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Re: переломы шейки бедра
Odessky Jacob M.D. 23 Июль 2008, 23:33
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Уважаемый Михаил Викторович!
Вы задали очень общий вопрос!!!
Метод лечения переломов шейки бедра зависит от локализации перелома, степени его смещения, времени с момента перелома, биологического возраста пациента, его активности и сопутствующей патологии.
Как Вам известно Гарден 1 и 2 перломы хорошо срастаются и могут вестись без оперативного вмешательства, предусматривающего не нагружать поражённую ногу в течении 3 месяцев. Для того, чтобы лечить таким способом, вы должны быть уверенны, что Ваш пациент будет безукоризненно следовать Вашим рекомендациям. Если Вы не доверяете пациенту, либо возможность вторичного смещения велика из-за сопутствующего заболевания ( эпилепсия, двигательные гиперкинезы, деменция и т.д.), либо парог болевой чувствительности очень низкий и Вы не можете контролировать боли с помощью медикаментов, показана внутренняя фиксация. При этом, если перелом субкапитальный -3-мя каннюлированными болтами, если базоцервикальный - DHS, либо PFN, в случае применения DHS, я рекомендую вначале ввести каннюлированный болт в верхнюю центральную часть шейки бедра и только после этого скользящий болт, а не ограничиватся установлением спицы или или направителя ( я видел, как во время введения скользящего болта происходит ротация проксимального фрагмента). Моё предпочтение - оперативное лечение во всех случаях, при которых риск анестезии не превышает риск смерти от осложнений, связанных с длительным постельным режимом или , иными словами, когда есть абсолютное противопоказание к анестезиологическому пособию.
Другое дело 3 и 4 типы по Гардену... Такие переломы у молодых и физически активных пожилых людей являются неотложным ортопедическим состоянием и должны оперироваться (закрытая или открытая репозиция + внутренняя фиксация) в первые 8 часов после травмы, т.к. процент асептического некроза головки бедренной кости возрастает в случаях отсрочки репозиции.
Что касается артропластик тазобедренных суставов при переломах... Пациентам от 60 до 70 лет показана THR. Старше 70- гемиартропластика.
Всё это хорошо описано:
http://www.jbjs.org.uk/cgi/content/citation/87-B/12/1701
http://www.jaaos.org/cgi/content/abstract/14/5/287
http://orthopedics.about.com/cs/hipsurgery/a/brokenhip.htm
http://www.e-radiography.net/radpath/f/femur%20fracture/neck_of_femur.htm
И ещё одно оперативное вмешательство, на мой взгляд незаконно забытое-операция по Гирдлстону - резекционная артропластика тазобедренного сустава , или по-проще удаление головки бедренной кости. Показана пожилым пациентам, которым опасно делать гемиартропластику по сопутствующим заболеваниям, хотя я видел стариков, способных ходить после подобной операции. Такие вмешательства показаны пациентам, прикованным к кровати и сильными болями в месте перелома.
С уважением!
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Re: переломы шейки бедра
Anton Vakulenko 24 Июль 2008, 16:39
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У нас принят такой подход:
до 60-65 лет при жизнеспособной головке - остеосинтез 2-3 спонгиозными
винтами. Старше этого возраста или при сомнениях в жизнеспособности головки - тотальное эндопротезирование. Старше 80 лет - однополюсное
эндопротезирование.
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Re: переломы шейки бедра
Марикин М В 25 Июль 2008, 08:01
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Спасибо ответившим коллегам. Я специально задал весьма обший вопрос о лечении данной патологии не вдаваясь в детали (классификация,анатомические особенности,проблемы кровоснабжения,прогнозируемые исходы и т.д.)Прооперировав не одну сотню таких больных сложилось определенное мнение о тактике лечения.Мнение коллег ответивших совпадает с моим мнением.Возможно повторюсь - меня интересовала тактика лечения внутрисуставных переломов шейки. Хотелось бы увидеть хоть несколько рентгенограмм с DHS PFN после операции и в отдаленном периоде.
Для Odessky - не могу открыть сайты, пишет - ошибка адреса. Существуют ли стандарты лечения данной патологии или кто во что горазд как в России.
С уважением всем кто ответил.Возможно кто либо еще напишет.
Марикин МВ МСЧ ММК Магнитогорск.
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Re: переломы шейки бедра
Адонин 25 Июль 2008, 08:30
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Уважаемый Михаил Викторович,
зачем устраивать опросники, если можно просто открыть книжку и все прочесть? Честно говоря, удивлен.
Hudson et al. reported an 8-year outcome study of 367 femoral neck fractures treated surgically. Their study showed a higher rate of revision in patients older than 80 years treated with internal fixation of a displaced femoral neck fracture compared with patients who were treated with hemiarthroplasty. There was no difference, however, in the revision rates of nondisplaced fractures treated by internal fixation or hemiarthroplasty in this age group. In patients 65 to 80 years old, regardless of the amount of displacement, no difference was noted in revision rates after hemiarthroplasty or internal fixation. These authors noted a significantly higher mortality rate associated with internal fixation than with hemiarthroplasty for patients in this age group. Complications, revision rates, and other outcomes were the same regardless of whether a unipolar or bipolar prosthesis was used and whether an anterior or posterior approach for hemiarthroplasty was used in patients 65 to 80 years old.
In a meta-analysis of 106 reports of displaced femoral neck fractures, Lu-Yao et al. found that the incidence of reoperation ranged from 20% to 36% within 2 years after internal fixation. The reoperation rate after hemiarthroplasty within the same time interval was 6% to 18%. A trend for higher mortality rates with hemiarthroplasty within the first month after the operation was noted, but was not statistically significant (P = .22). After the first month, there were no differences in the cumulative mortality rates between the two groups.
In Sweden, Rogmark et al. reported a 2-year prospective study of 409 ambulatory patients, 70 years or older with Garden stage III or IV fractures treated with arthroplasty or internal fixation. They found the rate of failure to be higher in patients with internal fixation than in patients with arthroplasty (43% versus 6%) and the rate of complications higher in the arthroplasty group (23% versus 15%). Functionally, 36% of patients with internal fixation had impaired walking and 6% had severe pain compared with 25% and 1.5% for patients with arthroplasty. There was no difference in mortality.
Bhandari et al., in a meta-analysis of nine trials comparing arthroplasty with internal fixation in 1162 patients, found that arthroplasty significantly reduced the risk of revision surgery. Increased blood loss, longer operative times, and greater infection and mortality rates occurred, however, with arthroplasty.
Several authors have listed the advantages and disadvantages of and the indications for prosthetic replacement for recent displaced fractures of the femoral neck, and no two totally agree. The advantages can be summarized as follows: 1. Prosthetic replacement allows immediate weight bearing to return elderly patients to activity and help avoid complications of recumbency and inactivity. When the concept of prosthetic replacement was first introduced, this perhaps was the most important advantage. As patients with internal fixation devices are more aggressively mobilized than in the past, and most are allowed at least partial immediate weight bearing, this advantage is less distinct than previously thought.
2. As a primary procedure, prosthetic replacement eliminates osteonecrosis and nonunion as complications of femoral neck fractures. There still is no completely reliable way of identifying femoral heads with a significantly damaged blood supply before definitive surgery. Developing technology may allow definitive preoperative identification of these avascular femoral heads and provide useful information in making the decision between prosthetic replacement and internal fixation.
3. Prosthetic replacement of displaced femoral neck fractures reduces the incidence of reoperation compared with internal fixation. This argument applies only to elderly individuals with a limited life expectancy because the cumulative rate of reoperation for prosthetic replacement increases with time.
The recognized disadvantages of using a prosthesis in a fresh femoral neck fracture are as follows: 1. After the femoral head and neck have been discarded in favor of a metal implant, salvage procedures become complicated if there is mechanical failure or infection. The use of a prosthesis for most fractures of the femoral neck ignores the fact that at least two thirds of patients treated by internal fixation have functional hips that last the remainder of their lifetimes. It is appropriate to remember Boyd and Salvatore's comment: “The sacrifice of the head and neck and replacement by a metallic foreign substance is not the answer for the majority of patients; in over half, the best available material is in the acetabulum, and its indiscriminate removal should be avoided.”
2. The operation for inserting a prosthesis generally is considered to be more extensive than that required for an uncomplicated internal fixation procedure. Larger exposure is required, and blood loss is greater. Many authors have reported slightly higher perioperative mortality rates for patients treated with prosthetic replacement than for patients treated with internal fixation. This finding has a definite selection bias, however, because patients undergoing hemiarthroplasty tend to be more elderly and have more medical comorbidities.
Relative indications for hemiarthroplasty are as follows: 1. Advanced physiological age. Advanced age alone is not a true indication for a prosthesis, although some local and systemic diseases that occur in older patients, especially if they occur in combination, might be. Prosthetic replacement probably should be reserved for patients 70 years old or older with a life expectancy of no more than 10 to 15 years. Some definite exceptions to this statement are mentioned later.
2. Fracture-dislocation of the hip in an older patient. If the fracture involves the superior weight bearing surface of the head (Pipkin type II; the Pipkin classification system is discussed in the section on dislocation and fracture-dislocation of the hip), the insertion of a prosthesis is preferable to closed treatment or open reduction of the fragment. If a substantial fragment of the inferior part of the head is fractured (Pipkin type I), the dislocation should be reduced promptly and, if the head fragment is not caught in the joint, treated closed; if necessary, open reduction of the hip can be performed, and the fragment can be removed. Such treatment results in a good hip if the superior weight bearing surface of the head is intact.
Stronger indications for hemiarthroplasty include the following: 1. A fracture that cannot be satisfactorily reduced or fixed with stability, especially with posterior comminution.
2. Femoral neck fractures that lose fixation several weeks after operation.
3. Some preexisting lesions of the hip. In patients with preexisting lesions, an arthroplasty already may have been indicated, and the fracture merely makes the decision immediate. Patients with osteonecrosis of the head of the femur from unknown causes, from irradiation, or from a previous dislocation and patients with severe rheumatoid or degenerative arthritis of the hip probably would have a better hip after insertion of a prosthesis than before the fracture. In one study of rheumatoid patients, Strömqvist, Kelly, and Lidgren reported a 95% rate of loss of reduction or superior segmental collapse compared with 50% in a matched nonrheumatoid group. Most of these patients are candidates for total hip arthroplasty rather than femoral head replacement.
4. Malignancy. A malignancy may be an indication for the insertion of a prosthesis. A patient with a short life expectancy, whether the fracture is pathological or primarily the result of trauma, is best treated with a prosthesis. If the fracture is pathological, the insertion of a prosthesis offers not only a good solution, but also an opportunity to perform an open biopsy and to establish a definite diagnosis. In pathological fractures, supplementing the fixation with methylmethacrylate usually provides sufficient stability.
5. Neurological disorders. Patients subject to uncontrolled epileptic seizures and patients with severe uncontrolled parkinsonism are treated better with a primary prosthesis. Many of these disorders are controllable, however, and the indication may not always be absolute.
6. Old, undiagnosed fractures of the femoral neck. Occasionally, a fracture of the femoral neck goes undiscovered for several weeks. Sometimes multiple injuries may delay treatment of a fractured femoral neck even after its diagnosis. An untreated, unreduced, and unimpacted fracture of the femoral neck that is more than 3 weeks old should have a primary prosthesis, other things being equal. Before the use of prostheses, we saw many patients with fractures of the femoral neck 3 weeks old that healed satisfactorily with nothing more than reduction and rigid internal fixation. The odds for favorable results decline, however, with the passage of time after a displaced fracture.
7. Fracture of the neck of the femur with complete dislocation of the femoral head. This lesion is rare and is best treated by primary prosthetic replacement because osteonecrosis of the head is certain under these circumstances.
8. A patient who probably cannot withstand two operations. If a patient's general condition prohibits a second operation, a primary prosthesis is justified. In patients who have unstable multiple medical problems, we occasionally perform a closed reduction with percutaneous multiple screw fixation using intravenous sedation and generous amounts of local lidocaine infiltration anesthesia.
9. Patients with psychoses or mental deterioration. Elderly patients with fractures of the femoral neck often already have Alzheimer disease, and protected weight bearing in such patients may be unreliable, with immediate unprotected weight bearing resulting in possible loss of fixation, especially in severely comminuted fractures. A primary prosthesis may be justified in these circumstances.
Увы, у кэмбелла алгоритм лечения - таблица, и скопировать сюда в текстовой файл я не могу
С уважением
Адонин
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переломы шейки бедра
