[Ortho] переломы шейки бедра

[Адонин]

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, Str Ж mqvist, 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