髋关节置换术后股骨近端假体周围骨折的内固定组合方式

Combination pattern of internal fixation for periprosthesis fractures of the proximal femur after hip replacement

目的探讨髋关节置换术后股骨近端假体周围骨折的内固定组合方式。方法回顾性分析2008年5月至2022年3月58例人工髋关节置换术后假体周围骨折患者的资料,男31例、女27例;年龄(75.5±18.2)岁(范围35~95岁)。全髋关节置换39例,半髋关节置换19例;生物型假体37例,骨水泥型假体21例;于术中发生假体周围骨折6例、术后52例。骨折通用分型系统(unified classification system,UCS):UCSⅣ.3A1型2例、3A2型1例、3B1.1型19例、3B2.1型25例、3B3型2例、3C型9例。骨折部位:股骨A区(大转子)3例、B区(股骨柄周围)46例、C区(股骨柄尖端以远)9例。内固定由主辅固定组成,主要固定方式为钢丝或钛缆环扎、锁定加压钢板、锁定附加钢板固定,辅助固定方式为钛缆环扎,要求覆盖A、B、C三区形成整体平衡固定。比较不同内固定组合的改良Harris评分(modified Harris Hip Scores,mHHS)、钢板长度、工作长度及螺钉数。结果随访时间为(54.2±21.6)个月(范围11~86个月)。所有患者于术后(10.2±1.5)周(范围7~13周)出现骨折愈合征象,术后(19.6±1.3)周(范围17~22周)显示骨性愈合,无一例出现延迟愈合或不愈合。术后1例出现应力性骨折,行双钢板内固定联合翻修;1例内固定失效,行双钢板内固定联合翻修加大段异体骨植骨。术后6个月UCSⅣ.3B2.1组mHHS评分[(80.3±4.6)分]最低,不同分型的组间差异有统计学意义(F=256.72,P<0.001)。单纯内固定组[(91.6±4.2)分]高于翻修联合内固定组[(81.9±4.1)分],差异有统计学意义(t=8.32,P<0.001)。UCSⅣ.3B1.1型钢板长度及工作长度分别为(24.9±2.5)cm及(12.6±1.7)cm、3B2.1型为(25.4±2.6)cm及(13.6±1.8)cm、3C型为(28.1±2.5)cm及(14.9±1.9)cm,组间差异均有统计学意义(F=5.33,P=0.005;F=6.78,P<0.001)。A区螺钉数:不同UCS分型的差异有统计学意义(F=52.67,P<0.001);UCSⅣ.3B1.1型(6.5±2.3)枚、3B2.1型(6.7±2.2)枚,较3B3型的(3.5±1.5)枚和3C型的(3.7±1.6)枚多,差异有统计学意义(P<0.05)。B区螺钉数:不同UCS分型的差异有统计学意义(F=42.15,P<0.001);UCSⅣ.3B1.1型(2.3±1.6)枚、3B2.1型(2.8±1.9)枚,较3B3型的(1.0±0.5)枚和3C型的(1.2±0.6)枚多,差异有统计学意义(P<0.05)。C区螺钉数:不同UCS分型的差异有统计学意义(F=39.62,P<0.001);UCSⅣ.3B1.1型(3.8±1.9)枚、3B2.1型(3.9±1.7)枚,较3B3型的(2.0±0.5)枚多,差异有统计学意义(P<0.05)。结论髋关节置换术后股骨近端假体周围骨折行单纯骨折内固定术后髋关节功能优于同时行翻修者;UCSⅣ.B1、B2型的A、B、C三区螺钉数较B3型多。

Objective To investigate the combination of internal fixation for periprosthetic fractures of the proximal femur(PFFF)after hip arthroplasty.Methods The data of 58 patients with periprosthetic fractures after hip arthroplasty from May 2008 to March 2022 were retrospectively analyzed,including 31 males and 27 females.The average age was 75.5±18.2 years(range,35-95 years).There were 39 total hip arthroplasty and 19 hemiarthroplasty;37 biological prosthesis and 21 cemented prosthesis.Intraoperative periprosthetic fractures occurred in 6 cases and 52 cases postoperatively.Unified classification system(UCS):UCS IV.3A1 type 2 cases,3A2 type 1 case,3B1.1 type 19 cases,3B2.1 type 25 cases,3B3 type 2 cases,3C type 9 cases.Fracture site:3 cases in zone A(greater trochanter),46 cases in zone B(around the femoral stem),and 9 cases in zone C(distal to the tip of the femoral stem.Internal fixation is composed of primary and secondary fixation,the main fixation method was the cerclage of steel wire or titanium cable,locking compression plate,and locking attachment plate fixation.The secondary fixation method was the cerclage of titanium cable,which was required to cover three zones A,B and C to form an overall balanced fixation.The modified Harris hip scores(mHHS),plate length,working length and screw number of different internal fixation combinations were compared.Results The follow-up time was 54.2±21.6 months(range,11-86 months).All patients showed signs of fracture healing at 10.2±1.5 weeks(range,7-13 weeks)after operation,and bony union was observed at 19.6±1.3 weeks(range,17-22 weeks)after operation.No delayed union or nonunion was observed.After operation,one case had a stress fracture and was revised with double-plate internal fixation;one case had a failed internal fixation and was revised with double-plate internal fixation and a large allograft bone graft.The mHHS score of UCSIV.3B2.1 group(80.3±4.6)was the lowest at 6 months after operation,and the difference between the groups of different types was statistically significant(F=256.72,P<0.001).The score of simple internal fixation group(91.6±4.2)was higher than that of revision combined with internal fixation group(81.9±4.1),and the difference was statistically significant(t=8.32,P<0.001).The plate length and working length were 24.9±2.5 cm and 12.6±1.7 cm for UCS IV.3B1.1,25.4±2.6 cm and 13.6±1.8 cm for 3B2.1 and 28.1±2.5 cm and 4.9±1.9 cm for 3C,respectively(F=5.33,P=0.005;F=6.78,P<0.001).The number of screws in zone A was significant difference among different UCS types(F=52.67,P<0.001);UCS IV.3B1.1(6.5±2.3)and 3B2.1(6.7±2.2)were more than 3B3(3.5±1.5)and 3C(3.7±1.6).The number of screws in zone B was significant difference among different UCS types(F=42.15,P<0.001);The number of UCS IV.3B1.1(2.3±1.6)and 3B2.1(2.8±1.9)were significantly more than that of 3B3(1.0±0.5)and 3C(1.2±0.6).The number of screws in zone C was significant differences among different UCS types(F=39.62,P<0.001);The number of UCS IV.3B1.1(3.8±1.9)and 3B2.1(3.9±1.7)were more than that of 3B3(2.0±0.5),the difference was statistically significant(P<0.05).Conclusion The function of hip after simple internal fixation of proximal femoral periprosthetic fractures was better than that of those who underwent revision at the same time;the number of screws of UCSIV.B1 and B2 is more than that of B3.