中国修复重建外科杂志

中国修复重建外科杂志

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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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-Jensen Ⅱ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。

ObjectiveTo evaluate the safety and efficacy of total hip arthroplasty (THA) following failed internal fixation of intertrochanteric fractures. MethodsBetween January 2007 and January 2016, THAs were performed in 32 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. ResultsThe 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 in 2 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). ConclusionTHA 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.

关键词: 股骨转子间骨折; 人工全髋关节置换术; 内固定; 安全性; 有效性

Key words: Intertrochanteric fracture; total hip arthroplasty; internal fixation; safety; efficacy

引用本文: 覃勇志, 周凯, 王端, 周宗科, 杨静, 康鹏德, 裴福兴, 沈彬. 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. 中国修复重建外科杂志, 2019, 33(2): 160-165. doi: 10.7507/1002-1892.201807089 复制

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