中国修复重建外科杂志

中国修复重建外科杂志

老年髋部骨折手术方法的选择原则及应用现状

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目的 针对老年髋部骨折主要骨折类型(股骨颈骨折及粗隆骨折),总结手术方法及内固定物选择标准以及临床应用现状。 方法 广泛查阅国内外有关老年股骨颈骨折以及粗隆骨折治疗的文献,并进行总结分析。 结果 对于老年股骨颈骨折患者,若无特殊手术禁忌证,65 岁以下患者建议行闭合复位内固定术或动力髋螺钉(dynamic hip screw,DHS),65~80 岁患者选择全髋关节置换术;身体情况相对较差的高龄患者可选择半髋关节置换术。对于老年股骨粗隆骨折患者,稳定型骨折可选用 DHS 或第 3 代 Gamma 钉;不稳定型股骨粗隆骨折,可根据骨折类型、骨质情况等选用股骨近端防旋髓内钉、股骨粗隆顺行髓内钉等髓内固定系统以及股骨近端锁定加压钢板、微创内固定系统等髓外固定系统;高龄粉碎性股骨粗隆骨折建议行髋关节置换。 结论 老年髋部骨折治疗应结合骨折类型及患者自身情况选择恰当的手术方案及内固定物,以提高手术疗效,减少并发症的发生。

Objective To summarize the selection criteria and clinical application of surgical methods for hip fractures (femoral neck fracture and intertrochanteric fracture) in the elderly. Methods The related literature concerning the surgical methods for femoral neck fracture and intertrochanteric fracture in the elderly at home and abroad was extensively reviewed and summarized. Results Among the elderly patients with femoral neck fracture, the closed reduction and internal fixation or dynamic hip screw (DHS), and total hip arthroplasty are recommended for patients under 65 years old and 65–80 years old respectively and without special surgical contraindication; whereas hemiarthroplasty is recommended for patients with poor physical conditions. Among the patients with intertrochanteric fracture, DHS or the 3rd generation of Gamma nails is recommended for patients with stable fracture while the intramedullary fixation systems (e.g., proximal femoral nail anti-rotation, intertrochanteric antegrade nail) and the extramedullary fixation systems (e.g., proximal femoral locking compression plate and less invasive stabilization system) can be applied to the patients with unstable fracture according to the fracture type and bone conditions. Notably, hip arthroplasty is recommended for elderly patients with comminuted fracture. Conclusion The surgical method and internal fixator should be chosen according to the fracture type and bone condition in the elderly in order to improve the effectiveness and reduce the complication.

关键词: 股骨颈骨折; 股骨粗隆骨折; 内固定材料; 髋关节置换; 老年患者

Key words: Femoral neck fracture; intertrochanteric fracture; internal fixator; hip arthroplasty; elderly patients

引用本文: 丁涛, 张保焜, 田少奇, 王远贺, 孙康. 老年髋部骨折手术方法的选择原则及应用现状. 中国修复重建外科杂志, 2018, 32(11): 1435-1440. doi: 10.7507/1002-1892.201804084 复制

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1. Close JD, Swartz K, Deu R. Hip fracture in older patients: tips and tools to speed recovery. J Fam Pract, 2013, 62(9): 484-92.
2. Leonardsson O, Rolfson O, Hommel A, et al. Patient-reported outcome after displaced femoral neck fracture: a national survey of 4467 patients. J Bone Joint Surg (Am), 2013, 95(18): 1693-1699.
3. Hedbeck CJ, Inngul C, Blomfeldt R, et al. Internal fixation versus cemented hemiarthroplasty for displaced femoral neck fractures in patients with severe cognitive dysfunction: a randomized controlled trial. J Orthop Trauma, 2013, 27(12): 690-695.
4. Parvizi J, Ereth MH, Lewallen DG. Thirty-day mortality following hip arthroplasty for acute fracture. J Bone Joint Surg (Am), 2004, 86-A(9): 1983-1988.
5. Inngul C, Blomfeldt R, Ponzer S, et al. Cemented versus uncemented arthroplasty in patients with a displaced fracture of the femoral neck: a randomised controlled trial. Bone Joint J, 2015, 97-B(11): 1475-1480.
6. Blomfeldt R, Törnkvist H, Eriksson K, et al. A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg (Br), 2007, 89(2): 160-165.
7. Hopley C, Stengel D, Ekkernkamp A, et al. Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older patients: systematic review. BMJ, 2010, 340: c2332.
8. He JH, Zhou CP, Zhou ZK, et al. Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced femoral neck fractures in patients over 70 years old. Chin J Traumatol, 2012, 15(4): 195-200.
9. LaBelle LW, Colwill JC, Swanson AB. Bateman bipolar hip arthroplasty for femoral neck fractures. A five- to ten-year follow-up study. Clin Orthop Relat Res, 1990, (251): 20-25.
10. Zi-Sheng A, You-Shui G, Zhi-Zhen J, et al. Hemiarthroplasty vs primary total hip arthroplasty for displaced fractures of the femoral neck in the elderly: a meta-analysis. J Arthroplasty, 2012, 27(4): 583-590.
11. Uhler LM, Schultz WR, Hill AD, et al. Health utility of early hemiarthroplasty vs delayed total hip arthroplasty for displaced femoral neck fracture in elderly patients: A Markov model. J Arthroplasty, 2017, 32(5): 1434-1438.
12. 许猛, 张立海, 毛智, 等. 三种手术方式治疗老年移位型股骨颈骨折疗效比较. 中国修复重建外科杂志, 2010, 24(12): 1419-1423.
13. Raaymakers EL. Fractures of the femoral neck: a review and personal statement. Acta Chir Orthop Traumatol Cech, 2006, 73(1): 45-59.
14. Yang JJ, Lin LC, Chao KH, et al. Risk factors for nonunion in patients with intracapsular femoral neck fractures treated with three cannulated screws placed in either a triangle or an inverted triangle configuration. J Bone Joint Surg (Am), 2013, 95(1): 61-69.
15. Gašpar D, Crnković T, Durović D, et al. AO group, AO subgroup, Garden and Pauwels classification systems of femoral neck fractures: are they reliable and reproducible? Med Glas (Zenica), 2012, 9(2): 243-247.
16. Oakey JW, Stover MD, Summers HD, et al. Does screw configuration affect subtrochanteric fracture after femoral neck fixation? Clin Orthop Relat Res, 2006, 443: 302-306.
17. 干耀恺, 唐坚, 孙月华. 股骨颈骨折内固定治疗选择. 国际骨科学杂志, 2013, 34(6): 396-398.
18. Morris AH, Zuckerman JD, AAOS Council of Health Policy and Practice, U SA. American Academy of Orthopaedic Surgeons. National consensus conference on improving the continuum of care for patients with hip fracture. J Bone Joint Surg (Am), 2002, 84-A(4): 670-674.
19. Jackman JM, Watson JT. Hip fractures in older men. Clin Geriatr Med, 2010, 26(2): 311-329.
20. Mardani-Kivi M, Mirbolook A, Khajeh Jahromi S, et al. Fixation of intertrochanteric fractures: dynamic hip screw versus locking compression plate. Trauma Mon, 2013, 18(2): 67-70.
21. Zhang CQ, Sun Y, Jin DX, et al. Reverse LISS plating for intertrochanteric hip fractures in elderly patients. BMC Musculoskelet Disord, 2010, 11: 166.
22. Butler M, Forte ML, Joglekar SB, et al. Evidence summary: systematic review of surgical treatments for geriatric hip fractures. J Bone Joint Surg (Am), 2011, 93(12): 1104-1115.
23. Simmermacher RK, Ljungqvist J, Bail H, et al. The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study. Injury, 2008, 39(8): 932-939.
24. Lenich A, Vester H, Nerlich M, et al. Clinical comparison of the second and third generation of intramedullary devices for trochanteric fractures of the hip-Blade vs screw. Injury, 2010, 41(12): 1292-1296.
25. Clawson DK. Trochanteric fractures treated by the sliding screw plate fixation method. J Trauma, 1964, 4: 737-752.
26. O'Malley NT, Deeb AP, Bingham KW, et al. Outcome of the dynamic helical hip screw system for intertrochanteric hip fractures in the elderly patients. Geriatr Orthop Surg Rehabil, 2012, 3(2): 68-73.
27. Jones HW, Johnston P, Parker M. Are short femoral nails superior to the sliding hip screw? A meta-analysis of 24 studies involving 3,279 fractures Int Orthop, 2006, 30(2): 69-78.
28. Saarenpää I, Heikkinen T, Ristiniemi J, et al. Functional comparison of the dynamic hip screw and the Gamma locking nail in trochanteric hip fractures: a matched-pair study of 268 patients. Int Orthop, 2009, 33(1): 255-260.
29. 王勇, 杨益宇, 于志华, 等. 股骨近段锁定钢板治疗老年股骨粗隆间骨折的对比研究. 中国骨伤, 2011, 24(5): 370-373.
30. 李坛珠, 张保焜, 莫小联, 等. 极高龄不稳定股骨粗隆间骨折的髓内和髓外固定疗效比较. 中华老年骨科与康复电子杂志, 2017, 3(1): 17-21.
31. Kumar R, Singh RN, Singh BN. Comparative prospective study of proximal femoral nail and dynamic hip screw in treatment of intertrochanteric fracture femur. J Clin Orthop Trauma, 2012, 3(1): 28-36.
32. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev, 2008, (3): CD000093.
33. Georgiannos D, Lampridis V, Bisbinas I. Complications following treatment of trochanteric fractures with the Gamma3 nail: is the latest version of Gamma nail superior to its predecessor? Surg Res Prac, 2014, 2014: 143598.
34. Westacott D, Bould M. Outcome in 36 elderly patients treated with the Gamma3 long nail for unstable proximal femoral fracture. Acta Orthopaedica Belgica, 2011, 77(1): 68-72.
35. Nüchtern JV, Ruecker AH, Sellenschloh K, et al. Malpositioning of the lag screws by 1- or 2-screw nailing systems for pertrochanteric femoral fractures: a biomechanical comparison of gamma 3 and intertan. J Orthop Trauma, 2014, 28(5): 276-282.
36. Vaquero J, Munoz J, Prat S, et al. Proximal femoral nail antirotation versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures. A randomised comparative study. Injury, 2012, 43(Suppl 2): S47-54.
37. George M, Stefanos K, Spyridon G, et al. Reply to letter to the editor: Does PFNA II avoid lateral cortex impingement for unstable peritrochanteric fractures? Clin Orthop Relat Res, 2013, 471(4): 1395-1396.
38. Zhang H, Zeng X, Zhang N, et al. INTERTAN nail versus proximal femoral nail antirotation-Asia for intertrochanteric femur fractures in elderly patients with primary osteoporosis. J Int Med Res, 2017, 45(4): 1297-1309.
39. Wu D, Ren G, Peng C, et al. InterTan nail versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures. Diagn Pathol, 2014, 9: 191.
40. Wang Q, Yang X, He HZ, et al. Comparative study of InterTAN and dynamic hip screw in treatment of femoral intertrochanteric injury and wound. Int J Clin Exp Med, 2014, 7(12): 5578-5582.
41. Yang X, Wu Q, Wang X. Investigation of perioperative hidden blood loss of unstable intertrochanteric fracture in the elderly treated with different intramedullary fixations. Injury, 2017, 48(8): 1848-1852.
42. Kim WY, Han CH, Park JI, et al. Failure of intertrochanteric fracture fixation with a dynamic hip screw in relation to pre-operative fracture stability and osteoporosis. Int Orthop, 2001, 25(6): 360-362.
43. Sidhu AS, Singh AP, Singh AP, et al. Total hip replacement as primary treatment of unstable intertrochanteric fractures in elderly patients. Int Orthop, 2010, 34(6): 789-792.
44. Cankaya D, Ozkurt B, Tabak AY. Cemented calcar replacement versus cementless hemiarthroplasty for unstable intertrochanteric femur fractures in the elderly. Ulus Travma Acil Cerrahi Derg, 2013, 19(6): 548-553.
45. Celiktas M, Togrul E, Kose O. Calcar preservation arthroplasty for unstable intertrochanteric femoral fractures in elderly. Clin Orthop Surg, 2015, 7(4): 436-442.
46. Fan L, Dang X, Wang K. Comparison between bipolar hemiarthroplasty and total hip arthroplasty for unstable intertrochanteric fractures in elderly osteoporotic patients. PLoS One, 2012, 7(6): e39531.