股骨颈骨折假体置换术后再发健侧骨折的原因与对策

Causes and countermeasures for contralateral fracture after prosthetic replacement for femoralneck fractures

目的探讨老年股骨颈骨折假体置换术后再发健侧股骨颈骨折的原因及治疗策略。方法回顾性分析2005年3月-2012年5月收治的股骨颈骨折假体置换术后再发健侧股骨颈骨折，且有完整记录12例患者设为再次置换组；同期由同组医师完成的初次股骨颈骨折行假体置换术治疗的73例患者设为初次置换组，比较两组患者致伤原因、年龄、性别、骨密度、伴发病、生存质量评分、现患髋对侧关节Harris评分及术式选择情况，评估再骨折原因，提出治疗方案。结果两组患者的直接致伤原因均为跌倒；初次置换组和再次置换组比较：年龄分别为（68．82-4-5．18）岁、（76．83±3．64）岁（P〈0．05）；男女性别构成比分别为0．66：1和0．09：1（P〈0．05）；骨密度分别为（0．507±0．062）g／cm。、（0．461．4-0．095）g／cm^2（P〈0．05）。高血压、糖尿病、白内障、脑卒中、类风湿性关节炎、帕金森病除糖尿病外，其余5种基础疾病的伴有率两组比较差异均有统计学意义（P〈0．05）。生理领域生存质量评分初次置换组与再次置换组分别为（76．26±14．17）分、（67．86±16．74）分（P〈0．05）；现患髋对侧关节Harris评分两组分别为（98．664-1．39）分、（90．75±5．39）分（P〈0．05）。在治疗方式选择上，初次置换组中全髋关节置换术（total hip arthroplasty，THA）32例，单纯股骨头置换术（femoral head arthroplasty，FHA）41例，其中选用骨水泥型假体44例，生物型假体29例；再次置换组THA2例，单纯FHA10例，选用骨水泥型假体11例，生物型假体1例（P〈0．05）。结论跌倒仍是老年人股骨颈骨折假体置换术后再发健侧骨折的直接原因，增龄、女性、骨密度降低、高伴发病、生存质量下降和初次假体置换后关节功能减退均是不利因素。假体置换仍是治疗首选，术式更倾向于选择骨水泥型单纯FHA。

Objective To investigate causes and treatments for a fracture of the contralateral femoral neck in the elderly with prosthetic replacement for femoral neck fractures. Methods A retrospective analysis was conducted on 85 cases undergone prosthetic replacement for femoral neck fractures between March 2005 and May 2012, including 12 cases in secondary replacement group due to fractures of the contralateral uninjured femoral neck after primary prosthetic replacement and 73 cases in primary replacement group. Variables were compared between the two groups including causes of injury, age, sex, bone density, complications, quality of life, Harris score of the contralateral hip joint, surgical choice. Refracture reasons were evaluated and treatment plans were proposed. Results Immediate cause of injury in all cases was falling. Primary and secondary replacement groups showed mean age of （68.82 ± 5.18） yearsvs （76.83 ± 3.64） years （P〈0.05）, male to female ratio of 0.66：1 vs 0.09 ： 1 （P 〈 0.05 ）, and bone mineral density of （0. 507 ±0. 062） g/cm^2 vs （0. 461 ± 0. 095 ） g/era2 （P 〈0.05）. Moreover, cases in the two groups suffered from the associated complications （hypertension,diabetes mellitus, cataract, stroke, rheumatoid arthritis, and Parkinson＇ s disease）. Except for the diabetes mellitus, incidence of the other five basic diseases presented significance differences between the two groups （P 〈 0.05 ）. Of primary and secondary replacement groups, quality of life was （ 76.26 ± 14.17 ） points vs （67.86± 16.74） points （P 〈 0.05 ）; Harris score of the contralateral hip was （98.66± 1.39） points vs （ 90.75 ± 5.39 ） points （ P 〈 0.05 ）. For treatment choice, 32 total hip arthroplasty （THA） and 41 femoral head arthroplasty （FHA） with cement fixation in 44 cases and cementless fixation in 29 cases were performed in primary replacement group; two total hip arthroplasty and 10 femoral head arthroplasty with cement fixation in 11 cases and cementless fixation in one were performed in secondary placement group （ P 〈 0.05 ）. Conclusions Fall remains the immediate cause of the contralateral fractures following prosthetic replacement of femoral neck fractures in the elderly. Aging, females, bone density reduction, high-incidence of complications, decreased quality of life, and joint function impair- ment after the primary prosthetic replacement are unfavorable factors. Prosthetic replacement is still the preferred choice of treatment and surgical procedure is more likely to be the simple cemented FI-IA.