医学病例讨论课件：青壮年股骨颈骨折的治疗

青壮年股骨颈骨折的治疗青壮年股骨颈骨折的治疗1青壮年一般指年龄＜60岁，该年龄段的股骨颈骨折多由高能量损伤造成，多为不稳定性骨折，并发股骨头坏死的几率很高，文献报告在

12%-86%

之间。青壮年一般指年龄＜60岁，该年龄段的股骨颈骨折多由高能量损伤2医学病例讨论课件：青壮年股骨颈骨折的治疗3查尔森合并症指数查尔森合并症指数4CCI=0,＞54CCI=1,2,＞47CCI≥3,＞44THAaremorecost-effectiveCCI=0,＞54THAaremorec5对于青壮年股骨颈骨折的首要目标是保髋，因此无论股骨颈骨折的分型如何，一般更倾向于使用内固定治疗。除骨折解剖复位和坚强固定对股骨颈骨折的预后有重要影响之外，其他多个因素，如手术时间，关节囊切开术，内固定的方法等对年轻患者股骨颈骨折的最终影响仍有较大争议。对于青壮年股骨颈骨折的首要目标是保髋，因此无论股骨颈骨折的分6内固定的选择内固定的选择760-degreePauwelsanglefractureinahealthy30-year-oldpatientAnExpertOpinionSurveyoftheOrthopaedicTraumaAssociation’s(OTA)Membership60-degreePauwelsanglefractu8生物力学研究垂直型，pauwels3型生物力学强度：

PFLP＞DCS＞DHS＞CCS生物力学研究垂直型，pauwels3型生物力学强度：9CSXCSAMBIFNLPCSXCSAMBIFNLP10生物力学强度：DHS+DS＞PFLP≈CCS生物力学强度：DHS+DS＞PFLP≈CCS11生物力学强度：CHS+DS＞CS≈IT生物力学强度：CHS+DS＞CS≈IT12Thenonunionratewas19%forfracturestreatedwithcannulatedscrewsaloneand8%forthosetreatedwithafixed-angledevice.62例患者Pauwels＞70Thenonunionratewas19%for13DHSaloneorDHSsupplementedwithaderotationalscrewhadsignifcantlylessosteonecrosisforGardenⅢ-ⅣfracturesDHSaloneorDHSsupplemented14SHSconstructsdemonstrateasignificantlylowershort-termfailureratethanCSconstructs.SHSconstructsdemonstrateas15higherincidenceofONFHinDHS+CSandofnonunionintheLCPgroup

higherincidenceofONFHinDH16Displaced

fractures

shortenedmorethanundisplaced

fractures

(mean:8.1vs.2.2mm,P<0.001),

fractures

treatedwith

SHS

+derotationscrewshortenedanaverageof2.2mmmorethan

fractures

treatedwithscrewsalone(P=0.03).(JOrthopTrauma.

2015)Arecentmeta-analysisoffemoralneckfracturesinyoungadultsreportedanoverallreoperationrateof18%,nonunionrateof9%,avascularnecrosisrateof14%,andanimplantfailurerateofnearly10%.(Injury.

2015)Thierryetal

recommendthetreatmentofGardenⅠ-ⅡfracturewithCSandGardenⅢ-ⅣwithaDHSandtheadditionofaderotationalscrewforPauwelstypeⅢfractures.(WorldJOrthop.

2014)Toimprovefixationstability,MirandCollingehypothesizedapplyingtheconceptofbuttressplatefixationtothetreatmentofverticalfemoralneckfractures.(MedHypotheses.

2015)通过钢板的支撑作用可将骨折断端间的垂直剪切力转化为利于骨折愈合的压应力，这种应力转化有利于预防垂直型不稳定股骨颈骨折常见的内翻塌陷及不愈合并发症。Displaced

fractures

shortened1728patientsunder60yearsofagewithPauwels

type3femoralneckfracturemeanfollow-upwas13.6months需要更大样本和更长的随访时间来观察内侧钢板的效果。28patientsunder60yearsof18手术时间ThecurrentS2guidelinerecommendstreatmentofafemoralneckfracturewithinthefirst24h.(Managementofhipfractureinolderpeople;ScottishIntercollegiateGuidelinesNetwork-SIGN)Asignificantriseingeneralandearly

surgical

complicationswasregisteredwhenthe

surgical

treatmentwasdelayedformorethan48h.(Unfallchirurg.

2013)Inelderlypatientswithhipfractures,earlysurgerywithin24hoursofadmissionisindependentlyassociatedwithlesspulmonarycomplicationsincludingpneumonia,failuretoextubate,andreintubation,aswellasshorterLOS.(BoneJointJ.

2017)手术时间ThecurrentS2guideliner19Theresultsoftreatmentwereinfluencedbyfracturedisplacementandthequalityofreduction.Andtherewerenodifferenceinosteonecrosisratesbetweenearlyanddelayedtimetofixation.(JBoneJointSurgAm.2004)Wedidnotfindsupporttothecurrentbeliefthatearlysurgical

fixation

ofneckof

femur

fracturesreducestheriskofosteonecrosisinpatientslessthan60years.

(IntOrthop.

2012)Fracturebiologyandrevascularisationplayagreaterrolethanoperationtiming.(Injury.

2016)Thebestresults(significantlybetterthaninothergroups)wereobtainedinpatientswhowereoperatedonearly(<24haftertrauma)(P<0.05).(Unfallchirurg.1995

)Itindicatedthatdelayof

internalfixation

ofmorethan24hcouldincreasesubstantiallytheoddsofnon-union.(

Injury.

2015meta)Theresultsoftreatmentw20关节囊切开术关节囊内压力增高是造成股骨头缺血坏死非常重要的因素。Upadhyayetalfoundnodifferenceintherateofosteonecrosiswithpatientstreatedwithopen(capsulotomy)orclosedreduction(nocapsulotomy)andinternalfxation.(JBoneJointSurgBr.2004)Therewasnorelationshipbetweencapsulardecompressionandosteonecrosisdevelopment.20patientswithameanageof11years(range,4-15years)with

femoralneckfractures

wereidentified.Themeanfollowupwas7years(range,1-28years).(ClinOrthopRelatRes.

2007)Capsulardecompressiondidnotimprovetheunionrateandtimetounioninundisplacedintracapsularhipfractures,butindisplacedfracturesitappearedtoreducetheincidenceanddelaytheonsetofavascularnecrosis.(JOrthopSurg(HongKong).2007)

Thepresentmeta-analysisindicatedtheriskofAVNof

femoral

headwassignificanthigherafterCRIF

fixation

comparedwithORIF.(BMCMusculoskeletDisord.

2014)关节囊切开术关节囊内压力增高是造成股骨头缺血坏死非常重要的因21富含血小板血浆ResultsofthisstudygenerallyshowedthatboththemedianclinicalandradiographichealingtimewereloweringroupBcomparedto.Allparticipantswerefollowedupforatotalof12–48monthswithanaverageof28months(InternationalOrthopaedics.

2015)富含血小板血浆Resultsofthisstudyg22低强度脉冲超声治疗Moderate-to-highqualityevidenceshowsthatLIPUStreatmentreducesthetimetofractureunionandimprovesthequalityoflifewithoutaffectingfunctionalrecoveryandincidentrateofdelayedunionandnonunion,suggestingthatLIPUStreatmentmaybeagoodtreatmentmodalityforadultswithfreshfractures.(Medicine.

2017meta)Treatmentofununitedfemoralneckfracturesinyoungadultsusing

low-intensitypulsedultrasound:Reportof2cases.(InternationalJournalofSurgeryCaseReports.

2016)低强度脉冲超声治疗Moderate-to-highqual23医学病例讨论课件：青壮年股骨颈骨折的治疗24医学病例讨论课件：青壮年股骨颈骨折的治疗25

In18cases(94.7%),thehipunionwasachievedatanaveragedurationof4.1months

(range:3.6-5months).Thenonunionwasobservedin1hip(5.3%)andtherevisiontoahipreplacementwasconductedaftertwelvemonthsoftheoperation.AccordingtotheHarrishipscore(HHS)thatwasavailablefor17hipswithsatisfactoryunion,excellentresultswereachievedin14cases(HHS≥90),fairresultsin3cases(HHS:80–90),andpoorresultin1hip(HHS<80).NopatientdevelopedavascularnecrosisoffemoralheadafteroperationAllpatientswerefollowedforanaverageof16months(range:8–24months)In18cases(94.7%),thehip26医学病例讨论课件：青壮年股骨颈骨折的治疗27Noneofthefifty-sixpatientswithbleedingfromthedrillholesinthe

femoral

headfragmentdevelopedavascularnecrosis.Eightofeightpatientswithnobleeding

after

reductiondevelopedavascularnecrosis.Therewerenoinfectionsornonunions.(JOrthopTrauma.

1998)predictorpredictor28Thisretrospectivecohortstudyenrolled44patients(33women;meanage,66.9years)whounderwentsurgicalfixationforfemoralneckfractures.EarlyandlateboneSPECTimageswereobtainedwithin2weekspostoperativelyandat3monthspostoperatively.Patientswerefollowedupforaminimumof24months(average,34months).(JOrthopSci.

2017)Thisretrospectivecohortstud29Predictionofavascularnecrosisofthe

femoral

headbymeasuringintramedullaryoxygentension

after

femoral

neck

fracture.Predictionofavascularnecros30总结解剖复位和坚强固定对股骨颈骨折预后有重要影响，可减少坏死、不愈合及其他并发症的发生。对于GardenⅢ-Ⅳ骨折建议进行SHS，对于PauwelstypeⅢ型骨折建议进行SHS+DS（内侧钢板的效果还需进一步的临床研究验证）；在无明显禁忌症的情况下建议尽早手术（24h）；如果闭合复位效果不佳，建议切开复位；富含血小板血浆和低强度脉冲超声治疗可能对股骨颈骨折的愈合有帮助；置钉孔流出血液量可预测术后股骨头是否坏死;术中骨折端附近髓内氧饱和度可预测股骨头坏死风险；术后3个月时可以进行SPECT检查，可预测股骨头坏死风险。总结解剖复位和坚强固定对股骨颈骨折预后有重要影响，可减少坏死31青壮年股骨颈骨折的治疗青壮年股骨颈骨折的治疗32青壮年一般指年龄＜60岁，该年龄段的股骨颈骨折多由高能量损伤造成，多为不稳定性骨折，并发股骨头坏死的几率很高，文献报告在

12%-86%

之间。青壮年一般指年龄＜60岁，该年龄段的股骨颈骨折多由高能量损伤33医学病例讨论课件：青壮年股骨颈骨折的治疗34查尔森合并症指数查尔森合并症指数35CCI=0,＞54CCI=1,2,＞47CCI≥3,＞44THAaremorecost-effectiveCCI=0,＞54THAaremorec36对于青壮年股骨颈骨折的首要目标是保髋，因此无论股骨颈骨折的分型如何，一般更倾向于使用内固定治疗。除骨折解剖复位和坚强固定对股骨颈骨折的预后有重要影响之外，其他多个因素，如手术时间，关节囊切开术，内固定的方法等对年轻患者股骨颈骨折的最终影响仍有较大争议。对于青壮年股骨颈骨折的首要目标是保髋，因此无论股骨颈骨折的分37内固定的选择内固定的选择3860-degreePauwelsanglefractureinahealthy30-year-oldpatientAnExpertOpinionSurveyoftheOrthopaedicTraumaAssociation’s(OTA)Membership60-degreePauwelsanglefractu39生物力学研究垂直型，pauwels3型生物力学强度：

PFLP＞DCS＞DHS＞CCS生物力学研究垂直型，pauwels3型生物力学强度：40CSXCSAMBIFNLPCSXCSAMBIFNLP41生物力学强度：DHS+DS＞PFLP≈CCS生物力学强度：DHS+DS＞PFLP≈CCS42生物力学强度：CHS+DS＞CS≈IT生物力学强度：CHS+DS＞CS≈IT43Thenonunionratewas19%forfracturestreatedwithcannulatedscrewsaloneand8%forthosetreatedwithafixed-angledevice.62例患者Pauwels＞70Thenonunionratewas19%for44DHSaloneorDHSsupplementedwithaderotationalscrewhadsignifcantlylessosteonecrosisforGardenⅢ-ⅣfracturesDHSaloneorDHSsupplemented45SHSconstructsdemonstrateasignificantlylowershort-termfailureratethanCSconstructs.SHSconstructsdemonstrateas46higherincidenceofONFHinDHS+CSandofnonunionintheLCPgroup

higherincidenceofONFHinDH47Displaced

fractures

shortenedmorethanundisplaced

fractures

(mean:8.1vs.2.2mm,P<0.001),

fractures

treatedwith

SHS

+derotationscrewshortenedanaverageof2.2mmmorethan

fractures

treatedwithscrewsalone(P=0.03).(JOrthopTrauma.

2015)Arecentmeta-analysisoffemoralneckfracturesinyoungadultsreportedanoverallreoperationrateof18%,nonunionrateof9%,avascularnecrosisrateof14%,andanimplantfailurerateofnearly10%.(Injury.

2015)Thierryetal

recommendthetreatmentofGardenⅠ-ⅡfracturewithCSandGardenⅢ-ⅣwithaDHSandtheadditionofaderotationalscrewforPauwelstypeⅢfractures.(WorldJOrthop.

2014)Toimprovefixationstability,MirandCollingehypothesizedapplyingtheconceptofbuttressplatefixationtothetreatmentofverticalfemoralneckfractures.(MedHypotheses.

2015)通过钢板的支撑作用可将骨折断端间的垂直剪切力转化为利于骨折愈合的压应力，这种应力转化有利于预防垂直型不稳定股骨颈骨折常见的内翻塌陷及不愈合并发症。Displaced

fractures

shortened4828patientsunder60yearsofagewithPauwels

type3femoralneckfracturemeanfollow-upwas13.6months需要更大样本和更长的随访时间来观察内侧钢板的效果。28patientsunder60yearsof49手术时间ThecurrentS2guidelinerecommendstreatmentofafemoralneckfracturewithinthefirst24h.(Managementofhipfractureinolderpeople;ScottishIntercollegiateGuidelinesNetwork-SIGN)Asignificantriseingeneralandearly

surgical

complicationswasregisteredwhenthe

surgical

treatmentwasdelayedformorethan48h.(Unfallchirurg.

2013)Inelderlypatientswithhipfractures,earlysurgerywithin24hoursofadmissionisindependentlyassociatedwithlesspulmonarycomplicationsincludingpneumonia,failuretoextubate,andreintubation,aswellasshorterLOS.(BoneJointJ.

2017)手术时间ThecurrentS2guideliner50Theresultsoftreatmentwereinfluencedbyfracturedisplacementandthequalityofreduction.Andtherewerenodifferenceinosteonecrosisratesbetweenearlyanddelayedtimetofixation.(JBoneJointSurgAm.2004)Wedidnotfindsupporttothecurrentbeliefthatearlysurgical

fixation

ofneckof

femur

fracturesreducestheriskofosteonecrosisinpatientslessthan60years.

(IntOrthop.

2012)Fracturebiologyandrevascularisationplayagreaterrolethanoperationtiming.(Injury.

2016)Thebestresults(significantlybetterthaninothergroups)wereobtainedinpatientswhowereoperatedonearly(<24haftertrauma)(P<0.05).(Unfallchirurg.1995

)Itindicatedthatdelayof

internalfixation

ofmorethan24hcouldincreasesubstantiallytheoddsofnon-union.(

Injury.

2015meta)Theresultsoftreatmentw51关节囊切开术关节囊内压力增高是造成股骨头缺血坏死非常重要的因素。Upadhyayetalfoundnodifferenceintherateofosteonecrosiswithpatientstreatedwithopen(capsulotomy)orclosedreduction(nocapsulotomy)andinternalfxation.(JBoneJointSurgBr.2004)Therewasnorelationshipbetweencapsulardecompressionandosteonecrosisdevelopment.20patientswithameanageof11years(range,4-15years)with

femoralneckfractures

wereidentified.Themeanfollowupwas7years(range,1-28years).(ClinOrthopRelatRes.

2007)Capsulardecompressiondidnotimprovetheunionrateandtimetounioninundisplacedintracapsularhipfractures,butindisplacedfracturesitappearedtoreducetheincidenceanddelaytheonsetofavascularnecrosis.(JOrthopSurg(HongKong).2007)

Thepresentmeta-analysisindicatedtheriskofAVNof

femoral

headwassignificanthigherafterCRIF

fixation

comparedwithORIF.(BMCMusculoskeletDisord.

2014)关节囊切开术关节囊内压力增高是造成股骨头缺血坏死非常重要的因52富含血小板血浆ResultsofthisstudygenerallyshowedthatboththemedianclinicalandradiographichealingtimewereloweringroupBcomparedto.Allparticipantswerefollowedupforatotalof12–48monthswithanaverageof28months(InternationalOrthopaedics.

2015)富含血小板血浆Resultsofthisstudyg53低强度脉冲超声治疗Moderate-to-highqualityevidenceshowsthatLIPUStreatmentreducesthetimetofractureunionandimprovesthequalityoflifewithoutaffectingfunctionalrecoveryandincidentrateofdelayedunionandnonunion,suggestingthatLIPUStreatmentmaybeagoodtreatmentmodalityforadultswithfreshfractures.(Medicine.

2017meta)Treatmentofununitedfemoralneckfracturesinyoungadultsusing

low-intensitypulsedultrasound:Reportof2cases.(InternationalJournalofSurgeryCaseReports.

2016)低强度脉冲超声治疗Moderate-to-highqual54医学病例讨论课件：青壮年股骨颈骨折的治疗55医学病例讨论课件：青壮年股骨颈骨折的治疗56

In18cases(94.7%),thehipunionwasachievedatanaveragedurationof4.1months

(range:3.6-5months).Thenonunionwasobservedin1hip(5.3%)andtherevisiontoahipreplacementwasconductedaftertwelvemonthsoftheoperation.AccordingtotheHarrishipscore