髋关节置换术后股骨假体周围骨折的临床治疗分析

Clinical analysis of peri-prosthetic femoral fractures after total hip arthroplasty

目的总结人工髋关节置换术后股骨假体周围骨折的病因及其治疗方法。方法回顾性分析自2011年1月至2017年1月于中山大学孙逸仙纪念医院治疗的并于术中、术后出现股骨假体周围骨折患者,排除初次手术前已经出现骨折的患者,共纳入男5例,女8例,平均年龄为(68±19)岁(34~93岁),初次置换病因:股骨颈骨折6例;股骨头缺血坏死5例,强直性脊柱炎1例,类风湿性关节炎1例。初次置换时股骨假体固定方式:骨水泥固定5例,其余8例病人为生物型假体。假体周围骨折病因包括7例有明确外伤史(不慎跌伤或车祸)、6例为翻修术中骨折。根据Vancouver分型,AG型3例,AL型1例,B2型4例,B3型3例,C型2例。翻修时骨折固定方式:5例采用大粗隆再结合装置加钢缆固定,7例使用钢板钢缆固定,1例病人使用异体皮质骨板加钢丝固定。在各类分型中,2例C型股骨假体周围骨折使用钢板钢缆固定骨折端,其余11例股骨假体均不稳定,仅1例使用骨水泥重新固定初次置换假体,余10例使用全涂层假体。通过Harris评分对患髋进行功能评价,X线或CT观察骨折愈合。采用Mann-Whitney检验对比术前、术后髋关节Harris评分、疼痛视觉模拟(VAS)评分。结果平均随访时间(29±19)月,平均骨折愈合时间为(4.5±1.1)月。Harris评分由术前13.0(4.0,25.0)提高至末次87.0(82.3,93.3)分,(Z=-4.34,P<0.05)。异体皮质骨板病例在末次随访时显示与宿主骨融合,所有病人末次随访均未见假体松动、脱位及感染。结论根据不同分型选择相应的骨折复位与固定方式,钢板钢缆组合有效提高了稳定性;对于骨量不足病人可以考虑使用异体皮质骨固定以增加患者骨量。

Objective To study the etiology and treatment of peri-prosthetic femur fracture（ PFF）after total hip arthroplasty（ THA）. Methods Retrospective analyze 13 peri-prosthetic femur fracture patients treated in Sun Yat-sen Memorrial hospital since Jan. 2011 to Jan. 2017. The mean age was（ 68 ±19） years. Five were males and eight were females. The reasons for primary THA were femoral neck fractures（ n = 6）,avascular necrosis of femoral head（ n = 5）,ankylosing spondylitis（ n = 1） and rheumatoid arthritis（ n = 1）. Five cemented and eight cementless prostheses were used in primary THA. The causes of PFF were trauma（ n = 7） and intraoperative fractures（ n = 6）. According to Vancouver classification,there was one case type AG,one case type AL,four cases type B2,three cases type B3 and two cases type C. Great trochanter reattachment was used to fix the fraction in 5, cable plate was applied in seven cases and allograft cortical bone plate was used in one case. Among them,two cases of type C PFF were conducted fracture fixation. The rest prostheses of 11 patients ’ were all unstable,one used cement fixation and 10 used extensively porous-coated implants. The function of the hip was assessed through Harris score and the healing of fracture was evaluated by X-ray and CT. Mann-Whitney test was used to compare Harris scores and VAS scores before and after operation. Results All the implants were stable at the last visit,with an average follow-up time of（ 29 ± 189） months（ range,9 to 73 months）. The average healing time of fracture were（ 4. 5 ± 1. 1） months. Harris score improved from 13. 0（ 4. 0,25. 0） to 87. 0（ 82. 3,93. 3）（ Z =-4. 34,P 〈0. 05）. No sign of implant loosening,dislocation,deep infection or other complications occurred during follow-up. Conclusions For peri-prosthetic femur fracture patients with unstable fracture or prosthetic loosening,surgical treatment could restore intrinsic hip stability,provide excellent pain relief and improve the walking capacity. According to different types of fraction,different kinds of fixation are chosen. Using cable plate could restore the stability effectively. For the patients with bone loss,allograft of cortical bone plate would be useful to increase bone volume.