医学病例讨论课件： 青壮年股骨颈骨折的治疗

higher incidence of ONFH in DHS +CS and of nonunion in the LCP group
Thierry et al recommend the treatment of Garden Ⅰ-Ⅱ fracture with CS and Garden Ⅲ-Ⅳ with a DHS and the addition of a derotational screw for Pauwels type Ⅲ fractures. (World J Orthop. 2014)
➢ A recent meta-analysis of femoral neck fractures in young adults reported an overall reoperation rate of 18%, nonunion rate of 9%, avascular necrosis rate of 14%, and an implant failure rate of nearly 10% . (Injury. 2015)
28 patients under 60 years of age with Pauwels type 3 femoral neck fracture mean follow-up was 13.6 months
需要更大样本和更长的随访 时间来观察内侧钢板的效果。
手术时间
➢ The current S2 guideline recommends treatment of a femoral neck fracture within the first 24 h.(Management of hip fracture in older people; Scottish Intercollegiate Guidelines Network - SIGN)
➢ A significant rise in general and early surgical complications was registered when the surgical treatment was delayed for more than 48 h. (Unfallchirurg. 2013)
青壮年股骨颈骨折的治疗
➢ 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。
查尔森合并症指数
CCI=0, ＞54 CCI=1,2, ＞47 CCI≥3, ＞44
THA are more cost-effective
➢ 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。
Hale Waihona Puke Baidu固定的选择
An Expert Opinion Survey of the Orthopaedic Trauma Association’s (OTA) Membership 60-degree Pauwels angle fracture in a healthy 30-year-old patient
DHS alone or DHS supplemented with a derotational screw had signifcantly less osteonecrosis for Garden Ⅲ-Ⅳ fractures
SHS constructs demonstrate a significantly lower short-term failure rate than CS constructs.
生物力学研究
垂直型，pauwels 3型
生物力学强度： PFLP＞DCS＞DHS＞CCS
CS FNLP
XCS AMBI
生物力学强度：DHS+DS＞PFLP≈CCS
生物力学强度：CHS+DS＞CS≈IT
62例患者 Pauwels ＞70
The nonunion rate was 19% for fractures treated with cannulated screws alone and 8% for those treated with a fixed-angle device.
To improve fixation stability, Mir and Collinge hypothesized applying the concept of buttress plate fixation to the treatment of vertical femoral neck fractures. (Med Hypotheses . 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 shortened more than undisplaced fractures (mean: 8.1 vs. 2.2 mm, P < 0.001), fractures treated with SHS + derotation screw shortened an average of 2.2 mm more than fractures treated with screws alone (P = 0.03).(J Orthop Trauma. 2015)
➢ In elderly patients with hip fractures, early surgery within 24 hours of admission is independently associated with less pulmonary complications including pneumonia, failure to extubate, and reintubation, as well as shorter LOS.(Bone Joint J. 2017)