated with UP,BP and THA in the first hospital affiliated to the suzhou university from January 1998 to January 2008. We all get 145 cases,in which 40 cases operated with unipolar prosthesis hemiarthroplasty,44 cases operated with bipolar prosthesis hemiarthroplasty and 61cases with total hip arthroplasty. In the UP group,there are 13 males and 27 females, and age from 67 to 93(average 80); In the BP group,there are 9 males and 35 females ,age from 65 to 97(average 81); In the THA group,there are 18 males and 43 females age from 65 to 80(average 72).In the HA group, there are 40 cases operated with contemporary prothesis with biologic fixtion , 29 cases operated with old prothesis like Austin Moore、Thompson and Bateman with cement fixtion and 15 cases with biologic fixtion .In the THA group,there are 15 cases operated with old prothesis with cement fixtion and 29 cases with biologic fixtion , and 20 cases with contemporary prothesis with biologic fixtion. clinical results include the operation time,blood loss in the operation,the in-hospital time ,complications after the operation and the Harris score. radiographic results : mesure the acetabular cartilage degenerates by Labell method and analysis the factors which may hasten the process.and mesure the lossement of implantation with Harris standard and so on.
Results: There were no severe complications in and after the operation.we followed-up all the cases for average 5.4 years,in which 27 cases losed visits ,and 15 cases dead for other reasons not related to the operation.103 cases were followed-up with complete results:24 cases with UP,26 cases with BP and 53 cases with THA.There were no differences in the operation time、blood loss in operation and the in-hospital time in the HA group.Wheras it shows obvious diffences between the THA group and the HA group. The Harris score 1 year after operation showed THA group is better than HA group ,and BP group is better than UP group. The Harris score of HA group decrease abselotely,while the THA group keeps well in the next 5 years after the operation.The HA group’s X ray film shows: The rate of cartilago acetabularis abrasion is 50%(25/50), and 83%(20/24)of the BP group shows better than 19%(5/26)of the UP group. The lossening rate of all cases is 36.7%(38/103)including 2 acetabular components and 38 femur prothesises.The old femur prothesises with cement fixtion was 11 cases and with biologic fixtion was 27 cases.The whole reoperation rate was 13%,37.5%(9/24) in the UP group and 12%(3/26)in the BP group,while the THA group is absolutely lower than the former groups with only 3.8%(2/53).
Conclusion: 1 Athroplasty shows obvious clinical results in the treatment of the displaced femoral neck fracture of the old patients.Primary athroplasty in the treatment of displaced femoral neck fracture in the elderly could avoid fracture nonunion after internal fixation and femoral head nacrosis so that it could improve the patients’life quality and prompt their recovery time. 2 We advise that THA can be the primary method in the treatment of the displaced femoral neck of the old patients because they could help get better function and avoid complications like reoperation and so on.while for the patients with poor health and less movement we advise BP as the primary treatment method. 3 Old stem with cement fixtion and contemporary stem with biologic fixtion shows better results in the lossement rate than old stem with biologic fixtion.
引文
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21. Sinha, R.K., D.S. Dungy, and H.B. Yeon.Primary total hip arthroplasty with a proximally porous-coated femoral stem. J Bone Joint Surg Am.2004, 86-A(6): 1254-61.
22. Sporer, S.M., R.J. Obar, and P.M. Bernini, Primary total hip arthroplasty using a modular proximally coated prosthesis in patients older than 70: two to eight year results. J Arthroplasty.2004, 19(2): 197-203.
23. Moskal, J.T, Jordan,Brown.The porous-coated anatomic total hip prosthesis: 11- to
13-year results. J Arthroplasty.2004,19(7): 837-44.
24. Roden, M, M. Schon, Fredin.Treatment of displaced femoral neck fractures: a randomized minimum 5-year follow-up study of screws and bipolar hemiprostheses in
00 patients. Acta Orthop Scand.2003,74(1): 42-4.
25. Blomfeldt, R, et al.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. Acta Orthop.2006,77(4): 638-43.
26.马若凡,刘尚礼,黄东生,等,内固定与人工髋关节置换术治疗老年性股骨颈骨折的疗效比较.中华创伤杂志, 2002,18(4): 232-23.
27. Bhandari, M,etal.Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am.2003,85-A(9): 1673-81.
28. Masson, M,Parker, Fleischer.Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev.2003,(2): CD001708.
29. Frank J, ChapmanC.B, Mauricio F.Unipolar or bipolar hemiarthroplasty for femoral neck fractures in the elderly? Clinical Orthopaedics & Related Research.2003,414: 259-265.
30. Shah, S.N,Wainess,Karunakar.Hemiarthroplasty for femoral neck fracture in the elderly surgeon and hospital volume-related outcomes. J Arthroplasty.2005,20(4):. 503-8.
31. Hudson, J.I, et al.Eight-year outcome associated with clinical options in the management of femoral neck fractures. Clin Orthop Relat Res.1998,(348): 59-66.
32. Cornell, C.N, et al.Unipolar versus bipolar hemiarthroplasty for the treatment of femoral neck fractures in the elderly. Clin Orthop Relat Res.1998,(348): 67-71.
33. Calder, S.J.et al. Unipolar or bipolar prosthesis for displaced intracapsular hip fracture in octogenarians: a randomised prospective study. J Bone Joint Surg Br.1996,78(3): 391-4.
34. Dalldorf, P.G., et al. Rate of degeneration of human acetabular cartilage after hemiarthroplasty. J Bone Joint Surg Am.1995. 77(6):877-82.
35. Bateman, J.E.Single-assembly total hip prosthesis--preliminary report. 1974. Clin Orthop Relat Res.1990,(251): 3-6.
36. LaBelle, L.W.,Colwil Swanson. Bateman bipolar hip arthroplasty for femoral neck fractures. A five- to ten-year follow-up study. Clin Orthop Relat Res.1990,(251): 20-5.
37. Soreide, O, R,Skjaerven.The risk of acetabular protrusion following prosthetic replacement of the femoral head. Acta Orthop Scand.1982,53(5): 791-4.
38. Kwok, D.C. and R.L. Cruess, A retrospective study of Moore and Thompsonhemiarthroplasty. A review of 599 surgical cases and an analysis of the technical complications. Clin Orthop Relat Res. 1982,(169):179-85.
39. Bateman, J.E, et al.Long-term results of bipolar arthroplasty in osteoarthritis of the hip. Clin Orthop Relat Res,1990,(251):54-66.
40.孙月华,戴克戎,双极人工股骨头置换术后的假体运动观察.中华骨科杂志, 1992,12(10): 581.
41. Ravikumar, K.J. and G. Marsh, Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur--13 year results of a prospective randomised study. Injury. 2000,31(10): 793-7.
42.李佛保,盛璞义,韩士英等,人工股骨头置换与全髋关节置换术治疗股骨颈骨折.中华骨科杂志, 1999,19(3):152-4.
43. Squires, B.Displaced intracapsular neck of femur fractures in mobile independent patients: total hip replacement or hemiarthroplasty? Injury.1999,30(5): 345-8.
44. Crossman, P.T, et al.A survey of the treatment of displaced intracapsular femoral neck fractures in the UK. Injury.2002,33(5): 383-6
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20. Zgoda, M. Evaluation of femoral neck fracture treatment with hemiarthroplasty in elderly patients. Chir Narzadow Ruchu Ortop Pol.2002,67(5): 473-9.
21. Sinha, R.K., D.S. Dungy, and H.B. Yeon.Primary total hip arthroplasty with a proximally porous-coated femoral stem. J Bone Joint Surg Am.2004, 86-A(6): 1254-61.
22. Sporer, S.M., R.J. Obar, and P.M. Bernini, Primary total hip arthroplasty using a modular proximally coated prosthesis in patients older than 70: two to eight year results. J Arthroplasty.2004, 19(2): 197-203.
23. Moskal, J.T, Jordan,Brown.The porous-coated anatomic total hip prosthesis: 11- to
13-year results. J Arthroplasty.2004,19(7): 837-44.
24. Roden, M, M. Schon, Fredin.Treatment of displaced femoral neck fractures: a randomized minimum 5-year follow-up study of screws and bipolar hemiprostheses in
00 patients. Acta Orthop Scand.2003,74(1): 42-4.
25. Blomfeldt, R, et al.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. Acta Orthop.2006,77(4): 638-43.
26.马若凡,刘尚礼,黄东生,等,内固定与人工髋关节置换术治疗老年性股骨颈骨折的疗效比较.中华创伤杂志, 2002,18(4): 232-23.
27. Bhandari, M,etal.Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am.2003,85-A(9): 1673-81.
28. Masson, M,Parker, Fleischer.Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev.2003,(2): CD001708.
29. Frank J, ChapmanC.B, Mauricio F.Unipolar or bipolar hemiarthroplasty for femoral neck fractures in the elderly? Clinical Orthopaedics & Related Research.2003,414: 259-265.
30. Shah, S.N,Wainess,Karunakar.Hemiarthroplasty for femoral neck fracture in the elderly surgeon and hospital volume-related outcomes. J Arthroplasty.2005,20(4):. 503-8.
31. Hudson, J.I, et al.Eight-year outcome associated with clinical options in the management of femoral neck fractures. Clin Orthop Relat Res.1998,(348): 59-66.
32. Cornell, C.N, et al.Unipolar versus bipolar hemiarthroplasty for the treatment of femoral neck fractures in the elderly. Clin Orthop Relat Res.1998,(348): 67-71.
33. Calder, S.J.et al. Unipolar or bipolar prosthesis for displaced intracapsular hip fracture in octogenarians: a randomised prospective study. J Bone Joint Surg Br.1996,78(3): 391-4.
34. Dalldorf, P.G., et al. Rate of degeneration of human acetabular cartilage after hemiarthroplasty. J Bone Joint Surg Am.1995. 77(6):877-82.
35. Bateman, J.E.Single-assembly total hip prosthesis--preliminary report. 1974. Clin Orthop Relat Res.1990,(251): 3-6.
36. LaBelle, L.W.,Colwil Swanson. Bateman bipolar hip arthroplasty for femoral neck fractures. A five- to ten-year follow-up study. Clin Orthop Relat Res.1990,(251): 20-5.
37. Soreide, O, R,Skjaerven.The risk of acetabular protrusion following prosthetic replacement of the femoral head. Acta Orthop Scand.1982,53(5): 791-4.
38. Kwok, D.C. and R.L. Cruess, A retrospective study of Moore and Thompsonhemiarthroplasty. A review of 599 surgical cases and an analysis of the technical complications. Clin Orthop Relat Res. 1982,(169):179-85.
39. Bateman, J.E, et al.Long-term results of bipolar arthroplasty in osteoarthritis of the hip. Clin Orthop Relat Res,1990,(251):54-66.
40.孙月华,戴克戎,双极人工股骨头置换术后的假体运动观察.中华骨科杂志, 1992,12(10): 581.
41. Ravikumar, K.J. and G. Marsh, Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur--13 year results of a prospective randomised study. Injury. 2000,31(10): 793-7.
42.李佛保,盛璞义,韩士英等,人工股骨头置换与全髋关节置换术治疗股骨颈骨折.中华骨科杂志, 1999,19(3):152-4.
43. Squires, B.Displaced intracapsular neck of femur fractures in mobile independent patients: total hip replacement or hemiarthroplasty? Injury.1999,30(5): 345-8.
44. Crossman, P.T, et al.A survey of the treatment of displaced intracapsular femoral neck fractures in the UK. Injury.2002,33(5): 383-6