What’s New in Orthopaedic Trauma2010
骨科创伤新进展2010
By John Weinlein, MD, and Andrew H. Schmidt, MD
The field of musculoskeletal trauma continues to benefit from advances in basic science, improved methods of treatment(both operative and nonoperative), innovation in surgical devices,and more sophisticated research methodology, with emphasis on comparative clinical trials and appropriate assessment of outcomes. The emphasis on evidence-based management continues in the literature and in presentations at academic conferences.
骨肌创伤领域继续受益于基础科学的进步、治疗方法的改进(手术治疗和非手术治疗)、外科器械的创新、高级的研究方法学以及强调对比性临床试验和适当的疗效评估。文献以及学术会议陈述继续强调循证医学的应用。
For this year’s summary of advances in orthopaedic traumatology, the authors again reviewed all issues of Acta Orthopaedica, Clinical Orthopaedics and Related Research, Injury,The Journal of Bone and Joint Surgery (both American and British volumes), Journal of Orthopaedic Trauma, Journal of Shoulder and Elbow Surgery, and The Journal of Trauma. Selected articles from other journals were also included. Finally, presentations from the annual meetings of the Orthopaedic Trauma Association (OTA) and the American Academy of Orthopaedic Surgeons (AAOS) were reviewed. Articles and presentations that represent Level-I and Level-II evidence are reviewed in this article along with other articles of clinical importance in the opinion of the authors.
为总结本年度骨科创伤学进展，作者回顾了矫形学报、临床骨科及相关研究、损伤、JBJS(美版和英版)、骨科创伤杂志、肩肘外科杂志和创伤杂志的全部内容，并从其它杂志选择部分文章。最后，回顾骨科创伤协会(OTA)、美国骨科医师学会(AAOS)年会的部分陈述。本文回顾了代表I级和II证据的文章和陈述。还有其它一些文章，其作者的观点有重要的临床意义。
Outcomes
结果
The rigorous documentation of outcome, especially from the patient’s perspective, has been one of the major advances in orthopaedic surgery over the past decade. Two studies investigated differences between patient and surgeon perceptions of outcome after orthopaedic trauma. One study evaluated patients six months after they had sustained a“major”fracture1. Surgeons were more satisfied with their patients’ progress than the patients themselves were. The only factor associated with surgeon satisfaction was fracture-healing. Objective injury and treatment factors were not associated with patient satisfaction in terms of progress. Attributing blame of the injury to others was associated with patient satisfaction in terms of progress, whereas blame, the use of a lawyer, and female sex were associated with patient satisfaction in terms of recovery1.
对临床结果特别是来自患者的期望的严格记录，成为过去十年中骨外科主要进步之一。两项研究调查了骨科创伤后患者和外科医师对临床结果感受的差异。一项研究评估了持续6月后仍未愈合的严重骨折患者状况1。外科医师对患者病情进展的满意程度要高于患者本人。唯一与外科医师满意度相关的因素是骨折愈合。就病情进展来说，客观的损伤和治疗因素与患者满意度无关，将损伤过失归因于他人与患者满意度有关；就病情恢复来说，雇佣律师应对过失、患者为女性与患者满意度有关1。
The Lower Extremity Assessment Project (LEAP) investigators reported data, obtained from their observational study of patients with limb-threatening lower extremity injury, that documented the discrepancy between patient and surgeon perceptions of functional and cosmetic outcomes2. Several factors were predictive of discordance; some were associated with higher surgeon satisfaction whereas others were associated with greater patient satisfaction. Self-reported patient dissatisfaction with overall medical care was predictive of discordance in the perception of both overall and cosmetic outcomes between patients and surgeons.
下肢评估项目(LEAP)的研究者们利用对严重下肢创伤患者的观察性研究得到数据，记录了患者和外科医师对功能和外观临床结果的不同感受2。若干因素预示着不一致性，一些与外科医师较高的满意度有关，而另外一些与患者较高的满意度有关。患者自我报告对全程医疗服务不满预示着患者和外科医师之间对于总体和外观结果感受的不一致性。
A third study assessed the outcomes of “after-hours”treatment of tibial and femoral shaft fractures with intramedullary nailing3. Patients undergoing femoral or tibial nailing at night had a higher rate of unplanned reoperation than those managed during the day, and patients with femoral fractures that were treated at night had a greater need for interlocking screw removal in comparison with those who were managed during the day (27% compared with 3%). The authors concluded that allocating resources to increase daytime surgery for non-emergency intramedullary nailing cases has the potential to decrease the rate of minor complications.
第三项研究评估了胫骨和股骨干骨折于夜间行髓内针治疗的结果3。在夜间应用股骨或胫骨髓内针治疗的患者较日间手术者有更高的非预期性再手术率，在夜间治疗的股骨骨折患者较日间患者更有必要取出锁定螺钉(27% : 3%)。作者认为，增加日间非急诊的髓内针手术资源配置可能会减少一些轻度并发症。
Polytrauma
多发伤
The concepts and proper application of damage-control orthopaedics continue to be defined. In one series of polytrauma patients undergoing treatment of femoral fractures, “normalizing lactate” was considered to be indicative of adequate resuscitation and the indication to proceed with primary intramedullary nailing of the fracture4. Overall, 88% of patients underwent femoral nailing with reaming at an average of fourteen hours after admission, whereas 12% underwent provisional external fixation.Adult respiratory distress syndrome occurred in 1.5% of patients, which was lower than the rate among historic controls. Adult respiratory distress syndrome was also less common than expected in patients with pulmonary injury and in the most severely injured patients. These findings indicate that simple measures of resuscitation (in this case, serum lactate) are reasonable indicators of when a patient is physiologically able to undergo nailing for the treatment of a femoral fracture.
继续明确损伤控制骨科的概念并合理应用。对于接受股骨骨折治疗的一系列多发伤患者，“乳酸正常”被认为是机体充分复苏的预示和进行初步骨折髓内针固定的指征4。就总体而言，88%的患者平均在住院后14小时进行股骨髓内针内固定治疗，另外12%暂行外固定治疗。成人呼吸窘迫综合症（ARDS）发生率为1.5%，低于以往对照。ARDS在肺部损伤和最严重的创伤患者中的发生率与预计相比，并不常见。这些发现表明，衡量机体复苏的简单指标(本病例中为血清乳酸含量)是患者生理上能够接受髓内针治疗股骨骨折的合理标志。
Another study challenged the idea that external fixation is the only effective method of provisional femoral fracture stabilization when employing damage-control orthopaedics5. There was no difference in terms of adult respiratory distress syndrome, multisystem organ failure, and pneumonia in polytrauma patients undergoing delayed stabilization of a femoral fracture that had been treated initially with skeletal traction or placement of an external fixator. There also were no differences when patients with associated chest trauma were compared. The authors concluded that, unless a patient is already undergoing general anesthesia, there is no significant advantage of external fixation as compared with skeletal traction.
另一种研究对基于损伤控制骨科学的外固定是暂时稳定股骨骨折的唯一有效方法的观念提出挑战5。首先行骨牵引和外固定而延迟股骨骨折内固定的多发伤患者在ARDS、多系统器官衰竭、发生肺炎方面并无不同。当与胸部损伤相关的患者对比时，亦无不同。作者认为，除非患者已经行全麻，否则外固定与骨牵引相比无明显优势。
Open Fractures, Wound Management, and Infection
开放性骨折，伤口处理和感染
A continued source of controversy in orthopaedic trauma is whether increased time to surgical debridement increases the infection rate in patients with open fractures. The LEAP investigators evaluated their cohort of patients with severe lower extremity trauma and found that the time from injury to debridement was not predictive of infection6. However, the time from the injury to admission to the definitive treatment center was a significant predictor of infection. Because of the observational nature of this study, the reasons for this finding are not clear, and the authors concluded that their data “should not be interpreted as an argument that operative debridement of open fractures should not be accomplished urgently.”
是否外科清创术时间的增加也增加了开放性骨折患者的感染率是创伤骨科持续争论的焦点。LEAP的研究者们评估了一组严重下肢创伤患者，发现自受伤至清创的时间不能成为感染的预测因子6。然而，自受伤至住院部治疗中心是感染的重要预测因子。由于这项研究观察的性质，这些发现的理由并不明确，并且作者认为他们的数据“不应该被理解成一种论据，即开放性骨折的不应该急诊行手术清创”。
Vacuum-assisted wound closure (also referred to as negative-pressure wound therapy) is now commonly used for the initial treatment of open fracture wounds, despite the fact that there are few data regarding the efficacy of this approach. Stannard et al. randomized sixty-two severe open fractures to treatment with negative-pressure wound therapy or sterile moist saline solution dressings until ultimate closure or coverage7. Overall, 5.4% of patients managed with negative pressure wound therapy developed an infection, compared with 28% of patients in the control group, a finding that was statistically significant and clinically important. Patients managed with negative-pressure wound therapy also had improved outcomes as measured with the Short Form-36 (SF-36).
真空辅助伤口闭合(即伤口负压疗法)现在常规用于开放性伤口的初始治疗，尽管关于此疗法的有效性的数据很少。Stannard等随机对比62例应用伤口负压疗法或无菌湿盐水敷料治疗的严重开放性骨折，直至伤口最终闭合或被组织覆盖7。总体上，应用伤口负压疗法的患者中感染率为5.4%，对照组为28%，这个发现在统计学和临床方面均有重要意义。以SF-36量表衡量负压疗法患者的临床效果亦有改善。
Diabetes is a recognized risk factor for complications following fracture surgery. Karunakar and Staples recently presented the effects of stress-induced hyperglycemia on the rates of infection in 110 nondiabetic orthopaedic trauma patients8. Overall, 25% of the patients developed an infection, including pneumonia (seventeen patients) and wound infection (eleven patients). Sixty-four percent of patients with a hyperglycemic index of ≥3.0 developed an infection, compared with 21% of patients with a hyperglycemic index of <3.0, indicating that stress-induced hyperglycemia may be an important prognostic factor. Additional work is needed to understand whether the correction of elevated blood sugar in nondiabetic patients reduces the risk of infection.
糖尿病是公认的引起骨折手术并发症的危险因素。Karunakar和Staples介绍了压力诱发高血糖在110名非糖尿病骨科创伤患者感染率中的作用。总体上，25%的患者并发感染，包括肺炎(7名)和伤口感染(11名)。其中64%高血糖指数≥3.0的患者并发感染，高血糖指数<3.0的患者感染率为21%，表明压力诱发高血糖可能是感染的重要预测因子。要理解是否纠正非糖尿病患者的高血糖状态可降低感染风险需要另外的研究。
Infection must be considered in cases of fracture nonunion.In one series of nonunions, a diagnostic protocol including preoperative laboratory tests (white blood-cell count, erythrocyte sedimentation rate, C-reactive protein level), white blood cell/sulfur colloid scans, and intraoperative frozen sections was followed9. Overall, 31.6% of patients were diagnosed with infection. The white blood cell/sulfur colloid scan was found to have a sensitivity of only 19%. The positive predictive value for infection increased with the addition of each positive laboratory value (white blood-cell count, erythrocyte sedimentation rate, C-reactive protein level).When all three values were positive, the positive predictive value for infection was 100%. On the basis of their data, the authors recommended preoperative laboratory studies and intraoperative frozensection analysis for the diagnosis of infection in this high-risk population.
骨折不愈合的病例必须考虑到感染。在一系列骨折不愈合的病例中，应用的诊断方案包括实验室检查(白细胞计数、血沉、C反应蛋白水平)、白细胞/硫胶体扫描和术中冰冻切片。总体上，36%的患者诊断为感染。白细胞/硫胶体扫描敏感率仅为19%。随着实验室检查(白细胞计数、血沉、C反应蛋白水平)阳性值的增加，感染的阳性预测值亦增加。当此三项值均阳性时，感染的阳性预测值为100%。基于他们的数据，作者建议对高危群体进行术前实验室检查和术中冰冻切片分析以诊断感染。
Venous Thromboembolism
静脉血栓栓塞
Thromboembolic disease is a major source of morbidity in patients with musculoskeletal injury and continues to be the focus of research. Very little data exist regarding the treatment of venous thromboembolism in patients with isolated leg injuries.Goel et al. performed a double-blind randomized trial in which a low-molecular-weight heparin (Dalteparin; Pfizer, New York, NY) was compared with placebo (saline solution injection) in 238 adult patients undergoing operative repair of a fracture distal to the knee10. After fourteen days of treatment, the rate of venographic deep-vein thrombosis was 12.6% in the placebo group, compared with 8.7% in the treatment group; this difference was not significant. All thromboses were distal to the knee, and none required treatment. However, the study was underpowered, and the absolute risk difference of 3.9% would equate to a number-needed-to-treat of twenty-six, which might be clinically relevant. Increased age and the type of fracture also were found to increase the risk of deep-vein thrombosis. There were no bleeding complications in the low-molecular-weight heparin group. A substantial limitation of that study is the fact that the end point of venographically proven but asymptomatic deep-vein thrombosis is also of uncertain clinical relevance, and the patients in the study were all operatively managed within forty-eight hours after the injury. The negative results of that study may not be generalizable to patients who have a longer delay to surgery. Larger studies of the treatment of venous thromboembolism in trauma patients are needed before conclusions can be made.
血栓栓塞性疾病是骨肌损伤患者的重要病源，一直以来都是研究的焦点。目前，关于单独腿部损伤患者静脉血栓栓塞治疗方面的数据很少。Goel等进行一项随机双盲试验，包括238名行手术治疗膝关节远端骨折的成人患者，对比低分子肝素(Dalteparin; Pfizer, New York, NY)和盐水溶液的作用10。治疗后14天，静脉造影显示深静脉血栓者在盐水溶液组占12.6%，低分子肝素组占8.7%，差异并不显著。所有血栓均在膝关节远端，且不需治疗。然而，本研究仍有不足之处，3.9%的绝对风险差异等同于需要治疗的患者人数26名，这可能与临床密切相关。年龄的增加和骨折的类型可增大深静脉血栓的风险。在低分子肝素组无出血的并发症发生。此研究最大的局限性在于以静脉造影术证明血栓形成，但是无症状的深静脉血栓也有不确定的临床相关性，并且所研究的患者均在伤后48小时内进行了手术治疗。此研究的阴性结果可能不适用于延期手术的患者。在得出最终结论前，需要对创伤患者静脉血栓栓塞的治疗进行大量的研究。
Geriatric Fractures
老年人骨折
Geriatric patients with fractures present a number of management issues, including the prevention of delirium. A randomized controlled trial demonstrated that, in elderly hip fracture patients managed with propofol, light sedation (bispectral index, >80) was associated with a dramatic reduction in the incidence of delirium as compared with deep sedation (bispectral index, <50)11. Patients in the deep sedation group also experienced delirium for a longer time than did those in the light sedation group.
老年骨折患者在治疗方面存在大量的问题，包括防止瞻望。一项随机对照试验证实，在应用丙泊酚处置的老年髋部骨折患者中，浅镇静(双频谱指数>80)与深镇静(双频谱指数<50)相比，明显降低了瞻望的发生率11。深镇静组患者瞻望发作时间较浅镇静组持久。
Two studies addressed the use of iron supplementation for the treatment of postoperative anemia after the fixation of hip fractures. In the first study, patients were randomized to either 200 mg of ferrous sulfate twice daily for four weeks or no therapy12. The authors found no significant difference in hemoglobin levels or change in hemoglobin levels at six weeks and found no differences in ter ms of the length of hospital stay or mortality. Seventeen percent of patients reported minor side effects attributable to iron therapy. In contrast, a smaller randomized trial demonstrated some benefit in association with the use of iron therapy for the correction of postoperative anemia after the fixation of a hip fracture. Patients were randomized to receive 200 mg of ferrous sulfate three times daily for four weeks or no therapy. At four weeks postoperatively, the treated patients had a small but significant increase in hemoglobin levels and a lower reported prevalence of side effects13.Larger trials are needed to definitively establish whether oral iron-replacement therapy is efficacious for correcting postoperative anemia in geriatric patients with a hip fracture.
两项研究介绍了补铁疗法治疗髋部骨折固定术后贫血。第一项研究中，患者随机分为硫酸亚铁组(200mg，2次/日，持续4周)和无治疗组12。在第六周时，作者发现两组血红素值无显著差异或变化，住院时间和死亡率亦无差异。17%应用补铁疗法的患者出现轻微副作用。与之相反，一项小规模随机试验证实了应用补铁疗法纠正髋部骨折固定术后贫血的一些益处。患者随机分为硫酸亚铁组(200mg，3次/日，持续4周)和无治疗组。在术后第4周，治疗组患者血红素值有轻度但却明显的增长，且副作用发生率较低13。大型试验需要最终确定是否口服补铁疗法对纠正老年髋部骨折患者术后贫血有效。
Many geriatric fractures are related to osteoporosis, but a study of a large insurance database in Korea suggested that the likelihood of further evaluation and treatment of osteoporosis is dependent on the type of fragility fracture that a patient sustains14. The authors analyzed >150,000 fractures in female patients who were more than fifty years old. The overall rate of diagnosis and subsequent treatment of osteoporosis was 19.3%. However, patients with wrist fractures were less likely to be evaluated and managed for osteoporosis as compared with the overall cohort. The authors believed that a “care gap” exists and suggested that further efforts and initiatives should be directed toward improving the evaluation and subsequent treatment of osteoporosis that may be manifested early by a fracture of the wrist.
许多老年人骨折由于骨质疏松导致，但是韩国一项大型保险数据库研究认为，对骨质疏松进一步评估和治疗的可能性取决于患者脆性骨折的类型14。作者分析了超过150,000例年龄超过50岁的女性骨折患者，诊断为骨质疏松并进一步治疗的患者占19.3%。然而，与总队列相比，很少对腕部骨折患者进行骨质疏松进行评估和处理。作者相信存在一个“医疗缺口”，并建议进一步的努力和行动应该直接用于改善骨质疏松的评估和治疗，这可能早已被腕部骨折病例所证明。
Pediatric Fractures
儿童骨折
Two recent studies presented different views of the controversial issue of the ‘‘pulseless hand’’ associated with pediatric supracondylar humeral fractures. Choi et al. analyzed 1255 consecutive children who had operative treatment of a supracondylar humeral fracture15. In this large group, only thirty-three patients (2.6%) presented with absent distal pulses; twenty-four of them had a pink, perfused hand. None of the twenty-four children with absent distal pulses but a wellperfused hand required vascular intervention. Of these twenty-four patients, thirteen regained a palpable pulse after fracture reduction and the other eleven maintained adequate distal perfusion. Nine other children presented with absent pulses and a poorly perfused hand. Four of these nine patients required vascular intervention, and two developed compartment syndrome. Thirty-two of the thirty-three patients were available for follow-up at a median of eight weeks, and all were noted to have satisfactory perfusion. The second study, by Blakey et al., evaluated the longer-term follow-up for twentysix children who had been referred to their institution with a history of a ‘‘pink pulseless hand’’ associated with a supracondylar humeral fracture16, which is a different patient population than was reported by Choi et al.15. The range of time between the injury and referral was broad (four days to three years). Twenty-three (88%) of the twenty-six patients developed some degree of ischemic contracture. The authors advocated an aggressive approach toward children with a ‘‘pink pulseless hand’’ in order to avoid such complications16. On the surface, these two studies seem contradictory. However, one had short-term follow-up, whereas the other had much longer follow-up, and, most importantly, the two study populations were very different. Additional research is needed to clearly identify whether there is a subset of patients with a “pink pulseless hand” who are at greater risk of long-term morbidity and should potentially be managed with urgent vascular exploration.
与儿童肱骨髁上骨折相关的“无脉手”问题尚存争议，最近2项研究提出了此问题的不同观点。Choi等分析了1255名行手术治疗的肱骨髁上骨折患儿的连续病例15。在本组中，仅有33名患儿(2.6%)表现为远端脉搏消失；24名患儿手掌充盈良好，呈粉红色，无远端脉搏消失，但是充盈良好的手掌需要血管介入。这24名患儿中，13名在骨折复位后可再次触及脉搏，另外11名可维持足够的远端充盈。其他9名患儿脉搏消失且手部充盈不佳，其中4人需要血管介入，2人发展为骨筋膜室综合症。33人中的32人获得随访，平均8周，全部患儿均手部充盈良好。Blakey等进行了第2项研究，对26名既往肱骨髁上骨折后‘‘粉红色无脉手’’患儿进行长期随访并评估16，这与Choi15报道的患儿群体不同。患儿从损伤至医疗处置的时间范围广(4天~3年)。23名(88%)发展为某种程度的缺血性痉挛。作者提倡对‘‘粉红色无脉手’’行有创治疗以避免并发症16。表面来看，这2项研究是矛盾的。然而，一项为短期随访，另一项为长期随访，更重要的是，2项研究所选的群体不同。要明确一组“粉红色无脉手”患儿是否有长期处于病态的高风险和是否应该急诊行血管探查的问题需要进一步的研究。
Several studies evaluated aspects of pediatric femoral fractures. Basener et al. performed a meta-analysis of sixteen articles (564 children) documenting that growth disturbance after distal femoral physeal fractures is common17 (see the Evidence-Based Orthopaedics section at the end of this article). Keeler et al. presented a series of eighty pediatric femoral fractures in patients with a mean age of 12.9 years who were managed with reaming and statically locked antegrade nailing with use of a lateral trochanteric entry portal18. All fractures healed without evidence of malunion, and no patient had evidence of osteonecrosis or of altered proximal femoral anatomy. The authors concluded that antegrade femoral nailing via a lateral trochanteric portal is safe and effective for children who are more than eight years old. However, the starting point that those authors used was very lateral and fairly distal on the trochanter, increasing risk of deformity.
一些研究评估了儿童股骨骨折方面的问题。Basener等对16篇文章(564名儿童)进行mata分析，这些文章记录了股骨干骺端骨折后生长障碍为患儿所共有17(见本文最后循证医学部分)。Keeler等介绍了80名股骨骨折患儿病例，平均年龄12.9岁，术式采用经大转子外侧入路扩髓并置入静力性顺行锁定髓内针18，全部骨折愈合良好，无骨不连、骨坏死及股骨近端解剖结构改变的证据。作者得出结论，经大转子外侧入路置入顺行股骨髓内针对年龄8岁以上儿童是安全有效的。然而，那些作者起始使用的入路在转子极外侧和远端，增加了畸形愈合的风险。
Proximal Part of the Humerus
肱骨近端
Fractures of the proximal part of the humerus continue to be a source of debate, and a particular problem is predicting outcome. A recent study evaluated the ability of the initial shoulder radiographs to predict the outcome of nonoperative treatment of proximal humeral fractures19. In a study of fiftyfive patients with minimally displaced proximal humeral fractures, the authors found a correlation between worse outcome scores (Constant-Murley and Disabilities of the Arm, Shoulder and Hand [DASH] scores) and changes in angulation during the first week after the injury on the trans-scapular ‘‘Y’’ radiograph but not on the anteroposterior radiograph.Patients with the poorest scores had a mean change in angulation of 30° on the scapular ‘‘Y’’ radiograph, compared with no change for those with the best outcome scores. Although change in angulation is just one of many items to consider, this change can be measured objectively and does appear to be predictive of outcome. Surgeons should take special care to assess changes in angulation on the lateral radiographs.
肱骨近端骨折继续成为争论的源头，一个值得注意的问题是结果预测。最近一项研究评估了最初肩部X线平片预测非手术治疗肱骨近端骨折临床效果的能力。一项研究包括55名轻微移位的肱骨近端骨折患者，其作者发现，较差的临床结果评分(Constant-Murley和臂肩手失能评分[DASH评分])和伤后一周穿肩胛位而非前后位X线平片上骨折成角变化存在相关性。评分最差的患者肩胛位X线平片骨折平均成角30°，与之相对，评分最佳的患者无成角变化。尽管成角变化是应该考虑的诸多因素之一，此种变化能够客观地进行测量，似乎可以成为预后的预测因子。外科医师在评估侧位X线片上成角变化应特别注意。
Locked plating has become commonplace for the treatment of proximal humeral fractures. A number of larger case series were recently published regarding the outcome of locked plating, although comparative studies are still lacking20-22.Taken together, all of these studies emphasize that final outcomes are not achieved for at least one year and that complications occur in one-third of patients, with screw penetration(either at the time of surgery or later), varus collapse, and osteonecrosis being most common20-22. Complications are more frequent in patients who are more than sixty years old and in those with more complex fracture patterns20. In general, varus malunion is associated with poor functional outcomes20.
应用锁定钢板治疗肱骨近端骨折已成为常规疗法。尽管缺少对比性研究，最近一项关于锁定钢板的大样本病例研究结果已经发布20-22。总的来说，所有这些研究都强调最终临床结果在一年时并未达到，1/3患者出现并发症，螺钉贯穿(术中或术后)，内翻畸形和骨坏死最为常见20-22。并发症更常见于60岁以上和骨折类型复杂的患者20。一般而言，内翻畸形与功能效果不良相关20。
Elbow
肘
Traditional fixation of intra-articular distal humeral fractures has relied on fixation with two plates oriented at 90° to one another. Recently, anatomic precontoured plates designed to be placed parallel to each other on the medial and lateral surfaces of the distal part of the humerus have been made available. A comparison of these two methods in a small randomized clinical trial showed no differences in terms of the ranges of elbow flexion and extension, the Mayo Elbow Performance Score, time to union, or complications23. Both methods seem to provide adequate stability, and either method can be used to achieve stable and anatomic reconstruction of the distal part of the humerus.
传统的肱骨远端关节内骨折内固定依靠互成90°角的两块钢板。最近，一种平行置于肱骨远端中间和侧方表面的解剖塑型钢板设计完成。对比两种方法的小样本随机临床试验显示，在肘关节屈伸范围、Mayo肘关节功能评分、愈合时间、并发症方面无差异。两种方法均可提供足够的稳定性，任何一种方法均可用于完成肱骨远端稳定及解剖重建。
Complex elbow injuries remain an area of active research.A recent study focused on Mason type-II injuries of the radial head,in which part of the radial head is displaced >2 mm24. The injuries were grouped according to whether or not there was cortical contact between the fractured fragment and the rest of the radius. Overall, 75% of the cases did not have cortical contact, and, of these, 91% were part of a complex elbow fracture pattern with associated fractures and/or ligamentous injury. In contrast, just 33% of the fractures with cortical contact were considered to be part of a complex injury.Therefore, complete loss of cortical contact in radial head fractures should alert the clinician that the radial head fracture may be just one part of a complex injury pattern and that additional evaluation and expert management are needed.
复杂的肘部损伤还有进行积极研究的空间。最近一项研究集中于Mason II型桡骨头损伤，即桡骨头移位>2 mm24。损伤根据骨折块与桡骨是否存在皮质连续性分组，75%的病例不存在连续性骨皮质，这其中91%为合并骨和/或韧带损伤的复杂肘部损伤。与之相对，仅33%的复杂损伤骨皮质存在连续性。因此，完全失去骨皮质连续性的桡骨头骨折应作为对临床医师的警示，桡骨头骨折仅作为复杂损伤的一部分，需要额外的评估和专家进行处置。
Three groups of investigators reported the results of long-term studies of elbow injuries involving the radial head25-27.In one study, good to excellent elbow function was seen in thirteen of sixteen patients who had had internal fixation of a stable Mason type-II radial head fracture between fourteen and thirty years earlier (mean duration of follow-up, twentytwo years)25. However, as the authors themselves pointed out, these long-term results of surgery for the treatment of stable, isolated partial articular radial head fractures were not better than the reported results of nonoperative treatment, and there were major complications of surgery in this series. Another study evaluated the results of radial head resection following a Mason type-II or III radial head fracture; the duration of follow-up ranged from fifteen to thirty-nine years26. No patient had complications or a reoperation, and the clinical result was graded as good or excellent in 92% of cases. The average carrying angle of the elbow was twice that of the contralateral elbow (21° compared with 10°), and a minor amount of radial shortening (average, 3.1 mm) was a typical finding. Radial head resection in young patients with isolated radial head fractures without instability can yield satisfactory long-term results. In the final study, twenty-one patients with a Mason type-IV fracture-dislocation, without a type-II or III coronoid process fracture, were evaluated after a mean duration of follow-up of twenty-one years (range, fourteen to forty-six years)27. All patients underwent closed reduction and had the elbow immobilized for two to six weeks. Eleven patients underwent complete radial head excision, two had partial radial head excision, and two others had an anular ligament repair. At the time of long-term follow-up, only one patient had severe impairment of the elbow, and no patient experienced instability or recurrent dislocation. The authors concluded that most patients who have a Mason type-IV fracture-dislocation of the elbow, without an associated coronoid fracture, have a good long-term outcome.
三组调查者报告了对合并桡骨头骨折的肘部损伤的长期研究结果25-27。在第一项研究中，对16名稳定的MasonII型桡骨头骨折行内固定术后患者随访14~30年(平均22年)，其中13名患者肘部功能良好25。然而，正如作者所述，对于部分累及关节的单纯稳定型桡骨头骨折，手术治疗效果与非手术治疗相比，无明显优势，并且本组手术患者合并较严重并发症。另外一项研究评估MasonII型、III型桡骨头骨折行桡骨头切除术患者，随访14~39年26，患者无并发症及二次手术发生，92%的患者临床结果评分良好。平均肘关节提携角是对侧的2倍(21° : 10°)，并有轻度桡骨短缩(平均3.1 mm)。单纯稳定型桡骨头骨折青年患者行桡骨头切除术远期临床结果满意。最后一项研究中，评估21名MasonIV型骨折-脱位，无II或III型喙突骨折患者，平均随访21年(范围14~46年)27。所有患者行闭合复位并肘关节制动2~6周。11名患者行完整桡骨头切除，2名患者行部分桡骨头切除，另有2名患者行环状韧带重建。长期随访中，仅有1名患者出现严重的肘部损害，所有患者均无肘部不稳和复发性脱位。作者认为，大多数肘关节MasonIV型骨折-脱位，不合并喙突骨折患者，远期临床结果良好。
Distal Part of the Radius
桡骨远端
There is wide variation in the rate of distal radial fracture depending on demographic group, with the highest rates in whites and females28. There is also wide geographic variation in incidence. According to Medicare data, operative intervention for distal radial fractures in the elderly has increased fivefold in the last decade, although nonoperative treatment remains most common29.Treatment modality varies widely across regions within the United States but is not affected by race.
依据人口统计学数据，桡骨远端骨折发病率差异巨大，高发于白人和女性28，发病地区亦有很大差异。根据Medicare的数据，尽管非手术治疗最为常用，需要手术干预的老年桡骨远端骨折患者在过去10年增长了5倍29。治疗方式在美国地区多样化，但与人种无关。
Many options exist for the treatment of distal radial fractures, without much evidence to choose among them.Several studies during the past year compared treatment methods and provided further guidance for surgeons who treat these injuries. In one randomized study of fifty patients, fragment-specific fixation provided better results at the time of the one-year follow-up than did closed reduction and external fixation in terms of grip strength, motion, and the rate of malunion30. However, there were no differences in terms of the DASH score at one year. In another study of patients with unstable fractures, early results as measured with DASH scores were better after volar plating than after closed reduction and pinning31. However, at the time of the one-year follow-up,the differences between groups had disappeared. A third randomized study compared three methods of treatment: external fixation, radial column plating, and volar plating32. In addition to DASH scores, grip and lateral pinch strength were measured. Treatment with a volar plate was associated with improved early outcomes, but there were no differences between groups at later follow-up periods (six months and one year). A final study used decision analysis methodology to show that volar plating was the preferred strategy in most scenarios,but the magnitude of differences was small33. In general, the long-term gains in quality-adjusted life-years outweighed the risk of surgical complications. Older patients who might tolerate a malunion may be better managed nonoperatively.
桡骨远端骨折的治疗有多种方式可供选择，关于选择哪种没有太多证据。去年有很多研究对比治疗方法并对治疗此种损伤的外科医师提供进一步的指导。一项对55名患者进行的随机研究显示，对具体的骨折块进行固定者在1年随访期时，在握力、运动和畸形愈合发生率方面优于闭合复位和外固定治疗者30。然而，术后1年DASH评分无差异。另外一项对不稳定骨折患者的研究显示，以DASH评分衡量的早期结果掌骨板固定优于闭合复位克氏针固定31。然而，在一年后随访时，组间差异消失。第3项随机研究对比三种治疗方法：外固定、桡骨板固定、掌骨板固定32。测量DASH评分、握力和手指夹持力。掌骨板固定早期效果良好，各组间在随后的随访中(6月和1年)无差异。最后一项研究应用决策分析方法，显示掌骨板固定在大多数病例中是优先被选择的策略，但差异等级较小33。大体上，质量调整生命年的增长优于手术并发症的风险。可耐受畸形愈合的老年患者可能通过非手术治疗妥善处理。
Spine Trauma
脊柱创伤
A topic of consistent debate is ‘‘clearance’’ of the spine in a patient with blunt trauma. A meta-analysis of the published literature concluded that an alert, asymptomatic patient without another distracting injury and no neurologic deficit can be cleared without radiographic assessment if he or she can complete a functional neck range-of-motion examination without pain or the elicitation of neurologic signs and symptoms34.Two Level-I diagnostic studies assessed screening tests for spine injury. In the first, the diagnostic accuracy of magnetic resonance imaging findings (as determined by a radiologist) for detecting injury to the posterior ligament complex of the cervical spine was evaluated, with use of intraoperative findings as the diagnostic standard35. The level of agreement between magnetic resonance imaging and intraoperative findings varied between fair (for injury to the ligamentum flavum, facet capsules, and cervical fascia) to moderate (for injury to the supraspinous and interspinous ligaments). In general, magnetic resonance imaging was found to be sensitive for the evaluation of injury, but the positive predictive value and specificity were lower because of “over-reading” of injuries on magnetic resonance imaging. Using magnetic resonance imaging findings alone as a guide to treatment could lead to unnecessary surgery, and other factors should be part of the decision-making process. Another study tested the reliability of nonreconstructed computed tomography of the abdomen and pelvis as a screening tool for thoracolumbar spine injuries in blunt trauma patients with altered mental status36. Such patients were studied with a protocol that included standard anteroposterior and lateral radiographs of the thoracolumbar spine in addition to standard 5-mm computed tomography slices of the chest, abdomen, and pelvis and ≤2-mm reconstructed slices dedicated to the spine. Compared with the dedicated computed tomography reconstructions, nonreconstructed 5-mm computed tomography slices had a sensitivity of 89% and specificity of 85% for the detection of all fractures, which was much greater than those of radiographs (37% and 76%, respectively). None of the fractures that were missed on nonreconstructed computed tomography examination required surgery or other intervention, and the authors concluded that computed tomography reconstructions do not need to be routinely performed in this setting unless further clarification is needed for an abnormality that has already been detected.
关于脊柱钝性创伤患者讨论的一贯性主题是 “损伤排除率”问题。一篇应用meta分析的已发表文献认为，如果患者能够完成颈部功能运动范围检查，无疼痛或未引出神经阳性体征和症状，动作灵活、无症状、不伴随其它损伤且无神经损伤症状可不需要影像学检查排除34。两项I级诊断研究评估了脊柱损伤筛选试验。第一项研究中，评估MRI影像表现(由放射科专家确定)对诊断颈椎后方韧带复合体损伤的准确性，以术中发现作为诊断标准35。MRI和术中发现的一致性水准在尚可(黄韧带、关节囊、颈筋膜损伤)和中等(棘上韧带、棘间韧带损伤)之间不同。一般而言，MRI对损伤的评价较为敏感，但是由于损伤在MRI上往往表现过重，导致阳性预测值和特异性较低。仅应用MRI表现来指导临床治疗可能导致对患者实行不必要的手术，其他因素必须作为决策制定过程的一部分。另一项研究测试非重建CT作为伴有意识改变的胸腰椎钝性损伤患者筛查工具的可靠性36。这些患者的研究方案包括标准前后位，侧位X线平片，以标准的5-mmCT层面扫描胸部、腹部和骨盆，并以≤2-mm层面进行脊柱重建。与CT重建相比，5-mm层面的非重建CT对所有骨折检测的敏感度为89%，特异性为85%，远优于X线平片(各自为37%和76%)。非重建CT对需要手术和其它治疗的骨折无一例漏诊。作者认为，此类病例不需要把CT重建作为常规检查，除非对已检查到的异常表现需要进一步的明确。
A randomized clinical trial of seventy-three patients with thoracolumbar burst fractures undergoing posterior shortsegment fixation with or without fusion demonstrated no differences in terms of clinical or radiographic outcomes, although two-thirds of the fusion patients had donor-site pain from the bone graft at the time of the latest follow-up37.
一项包括73名胸腰椎爆裂骨折行后路短节段固定融合或不融合患者的随机临床试验表明，尽管2/3的融合患者在末次随访时有植骨供骨区疼痛表现，但临床或影像学结果方面无差异。
Pelvic and Acetabular Fractures
骨盆和髋臼骨折
The effect of pelvic fracture on patient mortality was analyzed in a review of >63,000 patients from two level-I trauma centers38. Pelvic fracture was significantly associated with mortality, with odds ratios for mortality of 2.4 and 2.0 at the two centers. These odds ratios were equivalent to the mortality odds ratio associated with an abdominal injury but were less than the odds ratios associated with hemodynamic shock, severe head injury, and advanced age. When analyzed in combination with the other aforementioned risk factors for mortality, pelvic fracture was independently associated with mortality with the exception of a patient in hemodynamic shock with a severe head injury.While pelvic fracture is associated with mortality, it is only one factor to be considered in the overall care of the polytraumatized patient38.
回顾>63,000来自两家I级创伤中心的患者，分析骨盆骨折在患者死亡率中的作用38。骨盆骨折与死亡率显著相关，两家中心的死亡率优势比分别为2.4和2.0。这些优势比与腹部损伤相关的死亡率优势比相当，但小于血液动力学休克、严重脑损伤、老年患者相关的优势比。当结合前面提到的风险因素对死亡率进行分析时，除了血液动力学休克和严重脑损伤外，骨盆骨折独立与死亡率相关。尽管骨盆骨折与死亡率相关，它只是多发伤患者整体护理中要考虑的因素之一38。
Two highlight papers from the OTA annual meeting reviewed the treatment of lateral compression injuries of the pelvis. Sembler et al. presented a series of 120 patients with unilateral lateral compression fractures of the sacrum that were impacted and minimally displaced (<10mm)39. All patients were immediately mobilized, were allowed weight- bearing as tolerated, and were followed radiographically until healing had occurred. Only one patient had a failure of nonoperative treatment, with 5 mm of additional sacral displacement associated with severe pain. The remaining 119 patients had uneventful healing with minimal further displacement. Nonoperative treatment, including early weight-bearing, is appropriate for impacted unilateral lateral compression-type sacral fractures39. Another presentation reviewed 117 patients from two level-I trauma centers who had sacral fractures resulting from high-energy trauma40. These sacral fractures were part of a lateral compression pelvic ring injury and were initially displaced <5 mm. Patients were also managed nonoperatively with weight-bearing as determined by the treating physician. In contrast to the first series, twenty-three of 117 fractures had further displacement (>5 mm) at the time of healing. It was noted that a complete sacral fracture, typified by a visible fracture line in the posterior cortex of the sacrum, was associated with displacement 50% of the time. A complete sacral fracture combined with bilateral superior and inferior rami fractures was associated with displacement 68% of the time. An incomplete sacral fracture with no rami fractures or unilateral ramus fracture did not displace. The results of these studies highlight the importance of careful analysis of the fracture pattern and patient characteristics prior to allowing immediate weight-bearing after lateral compression sacral fractures. Further research is needed to define functionally relevant residual sacral displacement to determine what role operative treatment has, if any, in certain lateral compression sacral fractures.
2篇来自OTA年会的重要论文回顾了侧方挤压型骨盆损伤的治疗。Sembler等研报道了一系列120名伴轻微移位(<10mm)侧方挤压型骶骨压缩性骨折患者39。所有患者伤愈前可即时活动、允许可耐受的负重并行X线检查。只有1名患者非手术治疗失败，其严重的疼痛与骶骨移位增加5mm相关。其余119名患者愈合良好，伴极轻微移位。包括早期负重的非手术治疗，适用于单侧挤压型骶骨压缩骨折39。另外一项报告回顾了来自2家I级创伤中心的117名高能创伤造成的骶骨骨折患者40。这些骶骨骨折为骨盆环侧方挤压伤，初始移位<5 mm。治疗医师决定对这些患者实行包括负重训练的非手术治疗。与前一系列患者对比，117名患者中有23名在骨折愈合时移位>5 mm。以骶骨后方皮质出现明显骨折线为象征的完全性骶骨骨折，骨折移位发生率为50%。完全性骶骨骨折合并双侧上下耻坐骨支骨折，骨折移位发生率为为68%。不完全性骶骨骨折不伴有耻坐骨支或单侧耻坐骨支骨折则无骨折移位。这些研究结果强调了仔细分析骨折类型和单侧挤压型骶骨骨折允许负重前患者特征的重要性。阐明与功能相关的骶骨残留移位以确定手术治疗在侧方挤压型骶骨骨折中的作用需要进一步研究。
The treatment of the geriatric acetabular fracture is controversial. In one surgeon’s experience, the proportion of these fractures occurring in patients more than sixty years of age increased 2.4 times when the period from 1980 to 1993(10% of cases) was compared with the period from 1993 to 2007 (24% of cases)41. Involvement of the anterior column is more frequent among older patients, who are also more likely to have separate quadrilateral plate fragments, roof impaction in association with anterior fractures, and both comminution and marginal impaction in association with posterior fractures41. These factors make internal fixation of acetabular fractures more problematic in the elderly. A review of patients with an age of more than sixty-five years who underwent treatment of acetabular fractures demonstrated a one-year mortality of 25%42. Of the surviving patients, 85% had been managed operatively, most with formal open reduction and internal fixation. Twenty-eight percent of the living patients had undergone eventual total hip replacement at an average of 2.5 years later. The patients who had open reduction and internal fixation had Western Ontario and McMaster Universities Osteoarthritis Index(WOMAC) and SF-8 scores similar to population norms, although many had reported mild functional problems and some level of hip pain. A third study examined the results of a retrospective case series of patients (average age, seventy-two years) who were managed with combined open reduction and internal fixation and primary total hip arthroplasty43. Among the eighteen patients with at least one year of follow-up, there was only one acetabular failure requiring revision surgery, three weeks after the index procedure. At the time of the latest follow-up, the mean Harris hip score was 88 and radiographs showed minimal medial and vertical displacement of the cup, with no evidence of acetabular loosening. In appropriate patients, surgeons who are experienced in both techniques of internal fixation of the pelvis and arthroplasty can safely perform combined open reduction and internal fixation and total hip arthroplasty with minimal complications and can potentially avoid the need for a second procedure.
老年髋臼骨折患者的治疗存在争议。以一名外科医师的经验，髋臼骨折在65岁以上患者中的发病率在1993~2007间(24%)较之1980~1993间(10%)增长了2.4倍41。老年患者中累计前柱更为常见，游离的四边形骨折块、髋臼顶压缩与前柱损伤有关；粉碎性和边缘嵌插折与后柱损伤有关41。这些因素使老年髋臼骨折患者的内固定治疗充满争议。一篇综述证实，年龄≥65岁的髋臼骨折患者，接受治疗后，1年死亡率为25%42。幸存的患者中85%行手术治疗，大多数行切开复位内固定术。28%的生存患者平均2.5年后行全髋关节置换术。尽管许多研究报告了轻微功能问题和一定程度的髋部疼痛，这些行切开复位内固定的患者的Western Ontario and McMaster大学骨关节炎指数(WOMAC)和SF-8评分与常人标准类似。第三项研究验证切开复位内固定合并全髋关节成形术病例的回顾性结果，患者平均年龄72岁43。18名患者随访至少1年，仅一名患者术后3周髋臼假体失败需要翻修手术。末次随访时，Harris髋部评分为88分，X线片显示髋臼杯轻微的向内垂直移位，无证据显示髋臼假体松动。对于适合的患者，对骨盆内固定和关节成形术技术有经验的医师能够安全地进行切开复位内固定和全髋关节成形术，且并发症轻微，能够避免二次手术。
Fractures of the Proximal Part of the Femur
股骨近端骨折
Fractures of the proximal part of the femur impose an extremely large societal burden, and many studies have been presented or published in the past year that contribute to our overall understanding of the care of these complicated injuries.A recent meta-analysis in the Annals of Internal Medicine examined the mortality after hip fracture in >700,000 patients44. The relative risk of death from all causes in the first three months after hip fracture was 5.75 for women and 7.95 for men. The relative risk of death decreased dramatically over the first two years but continued to be elevated compared with age and sex-matched controls at ten years. Men continued to have a higher relative risk of mortality over time compared with women. A retrospective study of 97,894 patients in the Nationwide Inpatient Sample analyzed the effect of surgeon and hospital volume on morbidity and mortality after hip fracture45. The adjusted odds ratio for mortality for a low-volume surgeon (fewer than seven procedures per year) relative to a high-volume surgeon (more than fifteen procedures per year) was 1.24. A significant difference in mortality between low and high-volume hospitals was not found. Differences in morbidity were found between low and high-volume surgeons, with increased rates of pneumonia, decubitus ulceration, and transfusion requirements associated with low-volume surgeons. Similarly, increased rates of pneumonia, postoperative infection, and transfusion requirements were associated with low-volume hospitals.
股骨近端骨折给社会带来沉重的负担。过去的一年，许多陈述或发表的研究有助于我们充分理解这种复杂损伤的诊治问题。最近内科学年鉴中一项meta分析调查了>700,000髋部骨折患者的死亡率44。在髋部骨折后最初3个月，所有原因引起的死亡相对风险度为女性5.75，男性7.95。死亡相对风险度在最初两年显著降低，但是伤后10年与性别和年龄均匹配的对照组相比，是持续上升的。与女性相比，男性死亡相对风险度一直较高。一项对国家住院病人样本中97,894名患者的回顾性研究分析了外科医师和医院规模对髋部骨折后并发症发生率和死亡率的作用45。小规模医院(每年少于7例)相对大规模医院(每年超过15例)，其死亡率调整优势比为1.24。未发现小规模和大规模医院间死亡率的显著差异。患者并发症发生率在小规模和大规模医院的外科医师间存在差异。肺炎、压疮、输血需求发生率的增加与小规模医院外科医师相关。类似的，肺炎、术后感染、输血需求发生率的增加与小规模医院相关。
The treatment of proximal femoral fractures, especially those of the femoral neck, remains a source of controversy, especially with regard to the role of primary arthroplasty. Recently, the ten-year follow-up results of a previously reported randomized trial comparing arthroplasty with internal fixation for the treatment of displaced femoral neck fractures were published46. Overall, 45.6% of the surviving patients who were managed with internal fixation had a failure of fracture treatment, but only four of ninety-two failures occurred between two and ten years. In comparison, 8.8% of the patients who were managed with arthroplasty had a failure of treatment, and five of seven failures occurred between two and ten years. These late failures in the arthroplasty group were in patients who had undergone total hip arthroplasty. Only 5.2% of the initial patients who were managed with arthroplasty experienced recurrent dislocation, with relatively equal numbers occurring after total hip arthroplasty and hemiarthroplasty.The mortality rate was the same for the arthroplasty and internal fixation groups at ten years, and no significant differences were noted between the groups with regard to hip pain when walking or with regard to reduced mobility secondary to hip symptoms.
股骨近端骨折的治疗，特别是股骨颈骨折尚存争议，特别是关于初次关节成形术的作用。最近，一项先前报道过的对关节成形术和内固定术治疗移位的股骨颈骨折随访10年的随机对照试验业已出版46。总的来说，45.6%行内固定的幸存患者骨折治疗失败，92例失败病例中仅有4例发生在2~10年。与之相对，8.8%行关节成形术的患者治疗失败，7例失败病例中5例发生在2~10年。关节成形术组中这些迟发的失败病例是行全髋关节成形术的患者。最初行关节成形术的患者中仅5.2%发生复发性脱位，与全髋关节成形术和半髋关节成形术后所发生比率相当。关节成形术组和内固定组10年死亡率相同，关于髋部活动性疼痛或关于继发于髋部症状的关节活动度减少两组间无显著差异。
Gjertsen et al. reviewed 4335 elderly patients from the Norwegian Hip Fracture Register who had a displaced femoral neck fracture and who had been managed with internal fixation or bipolar hemiarthroplasty and followed for a minimum of one year47. Mortality at one year was not significantly different between the internal fixation and hemiarthroplasty groups (27% compared with 25%). The reoperation rate was 22.6% for patients managed with internal fixation, compared with 2.9% for patients managed with hemiarthroplasty. Patients who had undergone hemiarthroplasty had better functional outcomes at one year as measured on the EQ-5D index score. These data further support hemiarthroplasty as being superior to internal fixation for the treatment of displaced femoral neck fractures in this patient population.
Gjertsen等回顾来自挪威髋部骨折登记系统数据的4335名行内固定术或半髋关节成形术治疗的移位型股骨颈骨折老年患者，术后随访至少1年47。内固定组与半关节成形术组1年死亡率无显著差异(27% : 25%)。内固定组二次手术率为22.6%，半关节成形术组二次手术率为2.9%。以EQ-5D指数评分评价患者功能结果，1年随访时，半关节成形术组更为良好。这些数据进一步支持对于移位型股骨颈骨折老年患者的治疗，半关节成形术优于内固定术。
Two recent randomized trials compared hemiarthroplasty with or without cement for the treatment of femoral neck fracture. The first study randomized 400 patients to treatment with either a cemented (Thompson) or uncemented(Austin-Moore) stem48. Overall, patients who had a hemiarthroplasty with cement had less pain on the visual analog scale at eight weeks and a lower Charnley pain score at three, six, twelve, and twenty-four months. Patients who had a hemiarthroplasty with cement also did not experience as great a loss of mobility in comparison with patients who had undergone a hemiarthroplasty without cement. The second study, which included 223 patients, demonstrated very different results in association with the use of a more modern uncemented stem with a hydroxyapatite coating (Corail; DePuy)49. The Harris hip score was not found to be different between the group with the uncemented stem and the group with the cemented stem (SPECTRON; Smith & Nephew) at three and twelve months of follow-up. There also were no differences in terms of functional outcomes as measured with the EQ-5D index score at three and twelve months. The uncemented Austin-Moore stem should have little use in modern hip hemiarthroplasty, with its main application being as a “quick” endoprosthesis in a patient with minimal functional demands but in need of pain control. A study of hemiarthroplasty after hip fracture did not demonstrate significant differences in terms of blood loss, transfusion requirements, or seventy-two-hour postoperative hemoglobin levels between standard and minimally invasive approaches50. Better functional results were documented at two years postoperatively in patients managed with a standard approach.
近期有两项随机试验对比了半关节成形术治疗股骨颈骨折中使用或不使用骨水泥的效果。第一项研究包括随机应用骨水泥假体(Thompson)或非骨水泥假体(Austin-Moore)的400名患者48。总的来说，使用骨水泥的半关节成形术患者在第8周以目测类比评分法评价，疼痛较轻，Charnley疼痛评分在第3、6、12、24月较低。 与未使用骨水泥的半关节成形术患者相比，使用骨水泥的患者无严重关节活动度丢失。第二项研究包括223名患者，证实应用更现代的羟基磷石灰涂层非骨水泥假体(Corail; DePuy)临床结果显著不同49。Harris髋部评分在非骨水泥假体组与骨水泥假体(SPECTRON; Smith & Nephew)组在随访3月和12月时无差异。以EQ-5D指数评分评价的功能结果在3月、12月亦无差异。Austin-Moore非骨水泥假体在现代髋部半关节成形术中较少使用，主要应用于功能要求较低、需要控制疼痛要求“尽快”置换的患者。一项髋部骨折行半关节成形术的研究未证实标准入路与微创入路在失血量、输血需求或术后72小时血红蛋白水平方面存在显著差异50。标准手术入路患者术后2年功能结果良好。
Extracapsular fractures also have been a source of controversy, primarily related to the expanding role of cephalomedullary nails instead of sliding hip screws. Proponents of nailing techniques highlight the minimally invasive nature and improved biomechanical characteristics of nails. Proponents of sliding hip screws point out their familiar technique and their lower cost. A meta-analysis compared several minimally invasive approaches (intramedullary nailing, percutaneous plating, minimally invasive sliding hip screw placement, and external fixation) to traditional insertion of a sliding hip screw51. No significant differences were found between groups in terms of the rates of fixation failure or mortality. Although the relative risk of blood transfusion was lower in the combined minimally invasive group, the relative risk of blood transfusion associated with intramedullary nailing alone (four studies) was not significantly different from that associated with the standard sliding hip screw. A small randomized controlled trial comparing sliding hip screw placement via a minimally invasive technique (length of incision, 2.5 cm) with a standard incision (length of incision, 10 to 15 cm) was recently published52. Patients in the minimally invasive group had decreased blood loss and a decreased transfusion rate, with less pain and improved physical functioning on the third postoperative day. No differences were seen in terms of radiographic outcomes or functional scores at three months.
囊外骨折也成为一个争论的来源，最初是关于头状髓内针取代髋部滑动螺钉不断扩大的作用。髓内针技术的支持者强调髓内针微创的本质和改进的生物力学特征。髋部滑动螺钉的支持者指出其技术成熟且价格低廉。一项mata分析将几种微创术式(髓内针植入术，经皮钢板固定术，微创髋部滑动螺钉植入术和外固定术)与传统髋部滑动螺钉植入进行对比51。组间固定失败率和死亡率方面无显著差异。尽管输血的相对风险在微创组较低，与单独髓内针植入(第4项研究)相关的输血相对风险和传统髋部滑动螺钉相比无显著差异。一项对比通过微创技术(切口长度2.5cm)和标准切口(切口长度10~15cm)植入髋部滑动螺钉的小型随机对照试验业已发表52。微创组患者失血量和输血率均降低，术后第3日疼痛较轻，躯体功能改善。术后3月在影像学结果和功能评分方面无差异。
A meta-analysis of Gamma nails compared with compression hip screws emphasized the decreasing rates of femoral fracture that have occurred with time, likely because of improvements in patient selection, surgical techniques, and the implants themselves53.
一项对比γ钉和髋部压力螺钉的meta分析强调，可能由于患者选择、外科技术和 植入物本身的改进，术后股骨干骨折发生率逐渐降低53。
Other Femoral Fractures
其它股骨骨折
Cannada et al. reported on a large series of high-energy femoral neck-shaft fractures54. In that study of 2897 patients with a femoral shaft fracture, the overall prevalence of associated femoral neck fracture was 3.2%; 88% of patients had injuries to another body system and 75% had other orthopaedic injuries.One-fourth of the femoral neck fractures were not identified preoperatively. Missed injuries occurred in 18% of the patients who had thin-cut computed tomography scans. Nonunion or malunion occurred in association with 12.1% of femoral neck fractures, and half of these cases were in patients who were diagnosed late. A high degree of vigilance is required to diagnose a femoral neck fracture, and even thin-cut computed tomography is not sufficient to make the diagnosis by itself in every case54.
Cannada等报告一系列高能所致股骨颈-干骨折大量病例54。在这项包括2897名股骨干骨折患者的研究中，合并股骨颈骨折的发病率为3.2%；88%的患者合并其他系统损伤，75%合并其他部位骨科损伤。1/4的股骨颈骨折术前未做出明确诊断。薄层CT扫描的患者中18%发生漏诊。股骨颈骨折患者12.1%发生骨不连或畸形愈合，其中一半患者属诊断延误。对股骨颈骨折的诊断要求高度的警觉，仅依靠薄层CT对所有病例做出诊断是不充分的54。
In another study involving 1126 femoral shaft fractures that were treated with intramedullary nailing, forty-six patients with femoral nonunions (4% of the total number of cases) were compared with a matched control group of ninety-two patients with healed femoral fractures55. Open fracture and tobacco use were found to be predictive of nonunion. Interestingly,72% of patients who developed nonunions of femoral fractures had delayed weight-bearing as a consequence of other injuries. On the basis of the results of this study, the authors reported that they have become more aggressive with early weight-bearing whenever possible after intramedullary nailing of femoral shaft fractures.
另外一项研究包括1126名股骨干骨折行髓内针治疗的患者，与对照组的92名股骨骨折完全愈合患者相比，46名患者发生骨不连(总病例数的4%)55。开放性骨折和吸烟是预示骨不连的诱因。有趣的是，72%的股骨骨折骨不连患者由于其它损伤而推迟负重练习。基于这项研究的结果，作者称，只要可能，他们将更为积极的主张股骨干骨折行髓内针固定的患者早期负重训练。
Controversy still exists among surgeons with regard to the relative benefits of antegrade versus retrograde nailing of the femur. A recent randomized study evaluated knee function after antegrade and retrograde femoral nailing56. No differences in knee flexion (132° and 134° in the antegrade and retrograde groups, respectively), Lysholm scores, or isokinetic muscle performance were noted between the groups. Older patients also tended to have lower Lysholm scores and decreased knee flexion compared with younger patients, irrespective of treatment.
关于股骨顺行性髓内针对比逆行性髓内针的相对益处，在外科医师间尚存争议。最近一项随机研究评估了顺行性和逆行性股骨髓内针术后膝关节功能56。组间在膝关节屈曲(顺行组和逆行组分别为132°和134°)、Lysholm评分、等功能肌肉活动能力方面无差异。无论何种治疗，老年患者与年轻患者相比，Lysholm评分较低，膝关节屈曲受限。
Unlike femoral shaft fractures, there has been little controversy regarding distal femoral fractures, for which locking plates seem to have been widely adopted. Ricci et al. analyzed the risk factors associated with failure of locked plating for the treatment of distal femoral fractures in a study of 305 patients57. Overall, 9% of patients developed a nonunion, whereas another 6% required a planned staged bone-grafting procedure. A history of diabetes mellitus was the only independent predictor of nonunion. Implant failures occurred in 8% of cases; 60% of failures occurred in the proximal fragment. Independent predictors of implant failure included diabetes, an OTA A3 fracture pattern, body mass index, a stainless steel plate, and a shorter plate length. Proximal implant failure was less likely when plate length was ten holes or longer, when eight holes or more covered the proximal diaphyseal fragment, when more proximal screws were utilized, and when the screw density (percentage of screw holes filled) was <60% in the proximal portion of the plate57. These data provide useful guidelines for surgeons using locked plates in the distal part of the femur.
与股骨干骨折不同，关于股骨远端骨折的争议较少，锁定钢板看似已被广泛采用。Ricci等在一项包括305名患者的研究中分析了与锁定钢板治疗股骨远端骨折相关的风险因素57。总的来说，9%的患者发生骨不连，而另外6%患者需要有计划的分阶段植骨。糖尿病史是骨不连唯一独立预测因子。8%的病例植入物失败，60%发生在近端骨折部分。植入物失败独立预测因子包括糖尿病史、OTA A3型骨折、人体质量指数、不锈钢板和钢板长度过短。当钢板长度为10孔或以上时、骨折近端骨干覆盖钢板达8孔或以上长度时、近端使用更多螺钉时、钢板近端部分螺钉密度(螺钉数占螺钉孔数的百分比) <60%时，近端植入物失败很少发生57。这些数据对外科医师应用股骨远端锁定钢板提供了有用的指导。
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