全髋关节翻修手术时髋臼骨缺损的处理

骨缺损的重建是全髋关节翻修手术的一个难题,尤其是髋臼侧的巨大骨缺损。有效地重建骨结构,恢复关节功能是翻修手术的关键。本文就全髋关节翻修手术时髋臼骨缺损的分类及对应处理方法作一综述。     

人工全髋关节翻修术中髋臼缺损重建的研究进展

人工全髋关节置换术(THA)是治疗髋关节疾病的一种有效方法[1],但假体的寿命有限,多种原因常会导致假体需要翻修。而翻修术成功的关键就是充分植骨修复骨缺损及可靠地固定翻修假体[2],其中髋臼骨缺损的程度可以对假体的选择、手术方案的制定及手术疗效产生极大影响。因此笔者就全髋关节翻修术中髋臼骨缺损的重建做一综述。     

全髋关节翻修术髋臼骨缺损的处理体会

目的探讨全髋关节翻修术中对髋臼骨缺损的处理方法。方法收治并处理全髋关节翻修术中髋臼骨缺损患者36例,结合AAOS和CQAD分类对髋臼骨缺损进行分类评估,选择植骨方式和髋臼重建方式。结果所有患者术后Harris评分较术前具有显著性差异。结论全髋关节翻修术中的髋臼骨缺损结合AAOS和CQAD分型简单明确,有助于选择植骨方式和髋臼重建方式。     

人工髋关节翻修术中髋臼骨缺损的重建方法

随着全髋关节置换手术的普及,人工髋关节翻修术的数量也呈逐年增加的趋势.髋臼骨缺损的重建是髋关节翻修的难点.在进行全面术前评估和计划的同时,科学、合理的分型和选用合适的技术对实现髋臼的成功重建至关重要.生物型髋臼杯、骨小梁金属垫块等新方法显著改善了髋臼重建效果,3D打印等新技术也为髋臼重建提供了新的有效手段.     

人工全髋关节翻修术中髋臼骨缺损的分类和重建

人工全髋关节置换术作为一项逐渐成熟的技术,已经被越来越多的骨科医师所熟知和开展,但随之也使髋关节翻修术患者增多。翻修的原因主要包括假体的无菌性松动、不稳、周围骨折、内衬磨损等,而髋臼骨缺损和髋臼假体的选择一直困扰着广大医师。本文总结了人工全髋关节翻修术中髋臼骨缺损的分类和重建,比较各种分类法的优缺点,在此基础上有多种植骨方式及髋臼假体的选择来重建髋臼,阐述了植骨的材料来源、植骨方式、复杂髋臼骨缺损的重建以及假体固定方式的选择,为临床医生处理各种髋臼骨缺损提供依据,以期更精准地指导临床个体化治疗。     

全髋关节置换术中髋臼骨缺损处理

全髋关节置换术是髋关节重建手术中最为有效的一种方法,近年来在世界范围得到了广泛开展。不过,由于各种原因,需要进行翻修术的患者也日渐增多。尽管一般可通过重建髋关节的解剖结构和更换新假体来解除患者疼痛、恢复髋关节功能,但是那些由磨损碎屑、炎症产生的骨溶解所致髋臼骨缺损常常使翻修术变得异常困难,是目前翻修术中的难点。除此之外,髋臼发育不良、髋臼肿瘤、髋关节感染等疾病本身的病理变化所造成的髋臼骨缺损,也使得初次进行全髋关节置换变得非常棘手。     

金属钛网联合打压植骨治疗严重髋臼内壁骨缺损1例报告

随着全髋关节置换术病例数的逐年增加以及患者的年轻化,翻修手术也在逐年增多。常见的翻修原因包括无菌性松动、感染、脱位、假体磨损、假体周围骨折等,而骨溶解引起的假体松动是人工全髋关节翻修术的主要原因[1-2]。骨溶解往往会导致髋臼侧或股骨侧骨缺损,而髋臼侧骨缺损的处理往往比较棘手。因此,髋臼侧骨缺损的重建对于全髋关节置换术的成功至关重要。笔者于2017年10月收治1例严重髋臼底部缺损需行全髋关节翻修术患者,现将其临床资料及随访情况报告如下。     

人工髋关节髋臼侧骨缺损翻修

在人工全髋关节置换术 3～ 5年以上 ,有明显骨吸收而骨缺损 ,特别是髋臼侧有严重的骨溶解性骨缺损 ,不得不行髋臼骨结构性重建 ,是全髋关节翻修术面临的艰巨课题。因此 ,进行有效骨缺损修复 ,成功的髋部骨结构重建 ,是人工髋关节髋臼侧骨缺损翻修的关键。其中并不包括因假体设计缺陷、假体周围骨折松动、假体安置位置失当导致脱位、松动等原因引起的翻修问题。1　髋臼骨缺损的分类1.1　ＡＡＯＳ改进分类法分为 5类 :Ⅰ型 :髋臼骨节段性骨缺损 ,其又分为二种亚型 :ⅠＡ　边缘性髋臼骨缺损 ;ⅠＢ　中央性髋臼内壁骨缺损。Ⅱ型　髋臼腔隙性骨缺…     

人工髋关节翻修术中对髋臼骨缺损的处理

随着人工髋关节置换技术的广泛开展,因各种原因需进行人工髋关节翻修术的患者日渐增多。人工髋关节翻修术的目的是解除疼痛和恢复髋关节功能。一般可通过重建髋关节的解剖结构和更换假体来实现。在翻修过程中,可选用骨水泥或非骨水泥假体来获得坚强的固定。但那些由于磨损、磨损所产生的碎屑以及炎症产生的骨溶解而导致的骨缺损,常常使翻修术变得很困难。其中髋臼骨缺损是经常遇到的难题。对髋臼骨缺损的充填,需要充足的库存骨和各种类型的假体,并且要求手术医师熟悉股骨前、后方的手术入路,能充分显露骨盆,对各种并发症能及时处理。本文就…     

全髋关节翻修术中对髋臼骨缺损的处理

目的 探讨全髋关节翻修术中髋臼侧骨缺损的处理.方法 回顾分析22例(22髋)髋臼骨缺损行全髋关节翻修术病例,采用打压颗粒性骨植骨、髋臼加强环罩重建髋臼骨缺损后假体固定.术后及随访时拍双髋正位片,观察有无骨吸收和髋臼加强环罩及假体位置变化,并进行Harris髋关节评分比较.结果 术后随访12～42个月,平均25.5个月.Harris评分从术前平均(43.4±3.5)分提高到术后(82.6±2.8)分,X线片1例出现轻微骨吸收,未出现内固定移位及臼杯松动病例.结论 在髋关节翻修中采用打压植骨、髋臼加强环罩支撑能重建髋臼侧骨缺损,为髋臼假体提供早期稳定.     

Long-term results of salvage procedures following intrapelvic migration of loosened total hip arthroplasties

INTRODUCTION: Intrapelvic migrations of loosened total hip arthroplasties are rare. Primary objective of revision arthroplasty in these cases is the reconstruction of acetabular defects for example by acetabular reinforcement rings. Presenting 3 cases the possibilities and long-term results of Girdlestone situations or arthrodesis of the hip following intrapelvic migration of a total hip arthroplasty are described. PATIENTS AND METHODS: A Girdlestone procedure was performed in a 62-year-old female patient due to intrapelvic migration of a threaded cup and development of a false aneurysm of the iliac artery. 15 years later the patient was out of any complaints. In another patient an arthrodesis of the hip due to destruction of the acetabulum and central migration of a hemiprosthesis was performed. 15 years later, too, this patient was out of any complaints. In a third patient with a contralateral preexisting Girdlestone hip an arthrodesis of the hip due to excessive loosening and severe acetabular defects of a cemented total hip arthroplasty was performed on the other side. 13 years later both hips were stiff, nevertheless the patient was satisfied. CONCLUSION: Presenting these cases we come to the conclusion that even now a Girdlestone operation or an arthrodesis of the hip should be taken into account if reconstruction of acetabular defects is no more feasible. The long-term results are satisfactory.     

The Boiled-Egg Technique : A New Method for Obtaining Femoral Head Autograft Used in Acetabular Defect Reconstruction

Primary total hip arthroplasty can be complicated by acetabular bony defects, threatening the biomechanical integrity of the prosthesis. Traditionally, when autologous bone is used to pack these defects, it is obtained from thin slices of femoral head in addition to acetabular reamings. We report a novel technique for the acquisition of autologous femoral head bone graft used in the reconstruction of acetabular defects during primary total hip arthroplasty.     

The use of preoperative computed tomography scanning in total hip arthroplasty

Computed tomography (CT) scanning is a useful tool in many areas of orthopedics. This prospective study reviews the authors' experience with CT scans in 73 patients studied prior to total hip arthroplasty. The CT scan is valuable in the primary total hip arthroplasty if the radiograph suggests medial, posterior, or superior acetabular wall defects. In some instances, bone grafting or other special procedures are required for the reconstruction of these defects. In the present study, preoperative CT identified an abnormality in 18 cases with deficient acetabular walls, while plain radiographs identified only six of these difficulties. Although important information for planning revision total hip arthroplasties was noted in this series, CT scans are indicated primarily in instances of suspected acetabular wall defects.     

Cancellous allograft in revision total hip arthroplasty. A clinical review

There are numerous indications for the use of cancellous allograft bone in the context of revision hip arthroplasty. These indications range from the well-documented use of morselized bone chips to fill cavitary defects during cementless acetabular reconstructions--in which complete or near-complete graft remodeling is expected--to the use of particulate allografting with bipolar hemiarthroplasty for acetabular revision, which largely has been abandoned because of frequent component migration, graft resorption, and clinical failure. Most other indications, including femoral and acetabular impaction allografting techniques, curettage of osteolytic defects with component retention, and complex reconstructions using acetabular reconstruction rings or cages with cancellous donor bone, are controversial but are supported by published clinical series. The current study reviews the literature on cancellous allografting in revision total hip arthroplasty.     

人工全髋关节置换术中非感染性髋臼骨缺损的治疗策略

目的探讨人工全髋关节置换术在治疗非感染性髋臼骨缺损中的应用。方法 2000年1月至2010年1月间40例非感染性髋臼骨缺损初次行全髋关节置换患者,其中CroweⅢ、Ⅳ型先天性髋关节脱位18例,髋关节感染后融合14例,陈旧性髋臼骨折8例。内移髋关节旋转中心17例,结构性植骨13例,颗粒松质骨打压植骨10例;有14例应用钛网,9例重建钢板,7例加强杯固定。术前术后进行临床评估及X线评估。结果本组手术全部成功,术后无感染发生。本组40例患者随访8～42个月,平均（10.4±2.1）个月,随访时无假体松动,关节无疼痛,患者对手术结果满意,髋关节功能较术前明显改善,术前平均Harris评分为（58.4±6.1）分,术后为（88.6±3.1）分;术后平均Harris评分较术前提高明显,两者比较差异有统计学意义（P〈0.05）。结论对非感染性髋臼节段性和混合性骨缺损进行大块植骨并辅以颗粒骨,并选用牢固的钉板系统固定,将髋臼重建在真臼位置,并尽量采用非骨水泥型臼杯,通过不同的重建方法可以获得良好的髋关节功能。     

Assessment and classification of bone stock deficiency in revision total hip arthroplasty

It is critical for appropriate treatment choices in revision total hip arthroplasty that bone stock deficiency be assessed and classified. Acetabular and femoral defects must be separately assessed, although a combined assessment is needed at the time of surgery to select the appropriate match of components for a given patient. Classification systems help surgeons predict defects and determine reconstruction planning prior to surgery. This article presents the senior author's classification of acetabular and femoral defects for revision total hip arthroplasty.     

Results of total hip reconstruction using acetabular mesh in patients with central acetabular deficiency

Fifty-three patients (54 hips) treated with cemented total hip reconstruction with the aid of an acetabular mesh made of Vitallium (Howmedica Inc., Rutherford, New Jersey), a cobalt-chrome molybdenum alloy, to reinforce the medial cement for deficient bone stock in the central acetabular region, were evaluated at an average follow-up period of 6.8 years (range, five to ten years). Thirty of these patients (30 hips) were treated with revision operations for either failed cup arthroplasty (ten hips), failed endoprosthesis (six hips), or failed total hip arthroplasty (14 hips) and presented difficult problems for acetabular reconstructions. Although none of the hips required reoperations for acetabular loosening, three patients showed roentgenographic evidence of acetabular component migration, and three others showed signs of impending failure of fixation of the acetabular component. The overall mean Harris hip rating improved from a mean of 43 points preoperatively to 87 points at follow-up evaluations. The extent of bone loss in the central acetabular region had the greatest influence on the results of acetabular fixation at the follow-up evaluation. None of the hips with intact medial acetabular cortex had roentgenographic evidence of failure of fixation, while 14% of the hips with medial cortical defects measuring less than 1 cm, and 75% of the hips with larger defects developed acetabular component loosening. The results of total hip reconstruction using acetabular mesh were unsatisfactory in patients with moderate or severe central acetabular bone loss and defects through the medial wall.(ABSTRACT TRUNCATED AT 250 WORDS)     

颗粒骨打压植骨结合多孔非骨水泥臼杯在AAOSⅢ型髋臼大面积骨缺损翻修中的应用

背景：颗粒骨打压植骨是修复髋臼骨缺损的重要方法,对大面积髋臼骨缺损采用打压植骨结合非骨水泥臼杯重建仍然存在争议。目的：探讨同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术修复AAOSⅢ型髋臼大面积骨缺损的方法及近期疗效。方法：随访2005年6月至2010年4月收治的28例（28髋）AA0SⅢ型髋臼大面积骨缺损患者。男18例,女10例,年龄34-74岁,平均53．8岁。髋关节置换术后感染醐翻修9例,骨溶解及髋臼假体松动翻修19例。本组AAOSⅢ型髋臼骨缺损面积大,术中见髋臼骨缺损超过髋臼关节面的50％。全部采用同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术。术后定期随访,观察臼杯有无松动、植入骨与宿主骨整合情况,髋关节功能评分采用Harris评分。结果：28例均获得随访,术后随访时间为13-70个月,平均43个月。Harris评分由术前32-48分,平均41分,提高至末次随访时86-95分,平均90分。28例髋臼假体均固定牢固无松动征象,植入骨逐渐与宿主骨整合,无感染及坐骨神经损伤。结论：在获得臼杯初始稳定固定的情况下,大面积颗粒骨打压植骨（臼杯与宿主骨接触面积〈50％）结合多孔非骨水泥臼杯髋臼重建术修复AAOSⅢ型髋臼大面积骨缺损近期疗效较好,远期疗效尚待进一步随访。     

Total hip replacement for acetabular fractures. Results in 121 patients operated between 1983 and 2003

Total hip replacement has an important role in the treatment of acetabular fractures. Immediate total hip arthroplasty is only indicated for some rare cases but late reconstruction is performed more frequently and may follow failed non-operative or operative treatment of the original acetabular fracture. INTRODUCTION: The purpose of this study is to determine the results of the use of total hip replacement for the treatment of acetabular fractures and to compare the results of the early and late reconstruction group. MATERIALS AND METHODS: 121 acetabular fractures treated with total hip arthroplasty between 1983 and 2003 at the University Hospitals Gasthuisberg in Leuven, Belgium were retrospectively studied. The patients were divided into two groups. In the "early reconstruction group" total hip arthroplasty was performed as primary treatment of the acetabular fracture. In the "late reconstruction group": total hip arthroplasty was performed following failed operative or non-operative treatment of the acetabular fracture. The indications for total hip arthroplasty and the surgical technique in both the early and late reconstruction group were compared. Secondly, complications were reviewed in both groups and a functional scoring system was applied for each patient. RESULTS: Primarily there was a significant difference in the age of the patient population of each group with a predominance for older patients in the early reconstruction group. Secondly, less revisions were performed in the early reconstruction group: 8% compared to 22% in the late reconstruction group. DISCUSSION: The results obtained in our patient groups were compared to the results found in literature by a Medline search. In general, our results were comparable to the results found in literature but a remarkable difference was found between different authors. CONCLUSION: Total hip replacement for acetabular fractures is rarely indicated in the acute phase. After failed treatment of an acetabular fracture, total hip replacement has to be considered as a salvage procedure. In both cases, one may not forget total hip arthroplasty is a severe intervention associated with a high number of complications.     

Surgical treatment of developmental dysplasia of the hip in adults: II. Arthroplasty options

Total hip arthroplasty is the procedure of choice for most patients with symptomatic end-stage coxarthrosis secondary to hip dysplasia. The anatomic abnormalities associated with the dysplastic hip increase the complexity of hip arthroplasty. When pelvic bone stock allows, it is desirable to reconstruct the socket at or near the normal anatomic acetabular location. To obtain sufficient bony coverage of the acetabular component, the socket can be medialized or elevated, or a lateral bone graft can be applied. Uncemented acetabular components allow biologic fixation with potentially improved results compared with cemented cups, especially in young patients. The location of the acetabular reconstruction and the desired leg length influence the type of femoral reconstruction. Cemented and uncemented implants can be used in femoral reconstruction, depending on the clinical situation. Femoral shortening is required in some cases and can be performed by metaphyseal resection with a greater trochanteric osteotomy and advancement or by a shortening subtrochanteric osteotomy. The results of total hip arthroplasty demonstrate a high rate of pain relief and functional improvement. The long-term durability of cemented total hip arthroplasty reconstruction in these patients is inferior to that in the general population. The results of uncemented implants are promising, but only limited early and midterm data are available.