Department of Orthopaedics, 3rd Hospital, Hebei Medical University, Shijiazhuang, Hebei, China.
J Orthop Trauma. 2012 Jul;26(7):427-32. doi: 10.1097/BOT.0b013e31822c050b.
Fractures of the femur above a total knee arthroplasty (TKA) are becoming increasingly common in the osteoporotic, aging populations of developed countries. Treatment of these fractures is complicated by the presence of a knee prosthesis, frequently limiting the bone available for distal fracture fixation. The recent application of minimally invasive surgical techniques and locked plate technology to this problem offers the promise of stable, fixed-angle fixation of small distal fracture fragments with limited surgical exposure. The purpose of this study is to report the clinical and radiographic outcomes of fracture fixation using this technique in patients with periprosthetic femur fractures above TKA.
Fifty-three patients presenting with periprosthetic femur fractures above a TKA were treated with osteosynthesis. One patient was lost to follow-up resulting in 52 patients with complete data. Thirty-four patients were treated with plate fixation and 18 patients underwent retrograde intramedullary nail fixation (RIMN). Using a comprehensive electronic medical record, we recorded data regarding patient-related demographics, nature of the fractures, the operative treatment, and clinical and radiographic outcomes for all patients treated with osteosynthesis.
Successful fracture healing occurred in 75% of patients (39 of 52). Mean operating time was 91.6 ± 6.8 minutes in the RIMN group and 87.4 ± 6.4 minutes in the locked plating (LP) group (P = 0.46). Mean intraoperative blood loss was 182 ± 31.6 mL in the RIMN group and 177.5 ± 23.4 mL in the LP group (P = 0.91). The mean time to bone union was 3.7 ± 0.30 months in the RIMN group and 4.0 ± 0.27 months in the LP group (P = 0.95). The most common cause of treatment failure was patient death within 6 months (9 patients [17%]); three of 18 were treated with a nail and 6 of 34 with a plate (P = 1.0). In the LP group, three (9%) sustained fracture nonunions, three (9%) sustained fracture malunions, and two (6%) sustained surgical site infections. In the RIMN group, one (6%) failed to unite as a result of infection and two (11%) developed fracture malunions. There were no significant differences between patients treated with LP and those treated with RIMN.
Despite significant advances in surgical technique and implant design, the treatment of periprosthetic femur fractures above a TKA remains a challenge. LP using an indirect reduction technique is applicable to most patients and prosthetic designs and can provide similar favorable results as compared with treatment with a RIMN in periprosthetic femoral fractures.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
在发达国家骨质疏松、老龄化人群中，全膝关节置换术（TKA）以上的股骨骨折越来越常见。这些骨折的治疗因存在膝关节假体而变得复杂，经常限制了用于远端骨折固定的可用骨量。最近，微创外科技术和锁定钢板技术的应用为解决这个问题带来了希望，可通过有限的手术暴露实现小的远端骨折碎片的稳定、固定角度固定。本研究的目的是报告使用这种技术治疗 TKA 以上假体周围股骨骨折的临床和影像学结果。
53 例 TKA 以上假体周围股骨骨折患者接受了骨内固定治疗。1 例患者失访，最终有 52 例患者有完整数据。34 例患者接受钢板固定，18 例患者接受逆行髓内钉固定（RIMN）。我们使用综合电子病历记录了与患者相关的人口统计学、骨折性质、手术治疗以及所有接受骨内固定治疗患者的临床和影像学结果数据。
75%（39/52）的患者成功愈合骨折。RIMN 组的平均手术时间为 91.6±6.8 分钟，锁定钢板（LP）组为 87.4±6.4 分钟（P=0.46）。RIMN 组术中平均失血量为 182±31.6mL，LP 组为 177.5±23.4mL（P=0.91）。RIMN 组骨愈合时间平均为 3.7±0.30 个月，LP 组为 4.0±0.27 个月（P=0.95）。治疗失败最常见的原因是患者在 6 个月内死亡（9 例[17%]）；其中 3 例接受钉固定，18 例接受板固定（P=1.0）。在 LP 组中，3 例（9%）发生骨折不愈合，3 例（9%）发生骨折畸形愈合，2 例（6%）发生手术部位感染。在 RIMN 组中，1 例（6%）因感染而未愈合，2 例（11%）发生骨折畸形愈合。接受 LP 和 RIMN 治疗的患者之间没有显著差异。
尽管在手术技术和植入物设计方面取得了重大进展，但 TKA 以上假体周围股骨骨折的治疗仍然是一个挑战。使用间接复位技术的 LP 适用于大多数患者和假体设计，可与 RIMN 治疗假体周围股骨骨折提供相似的良好结果。
治疗性 III 级。有关证据水平的完整说明，请参阅作者指南。
