Service de Chirurgie Orthopédique et de Traumatologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Laboratoire INSERM-UNISTRA UMR 1260, Bâtiment 3, 11, rue Humann 67085, Strasbourg, France.
Service de Chirurgie Orthopédique et de Traumatologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Laboratoire ICube, CNRS UMR 7357, 30, boulevard Sébastien-Brant, 67400 Illkirch, France.
Orthop Traumatol Surg Res. 2020 Jun;106(4):645-649. doi: 10.1016/j.otsr.2020.02.011. Epub 2020 May 11.
Failure of internal fixation in trochanteric fracture (or extracapsular proximal femoral fracture: PFF) is a serious complication often requiring total hip arthroplasty (THA). THA after PPF incurs a higher risk of complications than in intracapsular fracture due to frequent impact on local anatomy, notably with risk of implant dislocation. Recent studies demonstrated a protective effect of dual-mobility (DM) cups against instability in these cases but in a population mixing failure of internal fixation in intra- and extracapsular fractures. We therefore conducted a retrospective study focusing on fixation failure in PFF: 1) to assess surgical complications and notably dislocation rate using DM cups, and 2) to analyse the characteristics of the initial fixation and assess conformity with established standards.
DM cups exert a protective effect in PFF fixation failure at high risk of instability.
A single-centre retrospective study included 40 cases over a 10-year period: 30 women, 10 men; mean age, 77 years [range, 31-91 years]. All THAs used DM cups. Approaches were transgluteal in 24 cases, posterior in 15 and anterolateral in one. Clinical assessment comprised of: pain on visual analog scale (VAS), Harris Hip Score (HSS), and Postel Merle-d'Aubigné score (PMA). The rate of surgical complications (periprosthetic fracture, infection, non-union, dislocation) was assessed and the primary fixation quality was analysed for fracture complexity and conformity to standards.
At a mean 54 months' follow-up [range, 24-122 months], the post-THA complications rate was 22% (9/40), although with no cases of implant dislocation. Pre- to postoperative comparison found significant improvements on VAS (7.9±1.6 versus 1.35±1.5, respectively), HHS (20±11.8 versus 78±12.3) and PMA (4.7±2.9 versus 14.6±2.1) (p<0.0001), but non-significant change in Parker-Palmer score (5.5±2 and 4.8±1.9) (p=0.4). Fracture instability rate was 77% and 85% (31 and 34/40) on the AO and Evans-Jensen classifications respectively. Analysis of primary fixation found non-conformity with reduction standards in 68% of cases (27/40): most frequently, cervical screw centering defect (58%, 23/40) and reduction defect (28%, 11/40). The non-conformity rate was 44% (4/9) in AO stable fracture and 74% (23/31) in unstable fracture.
The study hypothesis was confirmed, with no dislocations in this high-risk population. This can be attributed to exclusive use of DM cups, which should be systematic in high-risk contexts. The study confirmed the importance of primary fixation quality, although a risk of failure remains, even in stable fractures.
IV, retrospective study.
转子间骨折（或囊外股骨近端骨折：PFF）内固定失败是一种严重的并发症，通常需要全髋关节置换术（THA）。由于经常对局部解剖结构产生影响，尤其是存在假体脱位的风险，因此 PFF 后行 THA 比囊内骨折后发生并发症的风险更高。最近的研究表明，双动（DM）杯对这些情况下的不稳定具有保护作用，但在混合了囊内和囊外骨折内固定失败的人群中。因此，我们进行了一项回顾性研究，重点关注 PFF 中的固定失败：1）评估使用 DM 杯的手术并发症，尤其是脱位率，2）分析初始固定的特征，并评估其是否符合既定标准。
DM 杯在 PFF 固定失败高不稳定风险中具有保护作用。
这是一项为期 10 年的单中心回顾性研究，共纳入 40 例患者：30 名女性，10 名男性；平均年龄 77 岁[范围 31-91 岁]。所有 THA 均使用 DM 杯。入路方式为经臀入路 24 例，后入路 15 例，前外侧入路 1 例。临床评估包括：视觉模拟评分（VAS）、Harris 髋关节评分（HSS）和 Postel-Merle-d'Aubigné 评分（PMA）的疼痛情况。评估了围手术期并发症（假体周围骨折、感染、骨不连、脱位）的发生率，并对骨折复杂性和与标准的符合程度进行了分析。
在平均 54 个月的随访中[范围 24-122 个月]，THA 后并发症发生率为 22%（9/40），但无假体脱位病例。术前与术后比较发现 VAS（7.9±1.6 与 1.35±1.5，分别）、HHS（20±11.8 与 78±12.3）和 PMA（4.7±2.9 与 14.6±2.1）（p<0.0001）有显著改善，但 Parker-Palmer 评分无显著变化（5.5±2 和 4.8±1.9）（p=0.4）。AO 和 Evans-Jensen 分类的骨折不稳定率分别为 77%和 85%（31 例和 34 例/40 例）。对初次固定的分析发现，68%的病例（40 例中有 27 例）不符合复位标准：最常见的是颈椎螺钉中心定位缺陷（58%，40 例中有 23 例）和复位缺陷（28%，40 例中有 11 例）。在 AO 稳定骨折中，不符合标准的比例为 44%（9 例中有 4 例），在不稳定骨折中为 74%（31 例中有 23 例）。
研究假设得到证实，在这一高危人群中未发生脱位。这可以归因于 DM 杯的排他性使用，在高风险情况下应系统使用。该研究证实了初次固定质量的重要性，尽管即使在稳定骨折中也存在失败的风险。
IV，回顾性研究。
