钽金属大杯重建严重髋臼骨缺损的早期临床疗效观察

目的评估在全髋关节翻修术中应用钽金属Jumbo杯重建严重Gross型髋臼骨缺损的早期临床疗效。 方法回顾性分析了从2012年10月至2016年5月在山西医科大学第二医院关节外科使用钽金属Jumbo杯实施髋关节翻修手术患者17例。男6例,女11例,年龄49～78岁,平均(68± 7)岁。纳入标准：单侧初次翻修(对侧髋关节正常);翻修原因均为无菌性松动;Gross Ⅲ型和Gross Ⅳ型使用Jumbo杯翻修。排除标准：缺血性骨坏死;假体与宿主骨接触面积<30%;任何原因导致的失访。观察其髋关节Harris评分、髋臼外展角变化、髋臼旋转中心(水平及垂直方向位移)变化等情况及并发症,使用SPSS 22.0统计学软件包对手术前后计量指标进行配对t检验。 结果所有患者均获得随访,随访时间(29±14)个月。没有出现假体松动,感染等并发症,只有1例患者于术后5 d后脱位,腰麻下闭合复位,术后皮肤牵引4周,至末次随访未发生脱位。术前Harris评分(32.8±4.8)分,末次随访时(87.1±4.7)分,差异有统计学意义(t＝62.46,P<0.05)。髋臼外展角和位移变化分别小于4°和4 mm,患侧髋臼中心(垂直距离和水平距离),末次随访时和术前相比,差异有统计学意义(t＝10.95,P<0.05;t＝5.53,P<0.05)。末次随访时健患侧髋臼旋转中心位置相比,差异无统计学意义(t＝1.78,P>0.05;t＝0.44,P>0.05)。术后髋臼旋转中心相比术前得到明显改变,与健侧相比差异不明显,基本重建了正常的髋臼旋转中心。 结论钽金属Jumbo杯增加与宿主骨接触面积,假体植入技术简单,减少植骨量,最大限度恢复旋转中心,臼杯骨长入快,可以取得显著的早期临床疗效。     

髋关节翻修术中3D打印金属骨小梁垫块重建髋臼的近期疗效

目的探讨髋关节翻修术中采用3D打印金属骨小梁垫块修复PaproskyⅢ型髋臼骨缺损、重建髋臼的近期疗效。方法 2014年8月—2015年12月,于5例初次髋关节翻修术中采用3D打印金属骨小梁垫块修复PaproskyⅢ型髋臼骨缺损、重建髋臼环形结构。男3例,女2例;年龄50～72岁,平均66岁。初次置换至翻修术时间为10～18年,平均14.4年。初次置换假体类型:非骨水泥型3例,骨水泥型2例。髋臼骨缺损分型:PaproskyⅢA型3例、ⅢB型2例。术前Harris评分为(34.23±11.67)分。患髋旋转中心高度为(38.17±8.87)mm、水平位置为(35.62±9.12)mm。结果手术时间120～180 min,平均142 min;术中出血量800～1 700 mL,平均1 100 mL。5例患者均获随访,随访时间18～24个月,平均21个月。末次随访时,髋关节Harris评分为(79.82±8.70)分,较术前明显提高(t=16.991,P=0.000)。术后1周X线片测量髋臼杯外展角为38～42°,平均39.4°;前倾角为13～18°,平均14.6°。患侧髋关节旋转中心高度为(22.08±8.33)mm、水平位置为(29.03±6.28)mm,与术前比较差异均有统计学意义(P0.05);与健侧髋关节(28.62±7.73)、(27.29±4.22)mm比较,差异均无统计学意义(P0.05)。随访期间均无假体松动、脱位及假体周围骨折等并发症发生。结论髋关节翻修术中应用3D打印金属骨小梁垫块修复PaproskyⅢ型髋臼骨缺损,可重建髋臼环形结构,为髋臼杯提供稳定支撑结构,重建相对正常的髋关节旋转中心,避免医源性骨量丢失,髋关节功能恢复满意,远期疗效有待进一步随访。     

髋臼内壁内移截骨全髋置换治疗髋关节发育不良髋关节旋转中心重建的病例对比分析

目的通过临床病例的对比分析研究,探讨髋关节发育不良的患者行全髋置换时,髋臼内壁内移截骨术和传统术式在恢复髋关节旋转中心方面的作用。方法将笔者行传统全髋置换术治疗的髋关节发育不良11例(传统术式组),与文献报道张洪行髋臼内壁内移截骨全髋置换17例(髋臼内壁内移截骨组)进行对比,通过在骨盆正位X线片上绘制Ranawat三角获得髋关节理想旋转中心,测量手术前、后实际股骨头旋转中心距理想旋转中心的水平和垂直距离,探讨两种术式在全髋置换髋臼重建时恢复髋关节旋转中心方面的作用。结果传统术式组术前水平距离为8～58mm,平均25.92mm,术后为6～34mm,平均16.46mm,手术前后比较有统计学差异(t=3.802,P0.01);术前垂直距离为4～38mm,平均20mm,术后为2～36mm,平均18.46mm,手术前后比较有统计学差异(t=2.589,P0.05)。两组手术前后水平距离差值的平均值分别为17.36mm、8.81mm,髋臼内壁内移截骨组大于传统术式组,有统计学差异(t=2.56,P0.05);两组手术前后垂直距离差值的平均值分别为10.41mm、3.47mm,髋臼内壁内移截骨组大于传统术式组,有统计学差异(t=2.27,P0.05)。结论传统术式有恢复髋关节旋转中心的作用;在恢复髋关节旋转中心作用上,髋臼内壁内移截骨术优于传统术式。     

全髋关节置换假体位置对术后关节功能的影响观察

目的探讨全髋关节置换(total hip arthroplasty,THA)术后假体位置参数对关节功能恢复的影响。方法回顾性分析2008年6月至2014年6月在我院行THA治疗的246例患者的临床资料。测量假体位置参数,包括:髋臼外展角、前倾角、髋臼旋转中心及股骨偏心距。观察随访3年时Harris评分情况。采用等距分组法将假体位置参数进行分组,对比不同组间Harris评分及优良率。结果 THA术后脱位率为1.22%(3/246);髋臼外展角重建在35°~55°者185例,占75.2%;髋臼前倾角重建在5°~25°者174例,占70.7%;术侧髋臼旋转中心位置及偏心距与健侧比较差异具有统计学意义(P0.05)。平均随访时间为(18.32±6.57)个月,末次随访时的平均Harris评分为(90.76±8.45)分,优良率为88.6%(218/246)。髋臼前倾角和髋臼旋转中心水平位置不同组间的Harris评分及优良率比较差异无统计学意义(P0.05);髋臼外展角、髋臼旋转中心垂直位置及股骨偏心距不同组间的Hariis评分比较差异具有统计学意义(P0.05),但优良率比较差异无统计学意义(P0.05)。结论 THA手术髋臼外展角重建不宜大于55°;髋臼旋转中心垂直位置重建向上不宜大于健侧50%;股骨头偏心距重建增大不宜大于健侧20%,超过以上范围,术后髋关节功能恢复会受到影响;而髋臼外展角重建小于35°和股骨头偏心距缩小大于健侧20%有可能会影响关节功能恢复。     

自体骨植骨技术结合金属网杯重建髋臼骨缺损在全髋关节翻修术中的应用及效果分析

目的 探讨自体骨植骨技术结合金属网杯重建髋臼骨缺损在全髋关节翻修术中的应用及其效果. 方法 以因严重髋臼骨缺损、需要行全髋关节翻修术的15例患者为研究对象,均取自体同侧髂骨修复髋臼骨缺损,并以金属网杯重建髋臼.观察患者的手术情况,至少随访1年观察术后各时点的临床表现、髋关节Harris评分和X线片特征. 结果 全部患者均顺利完成手术,切口均Ⅰ期愈合;术后住院期间未发生感染、出血及假体松动和移植失败等并发症.平均随访（1.3±0.1）年,功能恢复良好;术后即刻、术后6个月、术后1年各时间点的髋臼假体的倾斜角、假体股骨头中心水平和垂直距离比较,差异均无统计学意义（F=0.23～0.96,P＞0.05）.未出现髋臼侧假体松动的情况;术前、术后6个月及术后1年时的髋关节Harris评分分别为（40.5±6.5）分、（65.2±5.0）分、（91.0±3.7）分,相邻时间段Harris评分比较,差异均具有统计学意义（t6=9.61,t12=7.90,P＜0.01）. 结论 自体骨植骨技术结合金属网杯重建髋臼缺损可能是全髋关节翻修术的一种较好方法,术后患者骨缺损修复和固定效果确切,功能恢复满意,对全髋关节翻修具有一定的指导借鉴意义.     

全髋置换治疗CroweⅡ/Ⅲ型髋关节发育不良的髋臼解剖重建方法及疗效

目的探讨在全髋关节置换术治疗Crowe Ⅱ/Ⅲ型成人髋关节发育不良(DDH)继发骨关节炎(OA)中髋臼侧解剖重建及髋臼假体外上方骨缺损的处理方法与疗效。 方法回顾性分析2012年1月至2016年12月期间,在南通大学附属建湖医院骨科进行人工全髋关节置换术治疗的38例。病例纳入标准为Crowe Ⅱ/Ⅲ型成人DDH继发终末期骨关节炎,髋关节疼痛影响正常行走功能;排除标准为患髋有感染史、骨折史、手术史,以及患肢合并其他疾病。术前、术后对术侧髋关节进行Harris髋关节评分(HHS),测量比较术前术后髋关节旋转中心的垂直与水平距离。HHS评分、手术前后髋关节旋转中心的水平距离及垂直距离的比较采用配对样本t检验。 结果所有患者均未发生血管、神经损伤、感染及假体松动,术前患肢平均短缩(2.6±0.7)cm,术后下肢平均延长(2.5±0.4) cm, HHS术前为(37±8)分(25～55分),术后末次随访(93±4)分(89～100分),术后HHS较术前明显增高,差异有统计学意义(t＝39.45,P<0.05),优良率为100%。手术前后骨盆正位X线摄片髋关节旋转中心对比：髋关节旋转中心垂直距离术前(36.7±6.1)mm,术后(13±4)mm,手术前后相比差异有统计学意义(t＝4.28,P<0.05)。髋关节旋转中心水平距离术前(41±7)mm,术后(23±5)mm,手术前后相比差异有统计学意义(t＝4.13,P<0.05)。 结论全髋关节置换术治疗Crowe Ⅱ/Ⅲ型成人DDH时,髋臼侧解剖重建,髋臼假体外上方骨缺损处骨泥植骨,可取得良好的手术效果。     

3D打印钛合金骨小梁金属臼杯联合植骨重建髋臼骨缺损的早期疗效

目的探讨髋关节翻修术中应用3D打印定制钛合金骨小梁金属(titanium trabecular metal,TTM)臼杯联合植骨重建髋臼骨缺损的早期疗效。方法回顾性分析2017年2月至2018年8月南京医科大学附属无锡人民医院使用3D打印TTM臼杯联合植骨治疗全髋置换术后骨缺损患者8例。其中男3例,女5例;年龄64～87岁,平均年龄(78.1±7.0)岁。Paprosky髋臼骨缺损ⅡB型2例,ⅡC型1例,ⅢA型3例,ⅢB型2例。采用3D打印技术,根据髋臼骨缺损形态设计并制作TTM臼杯,结合植骨技术,重建髋臼骨缺损。随访时以Harris髋关节评分评估疗效,摄X线片评价假体位置、稳定性和植骨愈合情况。结果随访18～36个月,平均(25.0±6.1)个月。Harris髋关节评分从术前(36.3±8.5)分提高至末次随访时的(82.8±6.3)分。术后髋关节旋转中心基本位于解剖位置,翻修侧髋关节旋转中心垂直距离与健侧相差(0.5±2.7)mm,水平距离与健侧相差(-2.0±6.1)mm。末次随访假体位置良好,随访期间假体周围未见进行性透亮线,无假体松动、移位及螺钉断裂,植骨愈合良好,无再次翻修病例。结论应用3D打印TTM臼杯联合植骨进行髋关节翻修重建髋臼骨缺损,可恢复髋关节旋转中心,改善髋关节功能,假体初始稳定性好,近期疗效满意。     

CroweⅡ/Ⅲ型髋关节发育不良继发重度骨关节炎髋臼解剖旋转中心重建方法及效果

目的探讨在全髋关节置换术治疗CroweⅡ/Ⅲ型髋关节发育不良(DDH)继发重度骨关节炎(OA)中准确去除髋臼骨赘及重建人工髋臼解剖旋转中心的方法与效果。方法回顾性分析2011年6月至2013年6月,上海交通大学第九人民医院骨科应用人工全髋关节置换术治疗的31例(36髋)CroweⅡ/Ⅲ型DDH继发重度OA炎患者。病例纳入标准:CroweⅡ/Ⅲ型成人DDH继发终末期OA(TonnisⅣ型),髋关节疼痛影响正常生活方式或工作;排除标准:患侧髋关节有感染史、骨折史及手术史,下肢有感觉障碍及肌力异常。CroweⅡ型25髋,CroweⅢ型11髋。术前应用平片、CT等影像学方法评估髋臼形态及髋臼缘骨赘部位与骨赘量,术中以坐骨结节作为真实髋臼后壁高度的参考标志,准确切除髋臼后缘增生骨赘,以卵圆窝为参考标志确定真臼位置及深度重建臼杯,最后以臼杯前缘为标志切除髋臼前缘残留骨赘。所有患者均应用生物型臼杯,臼杯直径为44~52 mm。术前、术后对术侧髋关节进行Harris髋关节评分(HHS),术后测量假体旋转中心的垂直与水平距离及外展角。SPSS 13.0统计学软件包处理数据,计量资料应用t检验,以P0.05为差异有统计学意义。结果所有患者均未发生血管、神经损伤及髋臼骨折,旋转中心垂直距离、水平距离分别为(22.5±3.2)mm及(29.4±2.6)mm,与解剖旋转中心符合率为86.11%,外展角为(44.3±3.2)°。随访期间未发生髋关节脱位、假体松动、感染等并发症。Harris髋关节评分(HHS)由术前(38±9)分(25~55分)升至术后末次随访(94±3)分(89~100分),差异有统计学意义(t=35.95,P0.05)。结论CroweⅡ/Ⅲ型DDH继发重度OA的髋臼形态发生明显改变,术前应用CT充分评估髋臼形态,术中准确切除骨赘,以卵圆窝为参考标志重建髋臼旋转中心接近解剖旋转中心,可达到满意的临床效果。     

髋臼内壁截骨术在发育不良髋关节全髋置换髋臼重建中的应用

目的探讨髋臼内壁截骨术在发育不良髋关节髋臼重建中的应用。方法2001年5月至2002年12月,采用结合髋臼内壁截骨术的全髋关节置换术治疗髋关节发育不良患者17例18髋,男1例1髋,女16例17髋,年龄35～70岁,平均51.4岁。其中CroweⅠ期4髋,Ⅱ期7髋,Ⅲ期4髋,Ⅳ期3髋。通过在手术前、后X线片上绘制Ranawat三角,对照手术前、后髋关节旋转中心与理想旋转中心的距离,测量术后臼杯穹顶与Kohler线的距离、臼杯直径等研究髋关节旋转中心重建与臼杯固定的效果。结果所有人工臼杯均安置于真臼位置,臼杯直径44～56mm,平均50.78mm。术前股骨头中心距理想旋转中心水平距离为12～40mm,平均21.09mm;术后股骨头中心距理想旋转中心水平距离为-3～10.1mm,平均3.73mm;手术前、后比较差异有统计学意义(t=7.95,P<0.01)。术前股骨头中心距理想旋转中心垂直距离为5～32mm,平均15.39mm;术后股骨头中心距理想旋转中心垂直距离为-18～26.3m m,平均4.98mm;手术前、后比较差异有统计学意义(t=3.42,P<0.01)。随访3个月以上者,截骨部位均骨性愈合。结论内壁截骨术有助于将发育不良髋关节的髋臼安置于真臼位置,保留髋臼底部的骨量,避免髋臼外上方植骨的并发症。     

全髋关节置换术治疗髋关节发育不良

目的探讨髋关节发育不良的全髋关节置换术的手术要点和术后疗效。方法25例(28髋)根据CroweX线分型,Ⅰ型14例,Ⅱ型7例,Ⅲ型和Ⅳ型各2例。髋臼旋转中心的重建方法包括标准的全髋关节置换术、结构性自体植骨和髋臼旋转中心内移。恢复下肢长度的方法包括术中彻底切除挛缩的关节囊和纤维瘢痕组织并酌情进行软组织松解。随访内容包括:①Harris评分;②X线测量双下肢长度差和髋臼旋转中心位置。结果所有病例平均随访28.5个月,Harris评分由术前的平均43分(18~72分)升高至91分(79~100分)。所有病例髋臼旋转中心都恢复正常。术前双下肢长度差为0.5~5.5cm,术后双下肢长度差为-0.4~0.9cm。结论髋关节发育不良的全髋关节置换术中,除了标准的髋臼重建方法之外,结构性植骨和髋臼旋转中心内移可有效恢复髋臼旋转中心的高度。术前详细的计划,术中彻底切除挛缩的关节囊和纤维瘢痕组织并酌情进行软组织松解有助于恢复下肢长度。     

Reconstruction of the rotation center of the hip after oblong cups in revision total hip arthroplasty

Background

The preoperative bone defect and the reconstruction of the center of rotation of the hip are critical in acetabular revision surgery. Uncemented oblong cups are employed in order to manage these issues. We analyzed the clinical results and rates of revision of two different uncemented oblong cups, the reconstruction of the center of rotation of the hip, as well as the rate of radiological loosening and possible risk factors.

Materials and methods

Forty-five patients (46 hips) underwent acetabular revision surgery using two different uncemented oblong cups. We assessed the clinical results and the survival rate for revision and aseptic loosening. Intraoperative bone loss was classified according to Paprosky, and acetabular reconstruction was assessed according to Ranawat. The mean follow-up was 7.2 years (range 4–11 years).

Results

There were four re-revisions (three due to aseptic loosening); the survival rate for re-revision due to aseptic loosening was 60.1 % at seven years. The mean distance between the center of the femoral head prosthesis and the approximate center of the femoral head improved from 21.5 to 10.2 mm. Thirteen cups showed radiological loosening; the survival rate for radiological loosening at seven years was 40.54 %. A smaller postoperative horizontal distance was correlated with cup loosening.

Conclusions

Although optimal acetabular reconstruction can be achieved by using oblong uncemented cups in revision hip surgery, the clinical and radiological results are not encouraging. Excessive medialization of the cup may increase the rate of loosening.     

人工髋关节翻修旋转中心重建的临床研究

目的 探讨在人工髋关节翻修手术中,根据Harris窝及髋臼切迹的残存解剖标记,定位髋臼中心点,正确安装髋臼假体和重建髋关节旋转中心的可行性.方法 2007年4月至2009年6月,行28例髋关节翻修术.依据Paprosky分型:Ⅰ型3例,采用生物固定型髋臼假体;ⅡA和ⅡB型8例,采用打压颗粒骨植骨和大直径骨水泥型髋臼假体固定;ⅡC、ⅢA和ⅢB型17例,采用打压颗粒骨植骨和髋臼加强杯固定,其中5例有髋臼内壁穿透者采用结构性和颗粒性植骨.手术中在髋臼切迹连线的垂直平分线上方25～28mm、Harris窝窝内头侧接近原月状软骨面处,定位为原髋臼中心点,以该点为同心圆的圆心安装髋臼杯假体(Ⅰ型)或打压植骨造臼,按照俯倾角40°～45°、前倾角15°～20°安放髋臼加强杯(Ⅱ、Ⅲ型).手术前后摄双侧髋关节正位X线片,测量髋关节旋转中心至两侧泪滴连线的垂直距离和至泪滴的水平距离.分别与术前和健侧比较,评价髋关节旋转中心的重建效果.结果 髋关节旋转中心至两侧泪滴连线的垂直距离:术前为(32.64±4.51)mm,术后为(14.22±3.39)mm,差异有统计学意义(t=3.65,P＜0.05).髋关节旋转中心至泪滴的水平距离:术前为(25.13±3.46)mm,术后为(32.87±4.73)mm,差异有统计学意义(t=2.72,P＜0.05).结论 在髋关节翻修手术中,以残存的Harris窝和髋臼切迹为解剖标记,定位髋臼中心点,能够较准确地安装髋臼假体和有效重建髋关节旋转中心.

Abstract：

Objective To discuss the feasibility of positioning the acetabular center,fixing acetabular implant correctly and reconstructing hip rotation center according to Harris fossa and the remaining anatomical markers of acetabular notch in revision hip arthroplasty.Methods Twenty-eight patients underwent revision hip arthroplasty from April 2007 to June 2009.Based on Paprosky type,3 cases with type Ⅰ were treated with biological fixed acetabular component;8 cases with ⅡA and ⅡB were reconstructed with using of morselized bone grafting and large diameter cemented acetabular prosthesis;17 cases with type ⅡC,ⅢA and ⅢB were treated with using of morselized bone grafting and fixation of acetabular reinforcement ring.Among them,5 patients with massive bone loss in acetabular wall were reconstructed with the use of the structural and morselized bone grafting.The center of the original acetabulum was believed to be in the lunate cartilage surface which was closed to Harris fossa.During the operation,the center was located in the site which was 25-28 mm above in line with perpendicular bisector of acetabular notch connecting line.The acetabular center was the point of positioning acetabular prosthesis (Ⅰ type) or making new acetabulum by impaction bone grafting.Acetabular reinforcement ring (Ⅱ,Ⅲ type) was fixed in accordance with proper transverse angle and anteversion angle.The vertical distance from hip rotation center to teardrop connection and the horizontal distance from hip rotation center to teardrop were measured on preoperative and postoperative radiograph.And the outcomes of reconstruction of rotation center were evaluated.Results The vertical distance was changed from (14.22±3.39) mm preoperatively to (32.64±4.51) mm postoperatively.The difference was statistically significant (t=3.65,P＜ 0.05).The horizontal distance was changed from (25.13±3.46)mm preoperatively to (32.87±4.73) mm postoperatively.The difference was statistically significant (t=2.72,P＜0.05).Conclusion Using residual Harris fossa and acetabular notch as the anatomical markers in revision hip arthroplasty,the restoration of the anatomical hip center has shown to be favorable.     

Restoration of the Center of Rotation in Revision Total Hip Arthroplasty

We measured the change of the center of hip rotation after the revision of acetabular loosening using an acetabular reconstruction ring and an impaction allogenic bone grafting. Thirty-five revision total hip arthroplasties were performed. The average follow-up was 3.8 years. Horizontal distance was changed from 34.01 ± 10 mm preoperatively to 41.07 ± 6 mm at the latest follow-up. Vertical distance was changed from 32.06 ± 9 mm preoperatively to 20.21 ± 7 mm at the latest follow-up. The Harris hip score was improved from an average of 47 in the preoperative period to 86 at the final follow-up. The restoration of the anatomical hip center has shown to be favorable in terms of functional and radiologic evaluation in total hip revision.     

同种异体颗粒骨打压植骨联合不同类型假体在严重髋臼骨缺损翻修中的应用

目的探讨对严重髋臼骨缺损患者采用同种异体颗粒骨打压植骨联合骨水泥型或非骨水泥型假体翻修的早中期疗效。方法回顾分析2011年2月-2018年5月采用同种异体颗粒骨打压植骨联合假体翻修治疗的42例(44髋)严重髋臼骨缺损患者临床资料,其中采用骨水泥型臼杯24例(24髋)、非骨水泥型臼杯18例(20髋)。男17例,女25例;年龄22~84岁,平均62.8岁。初次人工全髋关节置换术距该次翻修术时间为2.5~12.0年,平均8.3年。翻修原因:假体无菌性松动31例(32髋),假体周围感染11例(12髋)。按照髋臼骨缺损Paprosky分型标准:ⅢA型28例(29髋),ⅢB型14例(15髋)。术前髋关节Harris评分为(22.25±10.31)分。髋关节旋转中心高度为(3.67±0.63)cm,双下肢长度差值为(3.41±0.64)cm。结果手术时间为130~245 min,平均186 min。术中出血量600~2400 mL,平均840 mL。术后引流量250~1450 mL,平均556 mL。术后1例出现切口浅表感染,其余患者切口均Ⅰ期愈合。患者均获随访,随访时间6~87个月,平均48.6个月。末次随访时Harris评分为(85.85±9.31)分,与术前比较差异有统计学意义(t=18.563,P=0.000)。影像学复查显示同种异体骨与宿主骨逐步融合,未见明显骨吸收。末次随访时,髋关节旋转中心高度为(1.01±0.21)cm,与术前比较差异有统计学意义(t=17.549,P=0.000);双下肢长度差值为(0.62±0.51)cm,与术前比较差异有统计学意义(t=14.211,P=0.000)。与术前相比,末次随访骨水泥组、非骨水泥组Harris评分明显提高,髋关节旋转中心高度下降且均在Ranawat三角内,双下肢长度差值亦减小,差异均有统计学意义(P<0.05);两组髋关节旋转中心高度比较差异有统计学意义(t=2.095,P=0.042),Harris评分及双下肢长度差值比较差异无统计学意义(P>0.05)。结论对于PaproskyⅢ型髋臼骨缺损患者,根据缺损程度选择同种异体颗粒骨打压植骨联合骨水泥型或非骨水泥型假体翻修,均可有效重建髋关节,并获得较好的早中期疗效。     

Die Hakendachschale in der Revision schwieriger gelockerter Hüftprothesenpfannen

The long-term results of acetabular revision after total hip arthroplasty (THA) with the use of a reinforcement ring with hook were evaluated. The study included 57 cases of surgery dating back 10 years or more. Of a total of 54 patients (57 operated hips), 18 patients (19 hips) died during the 10-year period and 2 patients (2 hips) were completely lost to follow-up. At the time of the revision surgery, the mean age of the remaining 34 patients (36 hips) was 62.5 years (range: 47-80). A THA revision was done in 25 cases and an acetabular revision only in 11 cases. The most common acetabular defect was a combined segmental and cavitary defect (n = 19), and in three cases there was pelvic discontinuity. Autologous or homologous cancellous bone grafts were used to fill acetabular cavities in 17 hip joints. Structured bone grafts, predominantly homologous bone, were used in ten cases for acetabular reconstruction. At a mean follow-up of 11.4 years (range: 10-14.5) three hip joints (8%) had undergone further revision. The revisions were done for aseptic loosening of the acetabular component in two cases and a septic loosening of both components in one case. Three further cases (8%) revealed signs of acetabular loosening. Two of these three patients were symptomatic but refused further revision surgery. In the 33 unrevised hip joints, a good or excellent clinical result with a d'Aubingé score of more than 14 points was found in 30 cases (92%). Osseous acetabular reconstruction with the use of a reinforcement ring leads to favorable results compared to other techniques. In the authors' opinion, this technique is preferable to those using oversized cups without osseous reconstruction of the acetabulum.     

Acetabular reconstruction with impaction bone-grafting and a cemented cup in patients younger than fifty years old

BACKGROUND: Acetabular bone deficiency can present a challenge during total hip arthroplasty, especially in young patients. The purpose of the present study was to evaluate the long-term clinical and radiographic outcomes of primary and revision acetabular reconstruction with use of an impaction bone-grafting technique and a cemented polyethylene cup in young patients who had preexisting acetabular bone deficiency. METHODS: Forty-two consecutive acetabular reconstructions were performed in thirty-seven patients who were younger than fifty years old (average, 37.2 years old). The impaction bone-grafting technique was used for twenty-three primary and nineteen revision acetabular reconstructions. Twenty-eight patients (thirty-one hips) were available for review after a minimum duration of follow-up of fifteen years. Clinical and radiographic results were assessed, and survivorship analysis was performed with the Kaplan-Meier method. RESULTS: Eight hips were revised at a mean of twelve years (range, three to twenty-one years) after a primary reconstruction (four hips) or revision reconstruction (four hips). The revision was performed because of aseptic loosening of the acetabular component in four hips and because of culture-proven septic loosening in two. Two additional cups (both in hips that had had a revision reconstruction) were revised, during revision of the femoral stem, because of wear (one hip) or because of persistent intraoperative instability (one hip). Twenty-eight hips (in twenty-five patients) had retention of the acetabular component for a minimum of fifteen years. The mean Harris hip score for that group was 89 points. Twenty-six of these twenty-eight hips had no or slight pain. Kaplan-Meier analysis revealed a twenty-year survival rate of 80% (95% confidence interval, 67% to 94%) with acetabular revision for any reason as the end point and of 91% (95% confidence interval, 80% to 100%) with acetabular revision because of aseptic loosening as the end point. CONCLUSIONS: Acetabular reconstruction with use of impaction bone-grafting and a cemented polyethylene cup is a reliable and durable technique that is associated with good long-term results in young patients with acetabular bone-stock defects.     

High placement of an acetabular component inserted without cement in a revision total hip arthroplasty. Results after a mean of ten years

BACKGROUND: Revision of an acetabular component in a patient who has severe periacetabular bone loss is a complex problem, particularly when there is not enough bone stock to allow placement of an acetabular component near the normal anatomical hip center. A valuable option for revision in such a situation is placement of a hemispherical shell, fixed with screws and without cement, against the superior margin of the acetabular defect. The resulting hip center is more proximal than that seen following a typical primary total hip replacement. METHODS: Forty-six hips in forty-four patients were treated consecutively, between July 1984 and February 1988, with a revision in which a hemispherical acetabular component was fixed with screws and without cement. All shells but one were placed with a so-called line-to-line fit. The procedures resulted in a so-called high hip center--that is, the center of rotation of the revised hip was located at least thirty-five millimeters proximal to the interteardrop line. The mean age of the patients at the time of the index procedure was fifty-two years (range, twenty-five to eighty-one years). The most common diagnosis for which the original arthroplasty was performed was osteoarthritis secondary to congenital hip dysplasia or dislocation (twenty-two hips). Thirty-four hips had had a high hip center before the index revision, and most patients had had a substantial limb-length discrepancy, with a mean of 1.6 centimeters of shortening on the side of the operation. In thirty-three hips, the femoral component was replaced as well, with a long-neck or calcar-replacement stem used when necessary to maintain or increase the length of the limb. RESULTS: Six patients (six hips) died before the minimum eight-year follow-up interval; none had had another revision or loosening of the revised acetabular component. Of the remaining patients, four (four hips) had the implant removed. One of them had a resection arthroplasty and one of them had a hip disarticulation because of infection after a subsequent femoral reoperation. Another had a hip disarticulation because of late infection. The fourth implant was removed because it had displaced into the pelvis at approximately six years; this was the only reoperation for aseptic loosening in the series. The remaining thirty-six hips (thirty-four patients) were followed for a mean of 10.4 years (range, 8.5 to 12.7 years). One acetabular component migrated medially and was scheduled for revision. No other acetabular component was loose or had been revised. The mean Harris hip score was 81 points (range, 56 to 100 points) at the time of the most recent follow-up. Despite the use of a high hip center, the prevalence of a positive Trendelenburg sign was reduced from 98 percent (forty-five of forty-six hips) preoperatively to 44 percent (sixteen of thirty-six hips) at the time of the most recent follow-up. The short limbs were lengthened a mean of seven millimeters (range, five millimeters of shortening to forty millimeters of lengthening). CONCLUSIONS: In this study of acetabular revisions with use of a high hip center in patients who had major periacetabular bone loss, mechanical failure occurred in 4 percent (two) of the forty-six hips in the entire series and in 6 percent (two) of the thirty-six hips in patients who were alive and still had the implant in place after a mean of 10.4 years of follow-up. The use of a high hip center did not adversely affect function of the abductor muscles, and the mean limb-length discrepancy was reduced by the femoral reconstruction.     

Minor column structural acetabular allografts in revision hip arthroplasty

A minor column (shelf) allograft is used for uncontained defects that involve less than 50% of the acetabulum. The prospectively collected records and radiographs of 47 patients (51 hips) who had undergone minor column structural acetabular allograft reconstruction during revision hip arthroplasty were reviewed. The purpose was to identify the long-term results (minimum 5 years) and factors that may influence longevity of the allograft and predispose the patient to subsequent acetabular component failure. The mean duration of followup was 119 months (range, 68-195 months). There was one perioperative death and six patients were lost to followup. Eleven patients (22%) required additional surgery. Three acetabular cups could not be revised successfully, despite multiple attempts, and the patients were treated with Girdlestone excisions. Eight patients underwent successful revision surgery with only three requiring a repeat structural allograft. Survival time for the acetabular cup as determined by Kaplan-Meier analysis was 153 months (95% confidence interval; range, 136-169 months). Cup failure was associated with more operative procedures performed before revision surgery (mean, 3.2 procedures), and failure to restore the vertical center of hip rotation to within 12 to 14 mm of the predicted value. The acetabular abduction angle was not a predictor for failure. The current study shows that good results can be achieved with structural acetabular allograft reconstruction with mid-term to long-term implant survival (cup aseptic survival, 80.4% and allograft re-construction survival, 94.1%), especially if there is restoration of near normal hip biomechanics.     

成人髋关节发育不良不同Crowe分型的三维CT影像学特征

 目的 通过三维CT重建分析成人髋关节发育不良不同Crowe分型之间髋臼形态的演变规律。方法 2010年6月至2013年1月收治成人髋关节发育不良患者62例68髋,男6例8髋,女56例60髋;年龄47~59岁,平均（53.7±5.8）岁。CroweⅠ型14例17髋,Ⅱ型17例17髋,Ⅲ型15例17髋,Ⅳ型16例17髋。行标准髋关节CT扫描及三维重建。在侧位三维图像上标记Harris窝,确定髋臼旋转中心,利用十字坐标轴确定髋臼旋转中心的冠状面和横断面位置;在正位三维图像上利用Ranwant三角确定髋臼旋转中心的矢状面位置;在髋臼水平重建图像上确定髋臼旋转中心。观察髋臼前后缘增生及髋臼前后柱发育不良程度,测量并比较不同Crowe分型患者的髋臼前倾角、前覆盖角、后覆盖角和内壁宽度。结果 随Crowe分型增加,髋臼前倾角逐渐加大,两者呈正相关,除CroweⅠ型和Ⅱ型组间外,其余组间差异有统计学意义;髋臼前覆盖角逐渐减小,两者呈负相关,各组间差异均有统计学意义,CroweⅢ、Ⅳ型组平均值小于50°;髋臼后覆盖角逐渐减小,两者呈负相关,各组间差异均有统计学意义, CroweⅢ、Ⅳ型组平均值小于90° ;髋臼内壁宽度逐渐增加,两者呈正相关,各组间差异均有统计学意义。结论 不同Crowe分型成人髋关节发育不良的髋臼形态变化存在一定的演变规律。对CroweⅠ型和Ⅱ型髋臼的重建可充分利用髋臼前后柱骨量,对CroweⅢ、Ⅳ型髋臼的重建可适度上移和（或）内移髋臼中心。