Qin Yongzhi, Zhou Kai, Wang Duan, Zhou Zongke, Yang Jing, Kang Pengde, Pei Fuxing, Shen Bin
Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;Department of Orthopedics, the People，s Hospital of Guang'an, Guang'an Sichuan, 638000, P.R.China.
Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China.
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2019 Feb 15;33(2):160-165. doi: 10.7507/1002-1892.201807089.
To evaluate the safety and efficacy of total hip arthroplasty (THA) following failed internal fixation of intertrochanteric fractures.
Between January 2007 and January 2016, THAs were performed in 32 patients (33 hips) for failed internal fixation of intertrochanteric fractures. There were 15 males and 17 females, with mean age of 74.0 years old (range, 65-87 years). There were 3 hips of Evans-Jensen type Ⅱ, 10 hips of type Ⅲ, 8 hips of type Ⅳ, and 12 hips of type Ⅴ. The fractures were fixed with dynamic hip screw in 18 hips, proximal femoral nail antirotation in 9 hips, locking plate in 5 hips, and hollow screw in 1 hip. The internal fixation failure caused by fracture displacement and nonunion in 22 patients, traumatic arthritis in 6 patients, fracture nonunion and infection in 3 patients, and avascular necrosis of the femoral head in 2 patients. The mean interval from initial fracture fixation to THA was 20 months (range, 2-48 months). The safety evaluation indicators included operation time, amount of operative bleeding and postoperative drainage, blood transfusion, and perioperative complications. The efficacy indexes included the hip Harris score, the range of motion (ROM), visual analogue scale (VAS) score, and the length difference between both legs; the X- ray films were taken to assess the prosthesis survival condition.
The average operation time was 92 minutes (range, 55-135 minutes). The average amount of operative bleeding and postoperative drainage were 480 mL (range, 360-620 mL) and 350 mL (range, 220-520 mL), respectively. Intraoperative proximal femur fissure fracture occurred in 2 hips. After operation, 10 cases received allogeneic blood transfusion, 1 case occurred cerebral infarction, 2 hips experienced dislocation, 1 hip occurred greater trochanter re-fracture and dislocation because of spraining, and 1 case died of myocardial infarction. Twenty-nine patients (30 hips) were followed up 2-10 years (mean, 4.9 years). At last follow-up, there was no infection recurrence in 3 infected hips, and there was no prosthesis loosening, subsidence, or rupture in all cases. The Harris score, ROM, VAS score, and the length difference between both legs were significantly superior to preoperative ones ( <0.05).
THA is an effective salvage procedure after failed internal fixation of intertrochanteric fracture. But its perioperative risks and complications are pretty high. Adequate preoperative evaluation, elaborate and individualized perioperative management are keys to make sure the patient can safely survive the perioperative period.
评估股骨转子间骨折内固定失败后全髋关节置换术（THA）的安全性和有效性。
2007年1月至2016年1月期间，对32例（33髋）股骨转子间骨折内固定失败的患者实施了全髋关节置换术。其中男性15例，女性17例，平均年龄74.0岁（范围65 - 87岁）。Evans-JensenⅡ型3髋，Ⅲ型10髋，Ⅳ型8髋，Ⅴ型12髋。18髋采用动力髋螺钉固定骨折，9髋采用股骨近端抗旋髓内钉固定，5髋采用锁定钢板固定，1髋采用空心螺钉固定。22例因骨折移位和骨不连导致内固定失败，6例因创伤性关节炎，3例因骨折不连和感染，2例因股骨头缺血性坏死。从初次骨折固定至全髋关节置换术的平均间隔时间为20个月（范围2 - 48个月）。安全性评估指标包括手术时间、术中出血量、术后引流量、输血情况及围手术期并发症。疗效指标包括髋关节Harris评分、活动范围（ROM）、视觉模拟评分法（VAS）评分及双下肢长度差；拍摄X线片评估假体存活情况。
平均手术时间为92分钟（范围55 - 135分钟）。平均术中出血量和术后引流量分别为480 mL（范围360 - 620 mL）和350 mL（范围220 - 520 mL）。2髋术中发生股骨近端裂缝骨折。术后，10例接受异体输血，1例发生脑梗死，2髋发生脱位，1髋因扭伤发生大转子再骨折并脱位，1例死于心肌梗死。29例患者（30髋）随访2 - 10年（平均4.9年）。末次随访时，3例感染髋无感染复发，所有病例均无假体松动、下沉或破裂。Harris评分、ROM评分、VAS评分及双下肢长度差均显著优于术前（P<0.05）。
全髋关节置换术是股骨转子间骨折内固定失败后的一种有效挽救手术。但其围手术期风险和并发症较高。充分的术前评估、精心且个体化的围手术期管理是确保患者安全度过围手术期的关键。
