Simon P, Gouin F, Veillard D, Laffargue P, Ehlinger M, Bel J-C, Lopez R, Beaudet P, Luickx F, Molina V, Pidhorz L-E, Bigorre N, Rochwerger A, Azam F, Louis M-L, Cottias P, Hamonic S, Veillard D, Vogt F, Cambas P-M, Tabutin J, Bonnevialle P, Lecoq M, Court C, Sitbon P, Lacoste S, Gagey O, Dujardin F, Gilleron M, Brzakala V, Roussignol X
Centre hospitalier Saint-Joseph-Saint-Luc, 20, quai Claude-Bernard, 69365 Lyon cedex 07, France.
Rev Chir Orthop Reparatrice Appar Mot. 2008 Oct;94 Suppl(6):S108-32. doi: 10.1016/j.rco.2008.06.006. Epub 2008 Sep 19.
Despite many papers and instructional course lectures, therapeutic guidelines are not clearly defined about treatment of femoral neck fractures. The aim of this multicentric French symposium was to prospectively study the results of current therapeutic options in order to propose scientifically proven options.
Three prospective studies were carried out in order to answer to these questions: (1) is it possible with anatomical reduction and stable fixation to lower the non union and osteonecrosis rate? (2) is functional treatment of Garden 1 fractures successful in more than 65 years patients? (3) what criteria are useful to choose the kind of arthroplasty for more than 65 years patients?
For the 64 patients between 50 and 65 years old included in the first study, 44 ORIF and 17 prostheses were performed. No open reduction was performed in this series despite a 34% malreduction rate. The risk for displacement after functional treatment of Garden 1 fractures is 31%. For patients over 65 years old, almost fractures are treated in this series by an arthroplasty. The one-year mortality rate after displaced femoral neck fracture was 17%. Functional results were better in total hip prosthesis group than in bipolar or unipolar group. Non cemented stems were not safer than cemented ones in frail patients.
For young patients, ORIF should be the treatment of choice: the initial displacement and its effects on the femoral head vascularisation, the quality of reduction and fixation are the two most significant factors for good outcome. For Garden 1, fractures in patients 65 years old or more, it is proposed to performed an internal fixation despite in two thirds of the cases, it should be unnecessary because non identification of predictive factors of failure. For patients over 65 years old, the type of arthroplasty to perform in displaced fractures is to be chosen according to the preoperative mobility and comorbidities. Because of acetabular erosion with long-term follow-up, it is clearly indicated to perform total hip replacement for patients with life expectancy of 10 years or more. For frail patients, unipolar arthroplasty is the best option. The place for bipolar or uncemented implants is not yet well-defined and more prospective trials are needed. In this multicentric study, results appear quite different in terms of mortality, or functional status. These differences seem to be related to technical choice, geriatric care, nutritional consideration or surgical organisation, all factors that may be of major importance for prognostic.
尽管有许多论文和教学课程讲座，但股骨颈骨折的治疗指南仍未明确界定。本次法国多中心研讨会的目的是前瞻性地研究当前治疗方案的结果，以便提出经科学验证的方案。
开展了三项前瞻性研究以回答以下问题：（1）通过解剖复位和稳定固定能否降低不愈合和骨坏死率？（2）对65岁以上患者的Garden 1型骨折进行功能治疗是否成功？（3）对于65岁以上患者，选择何种关节置换术的标准是什么？
在第一项研究纳入的50至65岁的64例患者中，进行了44例切开复位内固定术（ORIF）和17例假体植入术。尽管存在34%的复位不良率，但本系列中未进行切开复位。Garden 1型骨折功能治疗后发生移位的风险为31%。对于65岁以上的患者，本系列中几乎所有骨折均采用关节置换术治疗。股骨颈移位骨折后1年的死亡率为17%。全髋关节假体组的功能结果优于双极或单极假体组。在体弱患者中，非骨水泥柄并不比骨水泥柄更安全。
对于年轻患者，切开复位内固定术应作为首选治疗方法：初始移位及其对股骨头血运的影响、复位和固定的质量是取得良好预后的两个最重要因素。对于65岁及以上患者的Garden 1型骨折，建议进行内固定，尽管在三分之二的病例中可能不必要，因为未识别出失败的预测因素。对于65岁以上的患者，对于移位骨折应根据术前活动能力和合并症选择关节置换术的类型。由于长期随访会出现髋臼侵蚀，对于预期寿命为10年或更长的患者，明确建议进行全髋关节置换。对于体弱患者，单极关节置换术是最佳选择。双极或非骨水泥植入物的地位尚未明确界定，需要更多的前瞻性试验。在这项多中心研究中，死亡率或功能状态方面的结果差异很大。这些差异似乎与技术选择、老年护理、营养因素或手术组织有关，所有这些因素对预后可能都很重要。
