骨水泥与非骨水泥型双极人工股骨头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:通过对用骨水泥或非骨水泥型双极人工股骨头置换治疗老年股骨颈骨折的患者进行随访研究，探讨那种治疗方法最为理想。
方法：选取1998年1月至2011年1月在苏州大学附属第一医院及溧阳市人民医院行双极人工股骨头置换治疗老年股骨颈骨折的患者进行随访研究。共获得62例62髋，其中采用骨水泥固定30例，平均年龄79岁，分别选择国产仿Austin Moore设计的股骨柄假体置入者16例、仿Thompson设计的假体8例、以及仿Bateman设计的假体6例。非骨水泥固定32例，平均年龄80岁，均选择多孔表涂的锥形柄置入。临床疗效方面从手术时间，术中失血量，住院时间，平均下地时间等方面对患者进行比较，并采用Harris评分对两者术后进行定期功能评价。影像学方面对行骨水泥固定型股骨假体的松动按Harris标准评定，对非骨水泥固定型股骨柄假体的松动按Engh标准评定。
结果：所有骨水泥与非骨水泥固定组均无术中并发症如：休克、心跳呼吸停止、以及误伤神经血管等的发生，也无术后并发症如：脱位、感染、肺栓塞等的发生。在平均手术时间，失血量及平均住院日上，两组有显著性差异（P<0.0001）。骨水泥与非骨水泥固定组的平均下地行走时间分别为8d和6d,半年后的平均Harris评分分别为84±5分和82±7分，1年后的平均Harris评分分别为86±4分和85±4分，优良率分别为86%和82%。两组统计学检验除平均下地行走时间有显著性差异外，其他功能评分均无显著性差异。
结论：1双极人工股骨头置换术治疗老年股骨颈骨折疗效显著，早期手术可避免保守治疗或内固定治疗带来的骨折不愈合，股骨头坏死等并发症，可使患者早日恢复关节功能，提高生活质量。
2非骨水泥与骨水泥型双极人工股骨头假体置换治疗老年股骨颈骨折术后患者髋关节功能无显著性差异。
3对老年股骨颈骨折患者建议采用现代柄设计的双极头假体，行非骨水泥固定的置换术治疗。
Objective To evaluate the outcoms of the bipolar hemiarthroplastywith or without cement for the displaced femoral neck fractures in elderlypatients..
Methods Between Janurary1998and Janurary2011,62patients (62hips) with displaced femoral neck fractures were performed the bipolarhemiarthroplasty fixed with or without cement in the First Affiliated Hospitalof Soochow University and Liyang People’s Hospital. There were30hips(average70years old) in the cemented group and32hips (average80yearsold) in the cementless group. In the cemented group, three different stemswere applied,16stems with similar geometry of Austuin Moore,8stemssimilar with Thompson design as well as6stems similar with Bateman design.Porous, tapered stems wers inserted in the cementless group. Datum werecollected and assessed between the two groups, including surgical time,intraoperative blood loss,average hospital stay, average ambulation time aswell as Harris Hip Scores. The criteria used to define loosening of thecemented femoral component have been previously reported by Harris et al. The stability of the uncemented femoral component was classified as boneingrown, stable fibrous ingrown, or unstable by Engh et al.
Results No intraoperative complications occured, such as shock,cardiopulmonary arrest and neurovascular injury. There were aslo nopostoperative complications, including dislocation, infection and pulmonaryembolism. There were significant difference in the surgical time, total bloodloss and average hospital stay between the cemented fixation group and theuncemented fixation group (p<0.0001). The two groups differed significantlywith regard of the average ambulation time, which was eight days in thecemented group and six day in the uncemented group. The average Harris hipscores in the group treated with cement (84±5points) and the group treatedwithout cement (82±7points) were similar and not significant different at thetime of six months after operation. It was similar of the average Harris hisscores at one year after operation in the cemented group and uncementedgroup,86±4and85±4points,respectively. There were no significantdifference in terms of excellent and good rates of the clinical outcome,86%inthe cemented group and82%in the uncemented group respectively.
Conclusions1. In comparison with internal fixation or conservativetreatment, bipolar arthroplasty for the treatment of a displaced femoral neckfracture significantly improves the function and the heath-related quality ofthe life and reduces the risk of avascular necrosis of femoral head and the nonunion, both of which are serious problems following internal fixation.
2. There was no significant difference in terms of hip function afterbipolar arthroplasty was performed for the the femoral neck fracture in theelderly patients with or without cement.
3. It is recommended that displaced femoral neck fractures in the elderlyshould generally be treated by bipolar arthroplasty without cement.
方法：选取1998年1月至2011年1月在苏州大学附属第一医院及溧阳市人民医院行双极人工股骨头置换治疗老年股骨颈骨折的患者进行随访研究。共获得62例62髋，其中采用骨水泥固定30例，平均年龄79岁，分别选择国产仿Austin Moore设计的股骨柄假体置入者16例、仿Thompson设计的假体8例、以及仿Bateman设计的假体6例。非骨水泥固定32例，平均年龄80岁，均选择多孔表涂的锥形柄置入。临床疗效方面从手术时间，术中失血量，住院时间，平均下地时间等方面对患者进行比较，并采用Harris评分对两者术后进行定期功能评价。影像学方面对行骨水泥固定型股骨假体的松动按Harris标准评定，对非骨水泥固定型股骨柄假体的松动按Engh标准评定。
结果：所有骨水泥与非骨水泥固定组均无术中并发症如：休克、心跳呼吸停止、以及误伤神经血管等的发生，也无术后并发症如：脱位、感染、肺栓塞等的发生。在平均手术时间，失血量及平均住院日上，两组有显著性差异（P<0.0001）。骨水泥与非骨水泥固定组的平均下地行走时间分别为8d和6d,半年后的平均Harris评分分别为84±5分和82±7分，1年后的平均Harris评分分别为86±4分和85±4分，优良率分别为86%和82%。两组统计学检验除平均下地行走时间有显著性差异外，其他功能评分均无显著性差异。
结论：1双极人工股骨头置换术治疗老年股骨颈骨折疗效显著，早期手术可避免保守治疗或内固定治疗带来的骨折不愈合，股骨头坏死等并发症，可使患者早日恢复关节功能，提高生活质量。
2非骨水泥与骨水泥型双极人工股骨头假体置换治疗老年股骨颈骨折术后患者髋关节功能无显著性差异。
3对老年股骨颈骨折患者建议采用现代柄设计的双极头假体，行非骨水泥固定的置换术治疗。
Objective To evaluate the outcoms of the bipolar hemiarthroplastywith or without cement for the displaced femoral neck fractures in elderlypatients..
Methods Between Janurary1998and Janurary2011,62patients (62hips) with displaced femoral neck fractures were performed the bipolarhemiarthroplasty fixed with or without cement in the First Affiliated Hospitalof Soochow University and Liyang People’s Hospital. There were30hips(average70years old) in the cemented group and32hips (average80yearsold) in the cementless group. In the cemented group, three different stemswere applied,16stems with similar geometry of Austuin Moore,8stemssimilar with Thompson design as well as6stems similar with Bateman design.Porous, tapered stems wers inserted in the cementless group. Datum werecollected and assessed between the two groups, including surgical time,intraoperative blood loss,average hospital stay, average ambulation time aswell as Harris Hip Scores. The criteria used to define loosening of thecemented femoral component have been previously reported by Harris et al. The stability of the uncemented femoral component was classified as boneingrown, stable fibrous ingrown, or unstable by Engh et al.
Results No intraoperative complications occured, such as shock,cardiopulmonary arrest and neurovascular injury. There were aslo nopostoperative complications, including dislocation, infection and pulmonaryembolism. There were significant difference in the surgical time, total bloodloss and average hospital stay between the cemented fixation group and theuncemented fixation group (p<0.0001). The two groups differed significantlywith regard of the average ambulation time, which was eight days in thecemented group and six day in the uncemented group. The average Harris hipscores in the group treated with cement (84±5points) and the group treatedwithout cement (82±7points) were similar and not significant different at thetime of six months after operation. It was similar of the average Harris hisscores at one year after operation in the cemented group and uncementedgroup,86±4and85±4points,respectively. There were no significantdifference in terms of excellent and good rates of the clinical outcome,86%inthe cemented group and82%in the uncemented group respectively.
Conclusions1. In comparison with internal fixation or conservativetreatment, bipolar arthroplasty for the treatment of a displaced femoral neckfracture significantly improves the function and the heath-related quality ofthe life and reduces the risk of avascular necrosis of femoral head and the nonunion, both of which are serious problems following internal fixation.
2. There was no significant difference in terms of hip function afterbipolar arthroplasty was performed for the the femoral neck fracture in theelderly patients with or without cement.
3. It is recommended that displaced femoral neck fractures in the elderlyshould generally be treated by bipolar arthroplasty without cement.
引文
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2. Xu, L., et al., Very low rates of hip fracture in Beijing, People's Republicof China the Beijing Osteoporosis Project. Am J Epidemiol,1996.144(9):p.901-7.
3. Rogmark, C., et al., A prospective randomised trial of internal fixationversus arthroplasty for displaced fractures of the neck of the femur.Functional outcome for450patients at two years. J Bone Joint Surg Br,
2002.84(2): p.183-8.
4.Leonardsson O,Sernbo I,Carlsson A,et al. Long-term follow-up ofreplacement compared with internal fixation for displacement femoralneck fractures.J Bone Joint Surg(Br),2010,92(3):406-412.
5.孙俊英.人工关节的有关基础和临床问题（专家论坛）,中华创伤杂志2007，23（11）：801-804。
6.Figved W,Opland V,Frihagen F, et al. Cemented versus uncementedhemiarthroplasty for displaced femoral neck fractures. Clin Orthop2009,467:2426-2435.
7.Ahn J，Man LX,Park SD, et al. Systematic review of cemented anduncemented hemiarthroplasty outcomes for femoral neck fractures. ClinOrthop2008,466:2513-2518.
8.Parker MI,Pryor G,Gurusamy K. Cemented versus uncementedhemiarthroplasty for intracapsular hip fractures.J Bone Joint Surg(Br),2010,92(1):116-122.
9.Harris WH, Crothers O,Indong O: Total hip replacement and femoral headbone grafting for severe acetabualr deficiency in adults.J Bone JointSurg59A:752-759,1977.
10.Harris WH, Crothers O,Indong O: Total hip replacement and femoral headbone grafting for severe acetabualr deficiency in adults.J Bone JointSurg59A:752-759,1977.
11.Engh CA,Glassman AH,Griffin WL,et al.Results of cementless revision forfailed cemented total hip arthroplasty.Clin Orthop,1988,235:91-110.
12. Macaulay W,Yoon RS,Parsley B,et al.Displaced femoral neck fracture:isthere a standard of care J.Orthopedics,2007,30(9):748-749.
13.危杰，毛玉江，贾正中，等.中空加压螺钉治疗新鲜股骨颈骨折212例J.中华创伤杂志，2000:16（3）：142-4.
14.卫小春.髋关节置换-老年股骨颈骨折的有效治疗方法J.中华医学杂志.2005,85（46）：3243-3244.
15. Wang J,Jiang B.Marshall RJ,et al.Arthroplasty or internal fixation fordisplaced femoral neck fractures:which is the optimal altemative forelderly patients? A meta-analysis J.Int orthop,2009.33（5）:1179-11897.
16. Kenzora JE,Magazines J.Hudson J,et al.Outcome after Himiarthroplastyfor femoral neck fractures in the elderlyJ.Clin Orthop Trauma,1998,29(3):51-58.
17. Phillips TW.Thompson hemiarthroplasty and acetabular erosion J.Bonejoint surg(AM),1989,71,913.
18.杨维权，刘大雄，孙荣华，等。三种假体置换治疗老年股骨颈骨折疗效观察J.骨与关节损伤杂志，2000,15（3）：163-164.
19.Lausten GS,Vedel P Fracture of femoral neck treated with bipolarendoprosthesis J.Clin Orthop,1987,218:65.
20. Ekelund A,Rydell N,Nilsson OS.Total hip arthoplasty in patients80yearsof age and older.Clin Orthop,1992,(281)：101-6.
21. Newington DP,Bannister GC,Fordyce M.Primary total hip replacement inpatients over years age.J Bone Joint Surg Br.1990,72（3）：450-2.
22. Konstantoulakis C. Anastopoulos G.Papaeliou A.et al.Uncemented totalhip arthroplasty in the elderly.International Orthopaedics.1999,23(6)：3347-6.
23.Pieringer H，Labek G，Auersperg V,et al. Cenentless total hip arthroplastyin patients older than80years of age.J Bone Joint Surg Br.2003,85
１．Ｋａｋａｒ Ｓ，D, Eanhorn T A.Can we improve fixation andoutcomes in the treatment of femoral neck fracture? The use ofpharmaceuticalsJ.J Orthop Traumu.2009.23(6):413-421
2.薛锦林朱文峰。老年股骨颈骨质治疗方法选择的探讨J.中国老年保健医学，2010,8（6）:11-12.
3. Bhandari M.Devereaux PJ.Swiontkowski MF,et al.Internal fixation ofcompared with arthroplasty for displaced fractures of the femoral neck:ameta-analysis. J Bone Joint Surg(Am).2003,85:1673-1681.
4.王亦璁。骨与关节损伤M.四版.北京：人民出版社，2007:1164-1175.
5.Oakey JW, Stover MD. Sumers HD, et al.Does screw configuration affectsubtrochanteric fracture after femoral neck fixation? Clin Orthop RelatRes,2006,(443):302-306.
6. UPadhyay A.Jain P, Mishra P, et al.Delayed internal fixation of fracture ofthe neck of the femur in young adults.J Bone JointSurg(Br),2004,86:1035-1040.
7. Alves T,Neal JW.Weinhold PS.et al.Biomechanical comparison of3possible fixation strategies to resist femoral neck shorting afterfracture.Orthopedics,2010,16:233-237.
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21. Bhandari M, Devereaux PJ,Swiontkowski MF,et al. Internal fixationcompared with arthroplasty for displaced fractures of the femoralneck.AJBJSA
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24.吴金伟，吴有荣，卢盛华，等。人工股骨头置换术和全髋关节置换术治疗老年股骨颈骨折的疗效观察J.河北医学，2009,15（8）：925－928.
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29. Pitto RP,Schramm M.Hohmann D, et al.Rrlevance of the drainage alongthe linea aspera for the reduction of fat embolism during cemented totalhip arthroplasty.A prospective randomized clinical trial.Arch Orthopand Trauma Surg,1999,119:146.
2. Xu, L., et al., Very low rates of hip fracture in Beijing, People's Republicof China the Beijing Osteoporosis Project. Am J Epidemiol,1996.144(9):p.901-7.
3. Rogmark, C., et al., A prospective randomised trial of internal fixationversus arthroplasty for displaced fractures of the neck of the femur.Functional outcome for450patients at two years. J Bone Joint Surg Br,
2002.84(2): p.183-8.
4.Leonardsson O,Sernbo I,Carlsson A,et al. Long-term follow-up ofreplacement compared with internal fixation for displacement femoralneck fractures.J Bone Joint Surg(Br),2010,92(3):406-412.
5.孙俊英.人工关节的有关基础和临床问题（专家论坛）,中华创伤杂志2007，23（11）：801-804。
6.Figved W,Opland V,Frihagen F, et al. Cemented versus uncementedhemiarthroplasty for displaced femoral neck fractures. Clin Orthop2009,467:2426-2435.
7.Ahn J，Man LX,Park SD, et al. Systematic review of cemented anduncemented hemiarthroplasty outcomes for femoral neck fractures. ClinOrthop2008,466:2513-2518.
8.Parker MI,Pryor G,Gurusamy K. Cemented versus uncementedhemiarthroplasty for intracapsular hip fractures.J Bone Joint Surg(Br),2010,92(1):116-122.
9.Harris WH, Crothers O,Indong O: Total hip replacement and femoral headbone grafting for severe acetabualr deficiency in adults.J Bone JointSurg59A:752-759,1977.
10.Harris WH, Crothers O,Indong O: Total hip replacement and femoral headbone grafting for severe acetabualr deficiency in adults.J Bone JointSurg59A:752-759,1977.
11.Engh CA,Glassman AH,Griffin WL,et al.Results of cementless revision forfailed cemented total hip arthroplasty.Clin Orthop,1988,235:91-110.
12. Macaulay W,Yoon RS,Parsley B,et al.Displaced femoral neck fracture:isthere a standard of care J.Orthopedics,2007,30(9):748-749.
13.危杰，毛玉江，贾正中，等.中空加压螺钉治疗新鲜股骨颈骨折212例J.中华创伤杂志，2000:16（3）：142-4.
14.卫小春.髋关节置换-老年股骨颈骨折的有效治疗方法J.中华医学杂志.2005,85（46）：3243-3244.
15. Wang J,Jiang B.Marshall RJ,et al.Arthroplasty or internal fixation fordisplaced femoral neck fractures:which is the optimal altemative forelderly patients? A meta-analysis J.Int orthop,2009.33（5）:1179-11897.
16. Kenzora JE,Magazines J.Hudson J,et al.Outcome after Himiarthroplastyfor femoral neck fractures in the elderlyJ.Clin Orthop Trauma,1998,29(3):51-58.
17. Phillips TW.Thompson hemiarthroplasty and acetabular erosion J.Bonejoint surg(AM),1989,71,913.
18.杨维权，刘大雄，孙荣华，等。三种假体置换治疗老年股骨颈骨折疗效观察J.骨与关节损伤杂志，2000,15（3）：163-164.
19.Lausten GS,Vedel P Fracture of femoral neck treated with bipolarendoprosthesis J.Clin Orthop,1987,218:65.
20. Ekelund A,Rydell N,Nilsson OS.Total hip arthoplasty in patients80yearsof age and older.Clin Orthop,1992,(281)：101-6.
21. Newington DP,Bannister GC,Fordyce M.Primary total hip replacement inpatients over years age.J Bone Joint Surg Br.1990,72（3）：450-2.
22. Konstantoulakis C. Anastopoulos G.Papaeliou A.et al.Uncemented totalhip arthroplasty in the elderly.International Orthopaedics.1999,23(6)：3347-6.
23.Pieringer H，Labek G，Auersperg V,et al. Cenentless total hip arthroplastyin patients older than80years of age.J Bone Joint Surg Br.2003,85
１．Ｋａｋａｒ Ｓ，D, Eanhorn T A.Can we improve fixation andoutcomes in the treatment of femoral neck fracture? The use ofpharmaceuticalsJ.J Orthop Traumu.2009.23(6):413-421
2.薛锦林朱文峰。老年股骨颈骨质治疗方法选择的探讨J.中国老年保健医学，2010,8（6）:11-12.
3. Bhandari M.Devereaux PJ.Swiontkowski MF,et al.Internal fixation ofcompared with arthroplasty for displaced fractures of the femoral neck:ameta-analysis. J Bone Joint Surg(Am).2003,85:1673-1681.
4.王亦璁。骨与关节损伤M.四版.北京：人民出版社，2007:1164-1175.
5.Oakey JW, Stover MD. Sumers HD, et al.Does screw configuration affectsubtrochanteric fracture after femoral neck fixation? Clin Orthop RelatRes,2006,(443):302-306.
6. UPadhyay A.Jain P, Mishra P, et al.Delayed internal fixation of fracture ofthe neck of the femur in young adults.J Bone JointSurg(Br),2004,86:1035-1040.
7. Alves T,Neal JW.Weinhold PS.et al.Biomechanical comparison of3possible fixation strategies to resist femoral neck shorting afterfracture.Orthopedics,2010,16:233-237.
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