At the present time proximal femoral fractures account for 30% of all fractures referred to hospitals for treatment. Our population is ageing, the proportion of patients with post-menopausal or senile osteoporosis is increasing and therefore the number of proximal femoral fractures requiring urgent treatment is growing too. In the age category of 50 years and older, the incidence of these fractures has increased exponentially. Our department serves as a trauma centre for half of Prague and part of the Central Bohemia Region with a population of 1 150 000. Prague in particular has a high number of elderly citizens. Our experience is based on extensive clinical data obtained from the Register of Proximal Femoral Fractures established in 1997. During 14 years, 4280 patients, 3112 women and 1168 men, were admitted to our department for treatment of proximal femoral fractures. All patients were followed up until healing or development of complications. In the group understudy, 82% were patients older than 70 years; 72% of those requiring surgery were in their seventies and eighties. Men were significantly younger than women (p<0.001) and represented 30% of the group. The fractures were 2.3-times more frequent in women than in men. In the category under 60 years, men significantly outnumbered women (p<0.001). The patients with pertrochanteric fractures were, on the average, eight years older than the patients with intertrochanteric fractures, which is a significant difference (p<0.001). The mortality rate within a year of injury was about 30%. Trochanteric fractures accounted for 54.7% and femoral neck fractures for 45.3% of all fractures. The inter-annual increase was 5.9%, with more trochanteric than femoral neck fractures. There was a non-significant decrease in intertrochanteric (AO 31-A3) fractures. On the other hand, the number of pertrochanteric (AO 31-A1+2) fractures increased significantly (p<0.001). A total of 1 394 fractures were treated with a proximal femoral nail; a short nail was used in 1260 and a long nail in 134 of them. A dynamic hip screw (DHS) was employed to treat 947 fractures. Distinguishing between pertrochanteric (21-A1, 31-A2) and intertrochanteric (31 -A3) fractures is considered an important approach because of their different behaviour at reduction. Pertrochanteric fractures occurred more frequently (81.5%); the patients' age was higher (80 years on the average) and women outnumbered men at a ratio of 3:1. Intertrochanteric fractures were found in significantly younger patients (average, 72 years), with a women-to-men ratio of 1.3:1. Stable pertrochanteric fractures (31-A1) were preferably indicated for DHS surgery. Unstable pertrochanteric (31-A2) and intertrochanteric (31-A3) fractures were treated with a nail. The patients underwent surgery on the day of injury or the next day. In the case of contraindications to an urgent intervention, surgery was performed after the patient's medical condition had stabilised. The number of complications was largely related to technical errors, such as insufficient reduction or an incorrectly inserted implant. Intertrochanteric fractures were associated with a higher occurrence of complications. No implant can compensate for errors due to surgery. Serious complications can be reduced by the correct assessment of fracture type, the use of an appropriate operative technique and early treatment of potential complications. The necessity of restoring continuity in the medial cortex of the femoral neck (Adams' arch) is the requirement that should be observed. Pseudoarthrosis or varus malalignment in a healed hip should be managed by valgus osteotomy. When the femoral head or the acetabulum is damaged, total hip arthroplasty is indicated. A prerequisite for successful surgical outcome is urgently and correctly performed osteosynthesis allowing for early rehabilitation and mobilisation of the patient

• MeSH
• dlahy využití   MeSH
• fraktury kyčle * epidemiologie   chirurgie   klasifikace   MeSH
• intramedulární fixace fraktury * metody   MeSH
• kostní šrouby využití   MeSH
• kyčelní protézy využití   MeSH
• lidé MeSH
• pooperační komplikace * etiologie   MeSH
• senioři MeSH
• Check Tag
• lidé MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• přehledy MeSH

PURPOSE OF THE STUDY It is the aim of our study to present the results of our way of treatment of the periprosthetic fractures, with the cemented as well as the cement-free stems. MATERIAL From 1.1.1988 until 31.3.2005 we operated 42 periprosthetic fractures of the hip in 41 patients. 31 of our patients were females, 10 of them males. In 22 cases we operated the right side, 18 times the left side and once we had to operate both sides, but at different times. We used the Vancouver classification scale for the grading of the fractures. In our study we excluded type A fractures; we registered 41 type B fractures and one only type C fracture. The reason for periprosthetic fracture in all these 42 cases was definitely a trauma. In 6 cases we found pre-existing loosening of the stem. We have grouped our patients under two headings: 1. Primary cemented stems (n=13) 2. Primary cement-free stems (n=29) The average age at the time of primary operation was 63,6 years in the group of cemented stems and 67,2 years with the cement-free implants. METHODS The principle of this operation lies in a stable technique of osteosynthesis. If one operates on a stable stem one uses a one and only technique of osteosynthesis. Patients who also suffer from a loosening of the stem, are treated by replacement of the stem combined with a particular form of osteosynthesis. We generally use a transgluteal access with an L-shaped detachment of the Musc. vastus lateralis. In the group of cemented stems (n=13) we carried out a replacement of the stem 6 times and in the group of cement-free stems (n=29) we had to replace the implant on 7 occasions. Analysing the osteosynthesis technique we find the use of titanium cerclages and titanium elements on 35 occasions, in both groups taken together. As implant for the stem we preferred the modulated revision stem according to Zweymüller. Clinical post-operational examination of our patients was carried out according to the Merle d?Aubigne score and two x-rays at different levels. RESULTS After an average post-operational check-up time of 3 years and 2 months, we were able to examine 8 patients with cemented stems (61,5 %), 4 of whom had replacement of the stem by a cement-free implant. In the cement-free group we evaluated 24 patients after an average time of 4 years and 11 months. In this group we had 5x a replacement of the stem, 3x of these we could operate cement-free. The post-operational radiological check showed an excellent building-up of bone structure without any dislocation of the implant in all 32 cases. DISCUSSION The average age of our patients shows 77 years with those with cemented stems and 74,5 years in the ones with cement-free implants. Analysis of the cemented stems shows a loosening rate of more than 50 %, which coincides with the findings of many other authors. After a couple of years using cups of polyaethylene we were confronted with the problem of the so-called Polyaethylene disease. These alterations may finally lead to a loss of bone quality, to mechanical loosening of the implant and an increase in danger of fracture. When we discuss the group of patients with cement-free stems and compare them to those with cemented ones, we find a number of quite different characteristics. B2 fractures appear in a quite higher number of patients with cemented and loosened stems. In this regard, our own study is congruent with the studies of other authors. In the cement-free group we had 75 % B1 fractures with a stable stem. The explanation for these figures is, that the cement-free implants were well incorporated in the bone structure. CONCLUSIONS The choice of operative procedure when treating periprosthetic hip fractures depends on the type of fracture and the stability of the prosthesis. Our own very positive experiences and the then emerging results lead to a certain strategy in procedure. That means, for us, the use of a cement-free modulated revision stem according to Zweymüller combined with a particular technique of osteosynthesis, using titanium cerclages and titanium elements.

• MeSH
• cementování MeSH
• fraktury kyčle chirurgie   MeSH
• kyčelní protézy MeSH
• lidé středního věku MeSH
• lidé MeSH
• náhrada kyčelního kloubu MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• vnitřní fixace fraktury metody   MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH