Chinese Journal of Tissue Engineering Research ›› 2017, Vol. 21 ›› Issue (3): 445-449.doi: 10.3969/j.issn.2095-4344.2017.03.022
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Li Bai-tong1, Zhou Tian-yi2, Liu Zhen2, Shang Jian2
Online:
2017-01-28
Published:
2017-03-14
Contact:
Shang Jian, M.D., Professor, Chief physician, Master’s supervisor, First Department of Orthopedics, First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
About author:
Li Bai-tong, Studying for master’s degree, Graduate School of Heilongjiang University of Chinese Medicine, Harbin 150040, Heilongjiang Province, China
CLC Number:
Li Bai-tong1, Zhou Tian-yi2, Liu Zhen2, Shang Jian2 . Treatment scheme selection strategy and progress of elderly femoral neck fracture of Garden type II[J]. Chinese Journal of Tissue Engineering Research, 2017, 21(3): 445-449.
2.1 GardenⅡ非手术保守治疗 老年股骨颈骨折GardenⅡ型的非手术治疗,主要是针对体质差,有严重的内科疾病不能耐受手术,或不能配合手术治疗的患者,其主要的治疗方法是早期给予皮肤牵引,对症消肿,接骨,抗血栓等的药物治疗,待炎症反应期过后,改成石膏固定,卧床牵引,定制“丁”字防旋鞋固定,早期恢复重建髋关节的功能,根据大量的临床资料数据显示,Taha等[8]学者针对61例GardenⅡ型老年股骨颈骨折的患者临床观察示55.7%患者出现再移位,虽然非手术患者早期避免了手术的风险及痛苦,但后期出现骨不连,股骨头坏死,下肢短缩,功能丧失,不能早期活动锻炼,相继出现并发症,最终导致了死亡率的增加。 2.2 GardenⅡ型手术治疗及固定方式的选择 2.2.1 内固定 空心钉:Gregersen等[9]统计322例行空心钉固定术的患者,年龄均大于65岁,2年后再次手术率达29%。Kain等[10]统计120例行空心钉固定术的患者,年龄均大于65岁,平均年龄(80±15)岁,1年后需要再次手术比例为15%。Riaz等[11]统计251例行空心钉固定的患者,其中男66例,女185例,平均年龄77岁(范围60-101岁),其中固定失败人数为15%。Kain等[12]统计了过去5年,120例(年龄大于65岁,平均年龄(80±15)岁)股骨颈骨折后进行空心钉内固定的患者,其中51例已死亡(42%),18例(15%)需要进行二次手术,原因为植入物感染、骨不连等。他们的结论是老年人稳定型股骨头骨折,采用空心钉内固定术,其二次手术概率极高,且年龄越大,概率越高,保守估计,80岁以上老人仅短期翻修率就高达10%。而优点是:空心钉内固定可经皮操作,手术创伤小,对股骨头血运破坏少,保留了自身股骨头,且较其他螺钉有更强的稳定性。缺点:Viberg等[13]研究发现,对于老年人及Garden Ⅱ型股骨颈骨折,空心钉内固定术后翻修率为明显高于髋关节置换术;Wang等[14]研究发现,空心钉内固定后股骨头坏死可能与患者骨折类型、术中复位情况及术后功能锻炼有关,且年龄越大,坏死可能性越高。 DHS:Schwartsmann等[15]分析96例行DHS患者,男56例,女40例;年龄平均(53±14)岁,3例患者出现骨不连,16例缺血性骨坏死,愈合率80.2%。Zhou等[16]分析60例行DHS患者,男22例,女38例;年龄均大于60岁(平均66.8±3.2)岁,1例患者术后出现骨不连接,愈合率98.33%。Makki等[17]分析60名行DHS患者,平均年龄70岁,4例缺血性骨坏死、1例出现骨不连、2例出现感染,愈合率89.2%。总结其优点在于: Tsai等[18]研究发现,虽然DHS与空心螺钉内固定在术中失血量、手术时间等方面无明显统计学差异,但其术后并发症发生率远低于空心螺钉内固定。缺点:①术中所需术野大;②DHS的钉板结构股骨侧承受压力较大,主钉易发生切割断裂,导致内固定失败。根据以上文献,DHS内固定技术的成功率约在80%-95%。其失败原因多为主钉断裂,从而可能造成骨不连、股骨头坏死等并发症,需要二次手术。而在中国,患者一般难以接受二次手术,且老年人本身一般状态差,身体状况一般,如进行二次手术,将对整体的生理状态是一个极大的冲击。故该术式在老年股骨颈治疗中的应用逐渐减少。 2.2.2 髋关节置换术 人工股骨头置换(FHR):目前临床上针对老年性股骨颈骨折的半髋关节置换主要包括双极头假体置换与单极头的假体置换2种,而假体又分为生物型和水泥型假体,对于老年股骨颈骨折GardenⅡ型现在大多数临床医生更倾向于人工双极头的置换,认为其多数髋关节的功能能够恢复至骨折之前水平,Gao等[19]通过回顾20项研究,发现老年股骨颈骨折,髋关节置换较复位内固定并发症少、5年内再手术率低,且髋关节置换后可早期负重、有效减轻术后疼痛,降低术后3年死亡率。Paker等[20]分析既往6个临床试验发现,采用骨水泥型人工股骨头的半髋关节置换后1年内疼痛减轻,患者生活能力改善。Taylor等[21]对160例股骨颈骨折患者随访2年,发现采用非骨水泥型人工股骨头患者较采用骨水泥型人工股骨头患者术后并发症多、骨折和下肢短缩发生率大,而髋关节功能评分亦较差。Yang等[22]回顾6个随机对照研究发现,单极头与双极头人工股骨头术后并发症发生率和死亡率无显著性差异,髋关节功能亦相似,但双极头人工股骨头髋臼磨损明显小于单极头人工股骨头。通过上述代表性文章,可以得出这样的结论:对于老年股骨颈骨折,骨水泥型人工双极头置换术具有更少的并发症,更低的脱位率。且双极头的2个人工关节面设计则提高了髋关节稳定性。但近年来,Ng等[23]研究发现,生物型双极头要优于骨水泥型,因为它可以减轻患者腿部疼痛,减少手术时间和术中失血量,并且在关节功能恢复,术后并发症、脱位率以及死亡率上无明显差异。Norrish等[24]对8年内500例,平均年龄82岁(范围53-100岁),采用行半髋关节置换术的患者进行长达5-12年的随访,发现这类假体的5年生存率为94%,12年生存率为83%,愈合率91.8%。Lin等[25]选取了10年内半髋关节置换和内固定治疗的患者各13772例,对比了他们的3个月、2年、10年内的二次手术率。结论:半髋关节置换的二次手术率无论在短期还是长期都明显低于内固定。 人工全髋关节置换术(THA):有部分学者认为,针对老年股骨颈骨折GardenⅡ型的治疗,并不赞同全髋关节置换,因为其在手术时间,创伤程度上均远远大于半髋关节的置换,在一定程度上增加了手术的风险,尤其对于高龄及身体条件差的患者,而Yu等[26]通过回顾性分析最终得出结论发现,全髋关节置换组较半髋关节置换组二次手术率低、术后1年内Harris髋关节功能评分高,但脱位率亦更高。Zi-Sheng等[27]回顾性分析发现,全髋关节置换术组与半髋关节置换术组术后死亡率相当,但全髋关节置换组较半髋关节置换术组二次手术率低,且在减轻患髋疼痛方面有明显优势。与复位内固定和半髋关节置换相比,全髋关节置换后髋关节功能恢复好、二次手术率低。随着新技术的发展,全髋关节置换疗效日益提高。随着科学技术的发展,新生产出的大直径人工股骨头可提高髋关节活动度,从而降低脱位率;全髋关节置换的优势在于患者术后可早期负重,并避免术后股骨头坏死和骨关节炎造成的二次手术。虽然髋关节置换相比内固定有更高的生存率,更低的感染率,术后早期下地等优势,但是它有一些其特有的并发症。假体周围骨折就是其中之一。Inngul等[28]回顾性分析统计了2757例行髋关节置换的患者,平均年龄82岁,其中63名(2.3%)在术后发生了假体周围骨折。Yoon等[29]统计了1563例行髋关节置换的患者,平均年龄79.6岁(范围65-103岁)。37例(2.4%)在术后44.4周内发生假体周围骨折,2/3的假体周围骨折发生于术后1年内,故应密切注意患者术后1年内是否发生假体骨折。Bhandari等[30]综合298位骨科医师的调查结果发现,大部分骨科医师主张对较年轻(< 50岁)患者采用内固定,对老年患者(> 70岁)采用关节置换术。Joshua等[31]通过统计914例(平均年龄81.5岁)股骨颈骨折患者,得出结论:60-80岁患者,随着患者年龄增加,关节置换的二次手术率则降低,而内固定的二次手术率则升高;在各年龄段患者中,关节置换的二次手术率均低于内固定。 2.3 骨水泥型假体与生物型假体 临床上无论选择半髋关节置换还是全髋关节置换,骨科医生需要面临的一个现实问题就是在骨水泥型与生物型假体之间的选择,目前二者之间的优劣、适应证上仍存在着争议。文章的前面作者在骨水泥的适应症方面已经有所叙述,在此就二者之间的临床观察再做一个分析,供临床骨科医生思考。马川等[32]对60例老年性股骨颈骨折的患者分成骨水泥型和生物型两组,认为骨水泥型和生物型关节假体在手术时间,出血量方面比较,无明显差异,但骨水泥型组住院的平均时间要短于生物型的假体,骨水泥型假体组术后的并发症要高于生物型。最终他们得出的结论是:两种假体相比,在手术时间,术中出血量方面无显著差异,骨水泥型假体患者的住院时间短,可以进行早期的髋关节功能锻炼,但并发症也多。李建刚等[33]通过Harris评分对151例老年股骨颈骨折的患者分成骨水泥假体和生物型假体两组,分别从手术时间,术中出血量,引流量,术后的疼痛,住院天数,围手术期的并发症,后期并发症等反面做了详细的研究,认为生物型假体组的并发症的总的发生率和术后髋关节脱位的发生率要明显低于骨水泥型假体,总的临床疗效是骨水泥型假体要优于生物型的假体。骨水泥型假体能够在短期内获得良好的功能,这里所说的功能的早期的髋关节的活动,且能够早期的下地负重,比生物型的假体在短期时间内证明更加牢固,其原因在于术者扩髓,骨水泥在髓腔内填充,加上假体的加压所用,这使得骨小梁与骨水泥之间相互交错,渗透,成为一体,且骨水泥能马上坚强凝固,从而减少了的患者术后的卧床时间,可早期下地,功能恢复快[34];而生物型的假体,是通过骨组织的长期反应增生才使得与假体能够紧密的结合在一起,这将需要很长的时间,且在短期内稳定性较差,卧床的时间长,可能导致出现一系列其他的并发症。且有研究证实,骨水泥型假体因在股骨干在注入了大量的骨水泥,这使得股骨干局部的生物力学发生改变,极易容易出现假体周围的骨折,且可能术中血压降低,心脑血灌注不足等并发症,都是很危险的,且给后期的髋关节翻修术带来了难度,但有临床观察证实:其术后引流量要优于生物型的假体,国外有报道称骨水泥型假体比生物型假体在术后的死亡率要高[35-36]。最终他们得出结论:无论是选择骨水泥型的假体还是生物型的假体,两者都能够在很大程度上改善患者的髋关节功能,减少因非手术治疗而产生的并发症,均可获得满意的临床效果。"
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