背景:超高龄(≥90岁)髋部骨折患者给骨科医师带来越来越大的挑战.目的:分析超高龄髋部骨折患者的合并症特点,探讨此类患者的围手术期安全性.方法:回顾性分析2006年1月至2020年12月我中心收治的髋部骨折病例,经筛选,纳入本研究1537例.以年龄分组:A组(≥90岁,139例)和B组(65～89岁,1398例).比较两组的性别、骨折诊断、合并症情况,然后进行匹配处理,比较匹配后两组(AP组和BP组)术前住院日、总住院日、围手术期死亡率和并发症发生率.结果:A组发生股骨转子间骨折的患者比例高于B组(χ2=16.471,P<0.01),合并糖尿病或其他代谢性疾病的患者比例低于B组(χ2=9.752,P=0.0028),而合并贫血的患者比例则高于B组(χ2=97.472,P=0.006).AP组和BP组的围手术期死亡率以及大部分并发症的发生率比较,差异无统计学意义;但肺部感染并发率差别具有统计学意义(χ2=4.187,P=0.041).结论:超高龄髋部骨折中有较多的转子间骨折;合并贫血的患者比例高,合并糖尿病等代谢疾病的患者比例低;围手术期较易并发肺部感染;死亡率和绝大多数并发症发生率并未升高.

Background:Most proximal tibia fractures are fixed with hardware if soft tissues are available,such as MIPPO technique.But the internal hardware is expensive;and incision-related complications is uncommon and tough to handle,due to the thin envelope of soft tissue around the knee.Objective:To report the results of management of proximal tibia fractures with external fixators,and analyze the indications and key points of this method.Methods:From January 2009 to December 2013,15 patients with proximal tibia fractures were included to this retrospective study.There were 13 males and 2 females with an average age of 39.3 years (range,16 to 57 years).All patients underwent close or limited-open reduction and fixation with hybrid extemal skeletal fixators.According to AO classification,8 patients had type A2 fracture,2 patients with type A3,and 5 patients with type B 1.Two cases of open fractures were classified to Gustilo type Ⅱ.The data were recorded,including interval from injury to surgery,operation time,perioperative blood loss,hospital stay,the time of extemal fixation,the time of bony union,and complications.The follow-up was performed in 1,2,3,4,6,12 and 24 months postoperatively.The function of knee was evaluated clinically with Iowa scale system.Results:Fifteen patients were followed up for 21.5 months on average (range,17 to 28 months).There were no complications related to incision or soft tissue,nonunion or delayed union.The mean time of external fixation was 13.7 weeks (range,10 to 18 weeks).The mean time of bony union on X-ray films was 21.5 weeks (range,18 to 25 weeks).One patient suffered from a pin track infection which was healed after removal of the pin and debridement.According to the Iowa scale system,the results were excellent in patients,good in 5,and fair in 2,and the excellent and good rate was 87％.Conclusions:The extemal fixation technique can achieve a satisfactory outcome in treatment of proximal tibia fractures.The fractures can be treated immediately after the injury,regardless of soft tissue envelope damage.The external skeletal fixation can be performed easily,and construction of fixator can be changed freely,which can avoid the difficulty of internal fixation on irregular surface of proximal tibia.The incidence of soft tissue related complications is acceptable and the bone union rate is high.

目的 探讨老年再发髋部骨折的治疗策略.方法 我科2005年1月至2014年12月收治老年再发髋部骨折患者56例,其中男15例,女41例;年龄71 ～ 96岁,平均82.1岁.初次骨折类型:股骨颈骨折46例,股骨转子间骨折10例;3例保守治愈,53例手术治愈.再发骨折部位:同侧1例,对侧55例;再发骨折类型:股骨颈骨折43例,股骨转子间骨折13例;均早期手术治疗,并强化抗骨质疏松治疗.结果 术后1年内死亡3例,死亡率为5.4％,53例患者获得1年以上随访.股骨颈骨折术后假体位置均良好.股骨转子间骨折均获得骨性愈合,平均15.3周.按Harris髋关节功能评分标准:优23例,良20例,可10例,优良率为81.1％.结论 对老年再发髋部骨折的患者,早期手术治疗仍是主要的治疗原则,大型综合医院多科协作的模式、较高的医疗水平有助于提高疗效、降低死亡率,同时应努力强化抗骨质疏松治疗等二级预防措施.

Objective To analyze the risk factors of postoperative in-hospital death in elderly hip fracture patients. Methods Four hundred and eighty patients (325 femoral neck fracture, 155 intertrochanter-ic fracture) treated in Peking Union Medical College Hospital from January 2004 to December 2014 were included in this retrospective study. Survival or in-hospital deaths (postoperative outcome) was chosen as the dependent variable, and gender, age, fracture type, ASA score, comorbidities and other parameters were tested as independent variable. Thirteen in-hospital death cases were assigned to death group. Forty-two cases survived at least 90 days postoperatively were randomly selected as control group. Multi-factor Logistic regression analysis was applied to evaluate the risk factor of postoperative in-hospital death.Results Pulmonary infection and acute myocardial infarction were two main direct causes of postoperative in-hospital death with 2.71%mortality. There was significant difference on age (t=2.623, P<0.05), comorbidities (c2=6.302, P<0.05), and smoking history (c2=6.061, P<0.05) by single factor analysis. Multi-factor Logistic regression analysis showed that age (Wald=5.209, P<0.05, OR=0.757), more than two complications (Wald=4.915, P=0.027, OR=0.155) and smoking history (Wald=6.853, P<0.05, OR=10.917) was independent risk factors of postopera-tive in-hospital death. Conclusions The risks of perioperative pulmonary infection and acute myocardial infarction were relatively higher in postoperative geriatric hip fractures. Attention should be paid on elderly patients with more comorbidity or smoking history.

Objective To report the clinical results of managing distal tibial fractures with a hybrid external skeletal fixator.Methods From January 2006 to June 2013,39 patients with distal tibia fracture were managed with limited-close or limited-open reduction and a hybrid external skeletal fixator.They were 26 men and 13 women,with an average age of 40.1 years (range,from 23 to 65 years).According to AO classification,15 fractures were of type A3,8 of type B2,10 of type B3,2 of type C2 and 4 of type C3.According to Gustilo classification,of the 12 open fractures,8 were of type Ⅱ,3 of type Ⅲ a and one of type Ⅲ b.According to Tscherne classification of soft tissue injury,4 cases were of grade l,24 of grade 2,and 11 of grade 3.Open fractures were managed first with radical debridement.Those complicated with fibular fracture were managed first with open reduction and internal fixation of distal fibula followed by close or limited-open reduction and minimal internal fixation depending on the position of distal tibial fracture.Next,the hybrid external skeletal fixation was applied.Five cases were immobilized with trans-articular fixators.The data were recorded regarding interval from injury to surgery,operation time,perioperative blood loss,hospital stay,time of external fixation,time of bony union,and complications.The ankle function was evaluated clinically with the Maryland Scale system at the final follow-ups.Results The 39 patients were followed up for 12 to 18 months (average,14.5 months).Primary incision healing was achieved in 37 cases,but the other 2 patients with open fracture suffered delayed wound healing which was cured by dressing changes for 4 weeks.Altogether,38 cases achieved normal fracture union and their average time of external fixation was 13.5 weeks.The time for complete infusion of fracture lines on X-rays averaged 19.7 weeks.Delayed union occurred in one case whose fracture united after removal of the external fixator,internal fixation with a locking plate and autogenous bone grafting.One case was complicated with pin track infection which was healed after debridement,drainage for 8 weeks and removal of the external fixator.No neurovascular complications were observed.According to the Maryland Scale system,the ankle function was excellent in 8 cases,good in 24 and fair in 7,with an excellent and good rate of 82.1％.Conclusions The hybrid external skeletal fixator is good for distal tibial fractures,because it can cffectively protect the skin and minimize invasion to the soft tissues,reducing incidences of skin necrosis and wound infection.Moreover,since it is flexible in screwing and structure formulation,it facilitates wound management,eslpecially in the management of open fractures.

目的 探讨切开复位内固定治疗成人锁骨中段移位骨折的疗效.方法 2006年1月至2010年12月手术治疗118例成人单纯锁骨中段移位骨折,男93例,女25例；年龄18～85岁,平均47.6岁.骨折按Robinson分类:2A2型4侧,2B1型61侧,2B2型55侧,均为闭合性骨折.均行切开复位,用重建接骨板固定,7例于骨折处植骨.按美国加州大学洛杉矶分校(UCLA)肩关节评分标准(Ellman法)评定术后功能.结果 107例患者术后获6～43个月(平均16.0个月)随访.伤口均一期愈合,无感染发生.骨折均获骨性愈合,平均愈合时间为10周.3例出现内固定失效.按UCLA肩关节评分标准(Ellman法)评定术后功能:优56例,良47例,可4例,优良率为96.3％.结论 对于成人锁骨中段移位骨折,一期采用切开复位、接骨板内固定疗效较好。

Background: Currently, there are few reports about surgical treatment of intertrochanteric fracture combined with Parkinson disease. Objective: To explore the surgical characteristics and perioperative management of intertrochanteric fracture in the patients with Parkinson disease. Methods: A retrospective study was performed on 14 intertrochanteric fracture patients who had suffered from Parkinson disease. There were 4 males and 10 females with an mean age of 78.2 years (range, 66-92 years). By Jensen-Evans classification, 3 cases in type Ⅲ, 6 cases in type Ⅳ, 5 cases in typeⅤ. Dynamic hip screw (DHS) system was used in 6 cases and intramedullary nail system was used in 8 cases. Results: Five patients died within 1 year after operation due to lung infection and heart failure. Nine patients were followedup successfully for 28.7 months on average. Postoperative Harris score of the 9 patients was signicantly higher than preoperative one (76.3 vs 20.2). No severe complications such as incision infection, hip varus, screw cut-out and refracture were found during follow-up. Conclusions: Good curative effect will be achieved if we choose appropriate surgical treatment, implants, proper perioperative period management and prevention of complications for intertrochanteric fracture in patients with Parkinson disease, who always have a poor prognosis compared with other hip fracture patients.

Objective To analyse the complications of intertrochanteric fractures of femur treated by close reduction and internal fixation for patients over 75 years old.Methods Totally 279 cases of intertrochanteric fractures over 75 years old from Jan.2002 to Jun.2010 were reviewed in fracture types,preoperative complications,operative methods and postoperative complications.Results The mean age of patients was 78.6 years(75-96).The cases had different physical diseases including cardiovascular,cerebrovascular,respiratory,endocrine,digestive,urinary,periphery vascular system and others.177 cases were fixed with DHS(or plus trochanteric steady plate) and 102 cases with intramedullary interlocking nail.The mean operation time was 77 minutes.85 cases(30%) need blood transfusion.220 cases were followed-up 6 months after operation and 89%patients got excellent or good results.9 types of complications were mentioned.Conclusion Most senile intertrochanteric fracture patients complex medical problems.Delicate pre-operative evaluate,early operation,avoid general anesthesia,shorten the time of operation and rigid fixation can reduce complications and mortality rates.Pulmonary infection and DVT are common complications.

Objective To evaluate the clinical results of open reduction and internal fixation(ORIF)and external fixation(EF)for the treatment of unstable fractures in distal radius.Methods From September 2005 to February 2008,44 patients(average age:61.5 years)with unstable distal radial fractures were treated in our department by the same surgeon with either ORIF or EF.According to AO Muller classification,there were 11 cases of type A,9 cases of type B,and 24 cases of type C.Twenty-one cases were treated with EF,while 23 cases with ORIF.The duration of operation and intra-operative blood loss were recorded.The patients were followed up 3 months,1 year,and 2 years after surgery.Clinical and radiological outcomes,including Gartland-Wertley(GW)scores,range of motion of wrist joint,and grip strength,were measured.Complications were observed and recorded.Results EF took shorter time and less blood loss than ORIF.At the 3-month follow-up,ORIF cases showed superior GW scores,volar flexion,dorsiflexion and grip strength than EF.At the 1-year follow-up,better volar flexion and grip strength were found in ORIF cases.At the 2-year follow-up,ORIF cases still showed better volar flexion than EF.Conclusion In the treatment of unstable distal radial fractures,ORIF can achieve better clinical outcomes in the first 2 years,while EF offers shorter operation time and less blood loss.

Objective To compare clinical outcomes of intramedullary nail(IMN) and plates for the management of humeral shaft fracture.Methods From January 2004 to December 2008,86 patients with close fracture of humeral shaft underwent internal fixation operation with IMN(38 cases) or plates(48 cases).Clinical outcome measurements included operation time,blood loss,fracture healing,shoulder function,and complications.Results There were significant difference in operation time and blood loss between the two groups,but not in fracture healing and shoulder function. There was 1 fracture ununion in plate group.There was 1 radial nerve palsy both in plate and IMN groups,and recovered completely after conservative treatment.Conclusion There is no significant difference in clinical outcome between plates and IMNs.The advent of locking-plates has made it possible to fix proximal and distal fracture of humeral shaft.The ex- perience of orthopedists,the operation conditions and fracture type are key factors of prognosis.

Objective To analyze the characteristics of injury,selection of operative methods,complication and outcomes of anterior and middle foot contusion.Methods Totally 14 severe foot contusion cases were reviewed from May 2002 to October 2009.There were 12 males and 2 females with an average age of 34.years(range,14-69 years).The classification of fracture or dislocation,soft tissue deficits,operative methods and peri-operative complications were evaluated. Results Five cases suffered of middle foot fracture and dislocation,4 cases in anterior foot,and 6 cases in anterior and middle foot.Two cases combined with DM and one with artery occlusion.After primary debridement,5 patients' skin deficits exceeded 3cm×3cm,and underwent flap transplantation.Two patients underwent amputation,and 5 patients with nerve,vascular or tendon problems treated operatively.Five patients were treated with plates and screws,5 with Kirschner wires,and 2 with plaster.Complications include one case of would necrosis,one flap necrosis,one DVT and one compartment syndrome.In 15 patients who had been followed up over 6 months,11 had excellent or good function. Conclusion Severe anterior and middle foot contusion is a compound injury concerning bone,joints and skin and other soft tissues.The therapy aim is to reconstruct the weight bearing structure of the foot and the soft tissue coverage. Internal fixation is not absolute contraindication.Cooperation is propitious to early recovery.

桡骨头骨折是临床常见的损伤,根据骨折移位、累及范围以及是否合并肘关节脱位可将其分为MasonⅠ-Ⅳ型,其中Ⅱ型及Ⅲ型骨折移位明显,在治疗方案选择和结果判断上争议颇多.

OBJECTIVE:To analyze the clinical manifestations, operative applications, complications and outcomes of peritrochanteric fracture of femur in patients 75-years old and over.METHODS:The clinical data of 261 patients, aged 79.5 (75-96), of peritrochanteric fracture (265 hips) were analyzed.RESULTS:The incidence of different accompanied medical diseases was 2.6/person on average. The internal fixation methods included DHS, DHS plus trochanteric steady plate or intramedullary interlocking nails, such as Gamma nail, PFN and reconstructive nails. The mean operation time was 73 minutes. 224 cases were followed-up over 6 months after operation 81% of which got excellent or good results. The complications included acute heart failure, brain infarction, cerebral thrombosis, pulmonary embolism, deep venous thrombosis of lower extremities, lung infection, and stress ulceration, bed sore, and acute respiratory failure. Thirteen cases died of cardiopulmonary insufficiency, cardiac infarction, brain thrombosis, or pulmonary embolism.CONCLUSION:Complications are frequent in aged patients. Appropriate operative methods help reduce complications and mortality rates.