颗粒打压植骨在髋臼骨缺损人工全髋关节置换术中的应用

目的 观察颗粒打压植骨在髋臼骨缺损人工全髋关节置换术（THA）中的应用效果.方法 随机选取伴有髋臼侧骨缺损拟行THA的患者20例22髋,术中应用颗粒打压植骨为主或结合钛网重建髋臼,恢复骨量;依照骨缺损量的不同,选择生物型或水泥型髋臼假体.结果 患者术后平均随访40个月,Harris评分由术前平均47.1分增至术后的91.6分（P＜0.05）,优良率90.9％;X线检查未见假体松动、下沉等情况,可见移植骨与原髋臼体结合处有连续性骨小梁通过,愈合良好,无感染、脱位等并发症.结论 在伴有髋臼侧骨缺损的THA中,采用颗粒打压植骨可有效重建髋臼,有利于髋关节功能的恢复.     

Delta陶瓷人工假体在全髋关节置换术中的应用效果观察

目的 观察Delta陶瓷人工假体在全髋关节置换术的近期应用效果.方法 对56例(61髋)严重髋关节疾病患者行Delta陶瓷对陶瓷人工假体全髋关节置换术.采用Harris评分标准对髋关节功能进行评定.通过双髋正位X线片,测量髋臼外展角和估算前倾角,观察有无陶瓷碎裂、假体脱位、假体周围透亮线和骨溶解、假体松动、感染及假体周围骨折情况发生.结果 手术时间为55～90 min,术中出血量120～200 mL,术后引流量150～400mL.术后平均随访1年7个月.术后1年,Harris髋关节评分为(89.3±7.9)分,明显高于术前的(40.3±10.5)分(P＜0.01).髋关节功能优37例,良18例,可1例.X线检查示髋臼外展角42.7°±2.6°,前倾角为19.6°±3.5°.随访期间无关节异响发生,未见陶瓷碎裂、假体脱位、骨溶解形成及假体松动、移位和下沉,无感染和假体周围骨折的发生.1例术后6个月时出现髋关节周围异位骨化,关节功能良好.结论 Delta陶瓷人工假体全髋关节置换术治疗严重髋关节疾病的近期疗效满意.     

人工全髋关节置换术假体松动原因的回顾性研究

目的探讨髋关节置换术假体松动失败的原因及机制。方法收集我院2009年8月~2011年8月共15例髋关节置换术后初次失败病例,其中无菌性松动13髋(其中股骨假体柄松动合并髋臼假体松动4例,股骨假体柄松动4例,髋臼假体松动5例),感染性松动2例,全部15例均行翻修术,其中4例行全髋翻修、4例柄侧翻修、5例行髋臼翻修,感染性松动行抗生素骨水泥占位控制感染后二期翻修。结果 13例行翻修术者术后伤口均一期愈合,2例感染患者在感染控制后均行全髋翻修。随访10~36月(平均20.60±7.06月)无松动及感染,在最后一次随访中,本组病例的Harris评分为56~93(平均79.60±11.90)分,其中优4例,良7例,可1例,差3例,优良率为73.3%。结论本组全髋关节置换假体松动发生机理涉及手术技巧、假体类型、髋臼假体位置、股骨截骨长度及外展肌力量。     

老年髋关节置换术后股骨侧假体周围骨折的治疗

目的 探讨老年人工髋关节置换术后发生股骨侧假体周围骨折的治疗。 方法 2005年3月至2011年5月收治的27例75岁及以上的股骨假体周围骨折并行手术治疗的患者,男11例,女16例。股骨假体周围骨折距初次关节置换手术时间为7～83个月,平均63个月;Vanconver分类,A型5例,采用“8”字钢丝捆绑技术;B型19例,选择加长柄技术,锁定钢板技术,环抱器技术;C型3例,采用植骨及钢板固定技术;患者均获得随访9～25个月,平均16个月。采用Harris髋关节功能评分,X线片对治疗结果进行评估。 结果 22例患者骨折愈合;5例患者骨折愈合欠佳,经再次植骨固定,其中3例骨折处愈合,2例能保持假体和肢体结构稳定。14例患者能自由行走;9例需用助行器;4例能在床上自如活动。末次随访Harris评分52～93分,平均76分。 结论老年患者发生股骨假体周围骨折,应根据患者的身体状况,骨折不同类型,以实用可靠为治疗原则。     

老年全髋关节置换术后VancouverB 2、VancouverB 3型股骨假体周围骨折行翻修术治疗的临床疗效

目的探讨老年人工髋关节置换术后VancouverB2、VancouverB3型股骨假体周围骨折行关节翻修手术时的假体选择对临床疗效的影响。方法回顾性分析采用手术治疗的32例髋关节置换术后股骨假体周围骨折的老年患者的临床资料。根据Vancouver分型及股骨峡部皮质骨完整情况采用不同治疗方法:14例VancouverB2型假体周围骨折患者以及2例VancouverB3型假体周围骨折,而且两种类型假体周围骨折16例患者其股骨峡部完整皮质骨均≥4 cm,应用生物型全涂层远端固定长柄假体翻修+钢丝或捆绑带环扎固定;13例VancouverB3型假体周围骨折患者和2例骨缺损虽然不严重但股骨峡部完整皮质骨4 cm的VancouverB2型患者,应用生物型组配式锥柄假体翻修,其中8例同时应用同种异体骨板捆绑固定,1例VancouverB 3型假体周围骨折患者应用骨水泥长柄假体+钢丝或捆绑带环扎固定。随访时记录Harris髋关节评分,通过骨折部位的疼痛情况及X线片来判断骨折是否愈合。结果病例均获得随访,随访时间12～36个月,平均(24.5±0.5)个月。骨折均愈合,愈合时间为6～12个月,平均(8.5±0.5)个月,8例使用异体骨板的患者中,均与宿主骨发生骨性愈合。Harris髋关节评分由术前(4.0±1.2)分提高至末次随访的(78.6±16.4)分,差异有统计学意义(t=2.82,P=0.018)。并发症:双下肢不等长2例;下肢深静脉血栓2例,并发症发生率12.5%(4/32)。随访期间未出现大腿疼痛、假体周围感染、无菌性松动及再骨折病例。结论根据Vancouver分型,综合考量股骨峡部骨质条件,对于股骨峡部完整皮质骨4cm的假体周围骨折老年患者,应用生物型组配式假体柄可以取得良好的早中期临床疗效;而对于股骨峡部完整皮质骨≥4 cm的假体周围骨折老年患者,在行翻修手术治疗时,应用一体化全涂层远端固定长柄假体甚至骨水泥假体,术中操作简单、省时,在减少术后并发症方面,较生物型组配式锥柄更具有实际应用性。     

股骨开窗在人工髋关节翻修术中的应用

目的探讨股骨开窗用于人工髋关节翻修术中的效果。方法对15例行人工髋关节翻修术患者术中于股骨前外侧假体柄尖端开窗,经骨窗直视下取出远端塞及残留骨水泥,引导髓腔锉位于髓腔中央位置,选用非水泥长柄假体应超过开窗处至少股骨直径2倍。开窗处取下骨块回植。术后6周内部分负重。记录手术时间、出血量,术后复查X线观察骨窗愈合情况、假体位置,采用Harris评分评价髋关节功能,观察并发症发生情况。结果本组手术时间115-235 min;出血量400-1 500 ml;术中无骨折、穿凿发生,术后未发生感染。随访时间24-35个月,X线片示无假体松动、脱位、下沉,骨窗平均愈合时间3.4个月;Harris评分由术前平均42.8分提高至80.2分。结论股骨开窗应用于人工髋关节翻修术疗效确切,并可降低术中骨折、穿凿发生率,缩短手术时间。     

全髋关节置换术中非水泥锥形股骨柄假体临床应用研究

目的 探讨非骨水泥锥形股骨柄在全髋关节置换术中的临床效果和意义.方法 回顾性分析48例(56髋)于我科行人工全髋关节置换术患者的临床资料,所有患者采用侧后方入路,手术股骨侧均采用同一种非水泥锥形股骨柄假体,术后平均随访15个月.结果 术前Harris评分平均56分,术后最后一次随访时Harris评分92分,有2例发生大腿痛,所有病例未发现不稳定征象,无翻修病例.结论 非水泥锥形股骨柄假体有着可靠的远期固定疗效和优异的临床效果.     

3D打印钛合金骨小梁金属臼杯治疗老年初次全髋关节置换术的疗效

目的探讨3D打印钛合金骨小梁金属臼杯在老年初次全髋关节置换术中的疗效。方法前瞻性选取西藏民族大学医学部临床医学院需行初次全髋关节置换术的老年患者27例,根据受试者个人意愿分为研究组(3D打印钛合金骨小梁金属臼杯)12例和对照组(经典Pinnacle臼杯)15例。分别与术后1 w、3个月、6个月进行门诊随访,进行髋关节功能(Harris)、骨性关节炎(WOMAC)指数,健康调查量表(SF-36)评分;同时进行影像学评估,使用DeLee和Charnley分区法检测髋臼假体位置;Anderson骨长入影像学评价标准对骨长入进行评估。结果术后6个月两组Harris评分、SF-36评分均显著高于术前,WOMAC指数显著低于术前(P<0.05);术后6个月研究组Harris评分、SF-36评分显著高于对照组,WOMAC指数显著低于对照组(P<0.05)。术后研究组臼杯未出现外展角变化和移位,10例术后1 w 3D打印钛合金骨小梁金属臼杯与骨面接触紧密且无透亮线,2例臼杯植入后1 w时可见透亮线,术后6个月时透亮线消失,随访期间未出现新的透亮带;术后随访期间1区无骨质增生,2区无应力遮挡,两个区均无髋臼表面辐射状排列的骨小梁,4例术后6个月3区出现骨质增强。对照组臼杯与关节面接触紧密,随访期间未出现透亮线,其中4例2区存在应力遮挡,均未出现骨质增强。结论老年初次全髋关节置换术中采用3D打印钛合金骨小梁金属臼杯的稳定性好,早期骨长入优于传统材料,短中期预后效果较佳,但长期效果仍需进一步研究。     

全髋关节置换术治疗髋关节发育不良继发骨性关节炎32例疗效观察

目的观察人工全髋关节置换术（THR）治疗髋关节发育不良（DDH）继发骨性关节炎（OAH）的临床疗效。方法对32例DDH继发OAH患者行THR,重建髋臼和股骨近端的解剖结构,正确安装假体。X线观察假体位置,并观察伤口愈合情况、疼痛缓解情况、关节活动度、跛行情况;采用Harris评分评价髋关节功能。结果X线示假体位置正常;伤口均一期愈合,无感染、血管神经损伤和脱位;疼痛基本缓解,关节活动度满意,跛行基本消失。Harris评分由术前平均46.415分提高至84.425分。结论THR治疗DDH继发OAH疗效确切,值得临床借鉴。     

锁定加压钢板结合异体皮质骨板治疗股骨假体周围骨折

目的探讨锁定加压钢板结合异体皮质骨板在治疗股骨假体周围骨折中的临床效果。方法对15例髋关节置换、股骨假体周围骨折患者行锁定钢板结合前侧异体皮质骨板钢丝捆绑固定治疗,术后Harris评分进行术后效果评价。结果所有患者均获随访,术后Harris评分90分,术后骨折全部愈合,骨折愈合时间12—24周、平均16周,股骨柄假体经X线检查无松动。结论锁定钢板结合异体皮质骨板治疗股骨假体周围骨折能够达到机械稳定性和生物稳定性有机结合,能够提高骨折愈合率,是治疗假体周围骨折有效手段。     

Measurements of bone mass and bone density

X-ray-based procedures are available to measure bone mineral density in vitro at almost any skeletal site. These bone density measurements are not useful in the diagnosis of the cause of bone loss but at present are the only tests available for assessing bone mass prior to the occurrence of irreversible changes such as fractures or vertebral compression, which are easily recognizable on x-rays. When fractures are present, the severity of the bone loss and the risk for future fractures can be assessed. Repeated measurements permit estimation of the rate of bone loss, which gives useful information for monitoring treatment effect or course of the disease. Measurement of total body calcium is of less clinical importance because of the predominantly trabecular bone loss that generally occurs in metabolic bone disease. Dual-energy x-ray absorptiometry (DEXA) and quantitative computed tomography (QCT) of the spine are of about equal clinical value in the first approach to the patient with metabolic bone disease, although DEXA allows greater variety in sampling sites. For repeated measurements, DEXA provides better precision at significantly lower radiation burden. For bone mineral measurements, the lumbar spine appears to be the most sensitive skeletal site.     

Histomorphometric analysis of bone in metabolic bone disease

Most of the tools necessary for a detailed study of bone remodeling are now available. These methods will enable us to substitute simple surface-based histomorphometry with pertinent derived variables that reveal more information about the processes going on. Because of the inherent variability of the methods, bone histomorphometry is less well suited for investigations in single individuals. However, in terms of basic investigations of cell and tissue activity in grouped materials of patients with metabolic bone disease and the evaluation of treatment regimens in these materials, bone histomorphometric investigations still yield the most detailed analyses.     

Metabolic bone disease and bone quality

On the progress of study concerned with pathology of metabolic bone disease such as osteoporosis, it has been known that most of bone strength can be explained by bone volume. As bone volume can be determine by bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA), it has been widely used for diagnosis of osteoporosis or efficacy of treatment. However, with the advance of bone morphometry, decrease of bone strength or existence of insufficiency fracture is influenced by not only loss of BMD but also deterioration of bone quality especially bone microstructure. In this chapter, we will give an outline of change of bone quality in metabolic bone disease.     

Recovery of bone mass and normalization of bone turnover in long-term survivors of allogeneic bone marrow transplantation

Osteoporotic fractures are potential long-term complications of bone marrow transplantation (BMT). We previously reported that bone mineral density (BMD) of patients undergoing allogeneic BMT decreased by 6% to 9% during the first 6 months after BMT and that bone turnover rate was still increased 1 year after BMT. BMT patients do not need lifelong immunosuppressive treatment, which should offer favorable circumstances for the recovery of BMD. Thus, 27 (14 women, 13 men) of 29 long-term survivors of our previous study were invited to a follow-up study at a median of 75 months after BMT. From 12 months after BMT the BMD of the lumbar spine had increased by 2.4% (P = 0.002). The respective changes in femoral sites were +4.1% in the femoral neck (P = 0.087), 4.0% in the trochanter (P = 0.095), +4.7% in Ward's triangle (P = 0.072) and +1.4% in the total hip (P = 0.23). The markers of bone formation, serum osteocalcin and type I procollagen aminoterminal propeptide (PINP) had returned to control levels, but out of the markers of bone resorption the mean level of serum type I carboxyterminal telopeptide (ICTP) was 41% higher (P = 0.0001) and that of urinary type I collagen N-terminal telopeptide/creatinine (NTx) 41% lower (P = 0.0002) in patients than in controls. The mean serum 25-hydroxyvitamin D [25(OH)D] was 33% lower in patients (P = 0.0002), most of whom had hypovitaminosis D [serum 25(OH)D < or = 37 nmol/l]. Except for two, males had serum testosterone level lower than before BMT and four men had hypogonadism. In conclusion, in long-term survivors of allogeneic BMT BMD recovers and bone turnover state normalizes as compared to the situation 1 year after BMT. More attention should be paid to the vitamin D status of all recipients and to possible hypogonadism of male patients.     

Histologic diagnosis of metabolic bone diseases: bone histomorphometry

Histomorphometry or quantitative histology is the analysis on histologic sections of bone resorption parameters, formation and structure. It is the only technique that allows a dynamic evaluation of the activity of bone modelling after labelling with tetracycline. Moreover, the new measurement procedures through the use of the computer allow an assessment of bone microarchitecture too. Histomorphometric bone biopsy is a reliable and well-tolerated procedure. Complications are reported only in 1% of the subjects (hematoma, pain, transient neuralgia). Histomorphometry is used to exclude or confirm the diagnosis of osteomalacia. It is employed in the evaluation of bone damage associated with particular treatments (for example, anticonvulsants) or in case of rare bone diseases (osteogenesis imperfecta, systemic mastocytosis). It is also an essential approach when clinical, biochemical and other diagnostic data are not consistent. Finally, it is a useful method to understand the pathophysiologic mechanisms of drugs. The bone sample is taken at the level of iliac crest under local anesthesia. It is then put into methyl-metacrilate resin where the sections are prepared for the microscopic analysis of the various histomorphometric parameters.     

Metabolic bone markers and bone cell biology

Various metabolic bone markers have been developed in order to analyze each process of bone resorption and bone formation. By evaluating the two processes using bone markers, an imbalance between bone resorption and formation can be estimated. Metabolic bone markers have already been in clinical use for the early diagnosis and the assessment of treatment efficacy in osteoporotic patients and for the diagnosis of cancer-induced bone diseases. Further elucidation of the mechanisms of formation and secretion, metabolic clearance, diurnal rhythm as well as their changes in various disorders should enable us to evaluate bone turnover at a real-time scale and to utilize for the diagnosis of a variety of metabolic bone diseases.     

Histoplasmosis of bone

A case of histoplasmosis of bone manifested by a single punched-out lesion in the humerus is reported in a man with asymptomatic mild chronic disseminated histoplasmosis. Roentgenologically evident lesions of bone due to Histoplasma capsulatum are rare, and this is the only report of a large punched-out lytic lesion. Such lesions are common in disseminated histoplasmosis due to the African strain H. duboisii. Although H. duboisii has been accorded species differentiation, there are only two clearly defined differences, compared to H. capsulatum. One is morphologic (size of yeast cell), and the other is a different clinical disease spectrum. Many believe that this organism is best viewed as a stable variant of H. capsulatum. At times, the two strains are indistinguishable morphologically, and at times, as in the case reported, there may be clinical similarities in their respective disease entities.