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病例漫谈108:髋股撞击征诱发股骨颈骨折不愈合:一则病例报告 [复制链接]

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银光图片
Introduction
Displaced femoral neck fractures in young adults necessitate anatomic reduction and stable internal fixation to preserve the femoral head, achieve union, and avoid osteonecrosis. Non-union rates as high as 10-30 % have been reported and associated with either general risk factors such as systemic disease, alcohol and other drug abuses, and/or local vascular, infectious, and mechanical factors. Inappropriate fracture reductions such as varus angulation and/or posterior tilt increase non-union rates up to 50 %. Barnes et al. also showed differences regarding the fixation method: a Smith-Petersen nailing exhibited a higher rate of non-union than cross-screw fixation or a sliding nail plate (50 vs. 70 % rate of union).
引言
青壮年移位性股骨颈骨折必需进行解剖复位和稳定的内固定术来保护股骨头、实现愈合并避免骨坏死。已报道不愈合率高达10-30%,并与一般风险因素(如全身性疾病、滥用酒精及其他药物),和/或局部血管、感染及机械因素有关。不恰当的骨折复位,如成角内翻和/或后倾使不愈合率增加至50%。Barnes等也表明了固定方式的差异:史密斯-彼得森钉比交叉螺钉固定或滑动钉板具有更高的不愈合率(不愈合率为50%对70%)。

The role of femoroacetabular impingement (FAI) in retarding or preventing fracture healing about the femoral head and neck is poorly understood. While the dynamic conflicts between femur and acetabulum may theoretically interfere with femoral neck fracture union, this has not been described in the literature previously. We present a case in which FAI most likely caused non-union of a well-reduced and well-fixed femoral neck fracture in a healthy young man with no known risk factors for poor fracture consolidation.
对于髋股撞击征(FAI)在延缓或阻止股骨头及股骨颈骨折愈合中的作用还知之甚少。虽然股骨与髋臼之间的动态冲突在理论上可能会干扰股骨颈骨折愈合,但尚无文献报道这一点。本文报道一例健康年轻患者,无已知骨折愈合较差的风险因素,髋股撞击征(FAI)极有可能造成复位并固定良好的股骨颈骨折不愈合。

Case study
A 35-year-old healthy office administrator sustained an isolated displaced mid-cervical fracture of the femur(Fig.1) in a motorcycle accident. Of note, the patient did not recall groin pain or decreased internal rotation prior to the injury. He was treated on the day of injury by closed reduction and internal fixation with three 7.3-mm cannulated lag screws under general anesthesia (Fig. 2a and b). Partial weight bearing was started the day after surgery and recommended for 12 weeks post-operatively. The patient was discharged home on post-operative day 4 after an uneventful hospital course. After 12 weeks, the patient was still on crutches and not able to increase weight bearing due to persistent groin pain.
病例分析
一名35岁的健康办公室管理员在一次摩托车事故中导致股骨颈移位骨折(图1)。值得注意的是,患者不记得受伤前腹股沟疼痛或内旋转减少。受伤当天,通过采用3个7.3毫米的空心拉力螺钉的闭合复位与内固定在全麻下治疗患者(图2a和b)。术后第二天开始部分负重,并建议术后持续12周。接受常规的医院疗程后,患者在术后第4天出院回家。12周后,由于持续性腹股沟疼痛,患者仍拄着拐杖且不能增加负重。

Fig. 1 Radiograph showing a mid-cervical fracture of the left femur obtained on the day of injury

图1 X光片显示左股骨颈中部骨折


Fig. 2 Radiograph after closed reduction and screwing of the proximal femur was performed showing an adequate reduction, correct length and positioning of the screws, and sufficient stability of the fixation construct. The calculated alpha angle has been provided(b)

图2 股骨近端进行闭合复位与螺钉固定后的X光片表明复位恰当、螺钉的长度与位置合适且固定结构足够稳定。


Six months after the index surgery, the patient consulted our outpatient clinic. He still endorsed groin pain during each step, when trying to bear weight, and when sitting for several minutes. Physical examination revealed a body height of 191 cm and weight of 86 kg (body mass index of 24 kg/m2). In the supine position, the patient experienced his typical groin pain with passive hip flexion to 80°, as well as with 10°of internal rotation at 80°of hip flexion. On radiographic analysis at this visit, the fracture line was still visible, and the neck slightly shortened when compared with prior X-rays (Fig.3). A fracture gap was seen on computed tomography scan, with unaltered reduction and no overt signs of screw loosening or hardware compromise (Fig.4a). Appropriate shortening of the neck along the partially threaded screw paths was seen. Additionally, a pre-existing severe cam deformity was seen. On the pelvic AP radiograph, a cranial crossover sign was seen, suggesting combined cam- and pincer-type impingement.

牵引手术后6个月,患者向门诊咨询。当试图负重或坐几分钟时,在每个步骤中患者仍感觉腹股沟疼痛。体检显示患者身高191厘米、体重86公斤(身体质量指数为24公斤/平方米)。取仰卧位,患者被动屈髋80°时患有典型的腹股沟疼痛,且屈髋80°时内旋转10°。与先前的X光片相比,本次就诊的影像学分析表明:骨折线仍然可见且颈部略微缩短(图3)。CT扫描中可见骨折间隙,复位不变且无明显螺钉松动或硬件故障的迹象(图4a)。沿部分带螺纹的螺钉路径可见颈部相应缩短。此外,可见预存在的严重凸轮畸形。在骨盆AP X光片中,可见颅骨交叉的迹象,表明凸轮型与钳型撞击相结合。

Fig. 3 Radiograph 6 months after surgery showing non-union of the femoral neck fracture

图3术后6个月的X光片显示股骨颈骨折不愈合


Fig. 4 a Computed tomography scan 6 months after surgery confirming that appropriate signs of fracture union were absent; note is made of severe pre-injury cam deformity of the proximal femur. b Bone scintigraphy showing increased uptake at the fracture gap, consistent with non-union

图4 a术后6个月的CT扫描证实无骨折愈合的迹象;记录股骨近端受伤前严重的凸轮畸形。b 骨扫描显示骨折间隙的摄取增加,与不愈合相一致


Deep sepsis was excluded by normal white blood cell count, erythrocyte sedimentation rate, and C-reactive protein. A bony scintigram with single photon emission computed tomography (SPECT) did not reveal signs of avascular head necrosis; however, the study did demonstrate increased uptake at the fracture gap, consistent with non-union (Fig.4b). Since there was no clear explanation for non-union, we hypothesized that a combined cam-/pincer-impingement contributed to the fracture non-union, due to mechanical conflict and resulting micro/macro-instability environment about the fracture gap.
根据正常的白细胞计数、红细胞沉降率及C-反应蛋白排除深度败血症。骨闪烁图结合单光子发射计算机断层显像(SPECT)未显示缺血性股骨头坏死的迹象;不过,这项研究证实了骨折间隙中摄取增加,与不愈合相一致(图4b)。既然骨折不愈合无明确解释,由于对骨折间隙的机械撞击及其造成的微/宏观不稳定环境,我们假设凸轮/钳形撞击组合造成骨折不愈合。

Because the overall fracture alignment and stability of fixation appeared acceptable, arthroscopic femoral neck osteochondroplasty was proposed and performed without complication. Patient positioning and portal placement were performed according to the technique described by Byrd and under general anesthesia. In the first step of the procedure, arthroscopy of the central compartment was performed under traction. A partially ossified labrum and antero-superior chondropathy was seen. To treat this pincer component, the labrum was addressed along with acetabular rim trimming. Subsequently, femoral osteochondroplasty was performed, without traction, along the anterolateral femoral neck, taking care not to compromise the postero-superior retinacular vessels (Fig. 5). The fracture gap itself was not clearly visible, and there was no specific debridement or resection of tissue at the fracture site. Bony resection was judged adequate when, by dynamic examination and under direct visualization, an impingement-free range-of-motion was achieved, including in the position of internal rotation of at least 30°with the hip flexed to 90°. Post-operative rehabilitation directed the patient to weight-bear as tolerated on two crutches; the patient self-administered passive hip motion on a bicycle ergometer for 6 weeks post-operatively. Indomethacin 75 mg orally and enoxaparin 40 mg intra-muscular were prescribed on a daily basis for a duration of 2 weeks to prevent heterotopic ossification and thromboembolic complication, respectively.
因为整体骨折对位和固定的稳定性似乎可接受,所以提出并进行关节镜下股骨颈骨软骨成形术,无并发症。全麻下根据Byrd描述的技术选取患者体位和入口位置。在该过程的第一步中,在牵引下进行中央室关节镜检查。可见部分僵化的盂唇及前上软骨病。为了治疗这种钳状成分,盂唇与髋臼边修整一起处理。接着,在无牵引下沿着前外侧股骨颈进行软骨成形术,注意不要破坏后上韧带血管(图5)。骨折间隙本身并不清晰可见,且骨折部位并未进行清创术或组织切除术。在动态检测和直视下,达到运动范围内无撞击时判断为骨切除适当,包括髋关节弯曲90°内部转动30℃以上的位置。术后康复指导患者承重依靠两根拐杖;术后患者在自行车测功计上自我被动进行6周的臀部运动。规定每天的基础为分别口服吲哚美辛75毫克和肌肉注射依诺肝素40毫克,持续2周时间,以预防异位骨化和血栓并发症。

Fig. 5 Axial view radiograph after arthroscopic osteochondroplasty of the head and neck of the proximal femur with a resulting improved head–neck offset

图5关节镜下股骨近端头颈部骨软骨成形术后的轴向X光片显示提高了头颈偏移


Six weeks after surgery, the patient was able to bear weight without pain, and the fracture non-union showed evidence of progressive healing (Fig.6). At 3 months post arthroscopy, the non-union had healed (Fig.7), and the patient returned to his pre-injury level of activity and work.
术后六周,患者能够无痛承重,且骨折不愈合呈逐步愈合的迹象(图6)。关节镜手术3个月后,不愈合痊愈(图7),且患者恢复到受伤前的活动和工作水平。

Fig. 6 Antero-posterior and axial view radiographs 6 weeks after arthroscopic surgery showing signs of progressive fracture healing

图6关节镜手术6周后的前后位及轴向X光片显示骨折逐步愈合的迹象


Fig. 7 Antero-posterior and axial view radiographs 12 weeks after surgery demonstrating union of the fracture

图7术后12周的前后位及轴向X光片显示骨折愈合


Discussion
Femoroacetabular impingement triggering femoral neck non-union by levering of the fracture site when hip joint movements are reduced beyond a physiological range of motion was suggested by Beck et al. in a series of 3 patients in 2004. In one case, a bony spur causing posterior impingement was removed, and in two cases, a cam-induced FAI was treated with open osteochondroplasty. However, since surgical revision included open reduction and fixation of the fracture site using a blade plate, it was unclear from this report whether improved joint clearance alone—rather than improved fracture fixation, or the two procedures in combination—contributed to union.
讨论
2004年,Beck等在3例患者的病例系列中提出当髋关节运动减少至超出运动的生理范围时,髋臼撞击借力于骨折部位引发股骨颈骨折不愈合。在1例患者中,去除了引起后侧撞击的骨刺,在2例患者中,通过开放式骨软骨成形术治疗凸轮引起的髋股撞击征(FAI)。然而,由于手术修复包括采用刀板进行骨折部位的切开复位与固定,本报告尚不清楚是否仅改善了关节间隙—而未改善骨折内固定,还是这两个过程的结合—促进了愈合。

In the present case, arthroscopic osteochondroplasty and trimming of the acetabular rim in a combined cam- and pincer-type FAI alone rapidly resulted in fracture union and strongly highlight FAI as a major contributing factor for non-union. Absence of evidence of hardware loosening and a technically appropriate primary fixation of the fracture justified retention of the index fixation. Possibly, there is an even greater impact of the pincer component since the prominent rim leads to a direct force. During range of motion of the hip joint, the femoral neck has a direct abutment on the acetabular rim and the labrum; thus, there is a posteriorly oriented force directly onto the femoral neck. The posterior force can cause contrecoup injury adjacent to the fovea, which was not clearly visible in this case. The injury to the antero-superior acetabular cartilage is due to the cam-type component of this combined FAI.
本病例中,在凸轮结合钳型髋股撞击征(FAI)中仅通过关节镜下骨软骨成形术和髋臼边缘修整使得骨折迅速愈合,并极力突出髋股撞击征(FAI)作为不愈合的一个主要因素。缺乏螺钉松动的证据且技术适当的骨折初级固定合理保留索引固定。因为突出的轮圈导致直接力量,所以钳子可能会遭受更大撞击。在髋关节运动范围内,股骨颈与髋臼缘和盂唇直接邻接;因此,有一个后侧定向力直接作用于股骨颈。后力可引起中心凹邻近的对冲损伤,本病例中并不明显可见。前上髋臼软骨损伤来源于这种结合髋股撞击征(FAI)的凸轮式成分。

We conclude that the presence of FAI morphologies might be a contributor to delayed union of otherwise well-reduced femoral neck fractures. The bony morphology of the head–neck junction of young patients sustaining femoral neck fractures has not been described in large groups. Therefore, radiographic and/or clinical factors related to either risk of fracture or response to fracture treatment and ultimate healing should be further explored with respect to FAI. Provided the fracture is well reduced and appropriately fixed, arthroscopic osteochondroplasty and trimming of the acetabular rim can effectively treat delayed and/or non-union of the fracture.
我们认为存在髋股撞击征(FAI)形态可能是股骨颈骨折延迟愈合的一个促成因素,否则其将充分复位。尚未对持续股骨颈骨折的年轻患者头颈交界处的骨性形态进行大范围描述。因此,关于髋股撞击征(FAI),骨折风险或影响骨折治疗及最终愈合的影像学和/或临床因素有待进一步探讨。倘若骨折复位良好且固定适当,关节镜下骨软骨成形术和髋臼缘的修整可有效治疗愈合延迟和/或骨折不愈合。

由MediCool医库软件 赵美凤 王露黔 编译

原文来自 Arch Orthop Trauma Surg

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