From the *Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York; and †Department of Neurology, NYU School of Medicine, New York, New York.
J Patient Saf. 2014 Jun;10(2):117-20. doi: 10.1097/PTS.0000000000000063.
Femoral neck fractures in the elderly comprise a significant number of orthopedic surgical cases at a major trauma center. These patients are immediately incapacitated, and surgical fixation can help increase mobility, restore independence, and reduce morbidity and mortality. However, operative treatment carries its own inherent risks including infections, deep vein thromboses, and intraoperative cardiovascular collapse. Cerebrovascular stroke is a relatively uncommon occurrence after hip fractures.
We present 2 cases with unusual postoperative medical complication after cemented hip hemiarthroplasty for femoral neck fracture that will serve to illustrate an infrequent but very serious complication.
Case 1 was a 73-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, he developed neurological deficits, and a postoperative noncontrast head computed tomography showed a right medial thalamic infarct. Case 2 was an 82-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, the patient became hemodynamically unstable. A postoperative noncontrast head computed tomography showed a large evolving left middle cerebral artery stroke.
General anesthesia in the setting of decreased cardiac function (decreased ejection fraction and output) carries the risk for ischemic injury to the brain from decreased cerebral perfusion. Risk factors including advanced age, history of coronary artery disease, atherosclerotic disease, and atrial fibrillation increase the risk for perioperative stroke. Furthermore, it is known that during the cementing of implants, microemboli can be released, which must be considered in patients with preoperative heart disease. As a result, consideration of using a noncemented implant or cementing without pressurizing in this clinical scenario should be an important aspect of the preoperative plan in an at-risk patient. Further studies are needed that can elucidate a causal relationship.
在一家大型创伤中心，老年股骨颈骨折在骨科手术病例中占很大比例。这些患者立即丧失活动能力，手术固定有助于提高活动能力、恢复独立性并降低发病率和死亡率。然而，手术治疗本身存在固有风险，包括感染、深静脉血栓形成和术中心血管衰竭。中风是髋部骨折后相对少见的并发症。
我们报告了 2 例在股骨颈骨折行骨水泥半髋关节置换术后发生的不常见术后并发症病例，以说明一种罕见但非常严重的并发症。
病例 1 为 73 岁男性，Garden IV 型股骨颈骨折，在全身麻醉下行右侧单极骨水泥半髋关节置换术。手术顺利，但术后出现神经功能缺损，术后头颅 CT 平扫未见明显异常。病例 2 为 82 岁男性，Garden IV 型股骨颈骨折，在全身麻醉下行右侧单极骨水泥半髋关节置换术。手术顺利，但术后患者出现血流动力学不稳定。术后头颅 CT 平扫显示左侧大脑中动脉大面积进展性脑梗死。
在心脏功能下降（射血分数和心输出量降低）的情况下进行全身麻醉，存在因脑灌注减少导致脑缺血损伤的风险。包括高龄、冠心病史、动脉粥样硬化疾病和心房颤动在内的危险因素增加了围手术期中风的风险。此外，已知在植入物粘接过程中会释放微栓子，这在术前有心脏病的患者中应予以考虑。因此，在高风险患者的术前计划中，应考虑使用非骨水泥植入物或在不加压的情况下进行粘接，这是一个重要方面。需要进一步的研究来阐明因果关系。
