【专题文献】之人工髋关节置换——下肢假体周围骨折的处理

advocated method to manage them is by using a retrograde intramedullary nail. The two pre-requisites are a large enough distal fragment to allow fixation of the distal locking screws, and a femoral component that allows access to the medullary canal. Hence, closed box devices are absolute contraindications.

If the fracture is too distal, or there is a closed box implant, locking plates are advocated and have been shown to do well (Figure 5).

处理

如果骨折没有移位且假体是稳定的（这是极少见的），非手术治疗是适当的，使用支具限制关节活动，保护负重。在更多的病例中，必须手术治疗。骨折超过股骨假体15cm应该不考虑为假体周围骨折，应使用传统办法处理。更常见和更广泛的推介方案是处理如此骨折使用倒打髓内钉。两要素是一个足够大的远端骨块以允许远端锁定钉的固定，和一个允许髓内钉通路的股骨假体。因此，假体底部是封闭的，是绝对禁忌症。

如果骨折太近远端，或有一个闭合的假体底部，推荐使用锁定钢板，并且显示出易于处理。（图

5）

图5

Patellar fractures are the second commonest periprosthetic fracture of the knee, with a reported incidence of patello-femoral complications (fracture, loosening, radiolucency) from 0.15%e 12%. Most occur with no evidence of injury within the first two years after surgery.23 Specific risk factors that apply to patellar fracture/component loosening include excessive bone resection or lateral release during the index procedure with resulting maltracking. Patellar resurfacing during the index procedure has a clear correlation.

Management of patellar periprosthetic fractures is determinedby fracture displacement, the degree of component loosening and whether the extensor mechanism is intact. Type III fractures are the commonest according to Ortiguera and Berry.24Management varies according to the type, but the majority (70%) are managed nonoperatively. Other options include revision arthroplasty (if the implant is loose), internal fixation, or patellectomy (partial or total). Internal fixation is associated with poor union rates, increased infection and a post-operative extension lag of 10 degrees.25,26

髌骨骨折是第二常见的膝部假体周围骨折，报道髌股并发症（骨折，松动，可透射线）的发生率自0.15%－12%。大多数在没有外伤的情况在初次手术操作中，髌骨重新表面化有一个明显的相关性。

髌骨假体周围骨折的处理，由骨折移位、假体松动的程度和是否伸肌机制完整所决定。根据Ortiguera和Berry，III型骨折是最常见的。根据骨折类型有不同的处理方式，但是大多数（70%）是非手术治疗。其他选择包括假体翻修（如果内植物松动），内固定和髌骨切除（部分或全部）。内固定和较差的愈合率，增高的感染和术后10度伸展延迟有关。 下发生于最初的术后两年。与髌骨骨折/假体松动有关的特殊风险因素，包括在最初的手术操作中过度的骨切除或外侧松解，导致髌股轨迹病。