Service d'orthopédie-traumatologie, hôpital Orthopédique - CHUV, avenue Pierre-Decker 4, 1011 Lausanne, Switzerland.
Orthop Traumatol Surg Res. 2019 Feb;105(1S):S95-S101. doi: 10.1016/j.otsr.2018.04.034. Epub 2018 Nov 16.
The optimal treatment of recent femoral neck fractures remains debated. The available options are internal fixation, hemiarthroplasty (HA) and total hip arthroplasty (THA). There is a consensus in favour of internal fixation in younger patients. In elderly individuals who are institutionalised and have limited physical activity, HA is usually performed when the joint line is intact. Whether HA or THA deserves preference in patients aged 60 years or over is unclear. In addition, there are two types of HA, unipolar and bipolar, and two types of THA, conventional and dual-mobility. Both HA types provide similar outcomes with satisfactory stability but a risk of acetabular wear that may eventually require conversion to THA. THA is associated with better functional outcomes and a lower risk of revision surgery in self-sufficient, physically active patients. Instability is the leading complication of conventional THA and occurs with a higher incidence compared to HA. With all implant types, preoperative factors associated with mortality and complications include walking ability and level of self-sufficiency, nutritional status, and haematocrit. An evaluation of these factors before surgery is of paramount importance. Factors amenable to treatment should be corrected by working jointly with geriatricians to develop a preoperative management strategy. In patients who are self-sufficient, physically active, and free of risk factors, THA remains the option of choice, as it provides better functional outcomes. A dual-mobility implant deserves preference to prevent instability. HA is indicated in patients whose self-sufficiency and physical activity are limited. A unipolar implant should be used, as no evidence exists that bipolar implants provide additional benefits. When performing HA, the posterior approach should be avoided given the risk of instability. For THA, in contrast, the posterior approach is a reliable option in the hands of an experienced surgeon using a dual-mobility cup. Cement fixation of the stem is recommended to minimise the risk of peri-prosthetic fracture.
近期股骨颈骨折的最佳治疗方案仍存在争议。可选择的方案有内固定、半髋关节置换术（HA）和全髋关节置换术（THA）。在年轻患者中，内固定具有优势，这已达成共识。对于那些已住院且体力活动有限的老年患者，如果关节线完整，通常会选择 HA。在 60 岁及以上的患者中，HA 或 THA 应优先选择尚不明确。此外，HA 有单极和双极两种类型，THA 有常规型和双动型两种。两种 HA 类型都能提供相似的结果，具有满意的稳定性，但髋臼磨损的风险较高，最终可能需要转换为 THA。THA 与更好的功能结果相关，并且在自理、活跃的患者中，翻修手术的风险较低。常规 THA 的主要并发症是不稳定，其发生率高于 HA。所有植入物类型中，与死亡率和并发症相关的术前因素包括行走能力和自理程度、营养状况和红细胞压积。在手术前评估这些因素至关重要。应通过与老年病学家合作，共同治疗可治疗的因素，制定术前管理策略。对于自理、活跃且无风险因素的患者，THA 仍然是首选方案，因为它能提供更好的功能结果。应选择双动型植入物以预防不稳定。对于自理和体力活动有限的患者，应选择 HA。应使用单极植入物，因为没有证据表明双极植入物具有额外的益处。进行 HA 时，由于不稳定的风险，应避免使用后入路。相反，对于 THA，在有经验的外科医生使用双动型髋臼杯时，后入路是一种可靠的选择。建议使用骨水泥固定股骨柄，以最大程度地降低假体周围骨折的风险。
