Fractures around femoral prosthesis after artificial hip replacement

doi:10.3969/j.issn.2095-4344.2013.30.022

Abstract

Abstract:

BACKGROUND: With the wide application and in-depth research of artificial hip joint, more secondary fractures around femoral prosthesis are reported.
OBJECTIVE: To investigate the reasons, preventive measures, classification and treatment method of fractures around femoral prosthesis after artificial hip replacement.
METHODS: The clinical data of the type classification, treatment method and clinical efficacy of fractures around femoral prosthesis after artificial hip replacement were retrospectively analyzed. The multi-level study was performed to investigate the trend of the relevant literatures. According to the Vancouver classification criteria, the various types of fractures and the results and complications of various treatment methods were analyzed, the treatment methods of different fractures were identified, and the effective and objective evaluation criteria were established to provide references for the clinical treatment.
RESUTLS AND CONCLUSION: The fractures around femoral prosthesis after artificial hip replacement were closely related with the age of the patients, basic diseases, osteoporosis and selection of prosthesis type. The Vancouver classification criteria and treatment programs have guiding significance to the clinical efficacy. The fractures should be treated with different methods according to the different types in order to promote the fracture healing. The fractures around femoral prosthesis after artificial hip replacement were commonly treated with shape memory alloy embracing fixator, minimally invasive fixation system, locking compression plate, allograft cortical bone plates, carbon fiber, impaction bone grafting and renovation. In the practice application, various methods are often used in combination. For the patients with B2 and B3 type fractures, we should pay attention to the bone grafting around the fractures and the inner and outer medullary cavity.

Key words: bone and joint implants, academic discussion of bone and joint, hip replacement, femoral prosthesis, fracture, bone mineral density, bone loss, internal fixation, allograft cortical bone plate, embracing, locking plate, bone grafting, renovation, complications

CLC Number:

R318

Liu Ying-fei, Wang Tao, Zhang Ping-de . Fractures around femoral prosthesis after artificial hip replacement [J]. Chinese Journal of Tissue Engineering Research, 2013, 17(30): 5557-5562.

Figures/Tables 1

2.1 人工髋关节置换后股骨假体周围骨折的原因股骨假体周围骨折可能与多种因素有关，主要包括以下几点： 2.1.1 年龄性别因素导致的骨质疏松进行关节置换患者大多数为老年人，且原发疾病多为骨关节炎、类风湿关节炎等，加之因疼痛而活动量减少，均不同程度存在骨质疏松，容易导致低能量骨折[18]。Franklin等[19]研究认为女性高龄是人工髋关节置换后股骨假体周围骨折发生的独立危险因素。目前骨质疏松是公认的股骨假体周围骨折的危险因素，其引起的骨机械力的降低，易导致骨折发生[20]。 2.1.2 假体的选择与固定方式国内外文献报道股骨假体周围骨吸收的情况大部分采用定性判定[21-22]，很少注意到骨水泥型和非骨水泥型的人工髋关节的选择对股骨假体周围骨密度的影响[23]。相关报道骨水泥型假体的股骨假体周围骨折的发生率为0.1%-3.2%，而非骨水泥型假体的股骨假体周围骨折的发生率为3%-28%，后者明显高于前者[24]。Tsiridis等[25]报道人工髋关节置换采用骨水泥型假体固定者治疗后发生股骨假体周围骨折的发病率为6.3%，行非骨水泥型假体固定者为17.6%。这与选择非骨水泥型假体时，期望假体与股骨有完美的匹配，而在选择假体时过分追求柄与股骨的紧密配合而使用过粗的股骨柄，在强行打入髓腔锉或在扩髓不充分的情况下打入股骨假体导致骨折有关。 2.1.3 基础疾病[26] 有广泛或局部骨溶解的患者，如假体松动，假体的末端会撞击外侧骨皮质，使局部应力增加，在轻微外力下即可造成骨折[27]。人工髋关节翻修患者常有骨量不足，可能导致假体固定困难，取出假体及骨水泥时需行股骨皮质开窗等，这些都会引起皮质损伤，从而降低股骨强度。另外，还有学者发现翻修次数越多，股骨假体周围骨折风险也越大。 2.1.4 股骨假体周围骨密度变化股骨假体周围骨密度变化对假体置换的疗效影响较大，因为它显著影响假体的初始稳定，而假体的初始稳定是骨长入微孔的重要前提，而骨长入微孔又是假体长期稳定的保证。人工髋关节置换有骨水泥固定型与非骨水泥固定型两种，二者对股骨假体周围骨密度变化的影响有各自的特点。骨水泥固定型对假体周围骨密度的影响：①骨水泥固定增加了碎屑，生物性因素引起的骨溶解在骨水泥固定中起的作用大。②骨水泥固定的假体置换后即时固定效果，相对于非骨水泥固定存在的早期假体微动和下沉问题，骨水泥固定的假体在骨组织-骨水泥-假体界面上没有任何微动发生，允许置换后早期负重。③骨水泥假体价格比非骨水泥型假体要低。非骨水泥固定型对假体周围骨密度的影响：①非骨水泥假体为达到骨组织长入的良好初始固定效果，要求之一是柄体能很好的充填骨髓、紧密嵌插，这使得非骨水泥固定型股骨柄假体多较骨水泥固定型粗大，无形中增加了假体的刚性，这也是非骨水泥假体应力遮挡现象严重，容易出现柄体远端大腿痛的原因。②通过骨长入来达到生物固定的人工关节，对置换结束要求较高，应避免早起下肢负重，所以对于高龄或者严重骨质疏松的患者，不宜使用非骨水泥固定人工假体。③非骨水泥假体置换后，患者跛行，疼痛、假体松动和返修率高。④一旦出现松动，在返修治疗中骨的缺失量可能比骨水泥型假体要少，需要的植骨量也少，因此，主张对年纪较轻的患者首选非骨水泥固定型假体。⑤髋臼侧非骨水泥假体置换后效果要好于骨组织长入骨水泥固定型髋臼假体，尤其是患者年轻和人工髋关节置换返修患者，骨组织长入主要发生于假体与自体骨紧密接触区域，移植骨处不发生改现象，骨组织长入在髋臼侧要明显高于股骨侧。 2.1.5 其他因素外伤或摔倒，绝大多数是微小创伤，如扭伤或摔伤，高能量创伤占少数，Beals等[28]报道，人工髋关节置换后发生股骨假体周围骨折66%是在室内摔倒所致，18%是在室外摔倒所致，仅有8%由较大创伤所致，其余8%为自发性骨折。人工髋关节置换后肢体负重增加引起的疲劳性骨折，不正确的功能锻炼，进行关节置换患者平均年龄较大，肌肉力量、身体协调性明显下降，治疗后常无法正确、科学的进行肌肉和关节活动度的训练，躯体稳定性及关节活动度差，容易出现意外损伤。 2.2 人工髋关节置换后股骨假体周围骨折的治疗股骨假体周围骨折的治疗目标是使骨折稳定在解剖位置上并获骨性愈合，假体牢固稳定避免松动，尽早开始功能锻炼。股骨假体周围骨折的治疗方法有很多种，包括保守治疗如牵引、石膏或支具等[29]。手术治疗如钢丝钢缆环扎、钢板、异体皮质骨骨板、髓内钉、长柄骨水泥型或非骨水泥型假体翻修联合或不联合使用植骨等。在治疗人工髋关节置换后股骨假体周围骨折时要兼顾骨折、假体及骨量3个方面。相关研究表明移位的骨折需要进行内固定，松动的假体需要翻修，骨缺损明显者需要植骨[30-31]。对假体松动的股骨骨折进行内固定的同时进行翻修已达成共识，使用长柄非骨水泥远端固定型假体联合异体皮质骨板来处理假体松动的股骨骨折，被认为是常规应采用的治疗方法[32]。黄揆洲等[33]探讨了人工髋关节置换后假体柄周围股骨骨折的治疗计划以及临床效果。将45例患者，依Vancouver分类系统，共有7例A型骨折，24例B1型骨折，7例B2型骨折，4例B3型骨折以及3例C型骨折。分别根据假体稳定度作骨折内固定或人工髋关节翻修治疗，应用钢板加钢丝或钢索、Dall-Miles钢板、异体结构骨、异体骨碎片等，翻修治疗应用常规骨柄或组合式股骨柄，并分析人工髋关置换后股骨假体周围各类型骨折及各种治疗方式的结果与并发症，结果见表1。"

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