双膦酸盐相关性非典型股骨骨折临床诊疗进展  

Research advances on atypical femoral fractures related to Bisphosphonates

作　　者：臧加成[1] 马信龙[1] Zang Jiacheng;Ma Xinlong(Department of Orthopaedics,Tianjin Hospital,Tianjin 300211,China)

机构地区：[1]天津市天津医院骨科,300211

出　　处：《中华骨科杂志》2018年第15期943-952,共10页Chinese Journal of Orthopaedics

摘　　要：双膦酸盐已成为临床治疗骨质疏松的一线药物,其通过抑制破骨细胞活性和增加骨密度来降低脆性骨折风险.双膦酸盐治疗骨质疏松的同时,会伴随一些不良反应的发生,其中双膦酸盐相关性非典型股骨骨折（atypical femoral fractures,AFF）逐渐被关注和认识.AFF具有典型的临床特征,患者多有长期双膦酸盐服用史,无创伤或低能量创伤或扭转造成的股骨转子下或股骨干骨折.AFF的X线表现为横行或短斜形骨折,内侧皮质呈“尖峰”状,骨折区域骨皮质因出现局部或弥漫性骨膜反应而表现为骨皮质增厚.AFF的病理机制尚不明确,大多认为与长期服用双膦酸盐而严重抑制骨转换有关,其他的学说包括：胶原异常与交联增加学说、矿物质异常学说、低磷酸酯酶症综合征样表现学说等.尽管AFF绝对发病率很低,但随着老龄化骨质疏松患者数量的激增和双膦酸盐应用的社会广泛化,AFF数量必然会随之增多,须引起临床的重视.AFF风险因素包括：双膦酸盐长期服用史,糖皮质激素治疗史,女性,在骨折发生前数月或数周出现大腿或腹股沟处疼痛、不适、无力等前驱症状;另外,股骨干的弯曲程度与AFF骨折部位具有相关性.目前,治疗AFF的观点是：①完全骨折,行股骨全长、扩髓髓内钉固定;②不全骨折,同样也考虑行预防性髓内钉固定治疗.AFF骨折愈合时间明显增长,治疗后最常见的并发症是延迟愈合和不愈合,延迟愈合发生率可高达26％,临床如何提高此类骨折的疗效尚需要进一步研究.通过检索AFF的相关文献,全面了解其临床特点、诊断标准、发病率、相关风险因素、病理机制、治疗方法及并发症发生的最新研究进展. Bisphosphonates have become the first-line drugs for the treatment of osteoporosis,which can reduce the risk of brittle fracture by inhibiting osteoclast activity and increasing bone density.Bisphosphonates bring benefits to osteoporosis patients,while some side effects can occur.In recent years,bisphosphonate related femoral atypical fractures （AFF） have been gradually recognized and become the focus of researches.AFF has typical clinical features and X-ray findings：Patients with long-term usage of bisphosphonate drug.AFF were defined as atraumatic or low-trauma fractures located in the subtrochanteric region or femoral shaft.X-ray showed transverse or short oblique fracture of the medial cortex which shaped like a ＂spike＂,and the bone cortex at the fracture area becomes thicker because of localized or diffuse periosteal reaction.AFF pathological mechanism is not clear,mainly with long-term use of bisphosphonates which seriously inhibit bone turnover,other theories including the theory of syndrome like collagen abnormal theory,mineral abnormal theory,hypophosphatasia,precise pathological mechanism still needs further study.Although the absolute incidence of AFF is very low,the number of AFF will inevitably increase with the increasing number of aging osteoporosis patients and the widespread application of bisphosphonates,which should be paid more attention to.AFF risk factors included long-term usage history of bisphosphonate,glucocorticoid treatment history,female patients,fracture prodromal symptoms including pain,discomfort or weakness in the thighs or groin and the bowing of the femoral shaft was associated with the location of AFF fracture.At present,the point of view of AFF treatment is：complete fracture of femoral length,reamed intramedullary nail fixation.Even for incomplete fractures,preventive intramedullary nailing should also be considered.The healing time of AFF fracture increases obviously.The most common complications are delayed union and nonunion.The rate of delayed union can b

关 键 词：股骨骨折 双膦酸盐 临床诊疗 相关性 非典型 扩髓髓内钉固定 患者数量 股骨干骨折 

分 类 号：R687.3[医药卫生—骨科学]