髋关节置换术后假体无菌性松动的原因及治疗

<正>人工关节置换是作为一种重建关节功能有效的方法之一,使患者的生活质量得到很大改善。随着人工关节使用年限的延长,人工关节无菌性松动已成为人工关节置换术远期疗效受限的最主要原因,并严重妨碍了人工关节的发展和推     

人工髋关节置换术后假体无菌性松动的机制及预防的研究现状

人工髋关节置换术(artificial hip arthroplasty/replacement)自发明至今已有70多年的历史,随着冶金、高分子工业的发展及临床上的广泛应用,人工髋关节置换术的理论与技术已较为成熟,但术后如何延长人工关节的使用寿命、避免二次手术翻修一直是困扰医务工作者的难题。早期翻修的主要原     

人工髋关节置换术后假体无菌性松动的临床及影像学评估

人工髋关节置换术(THA)后假体无菌性松动问题始终是临床上存在并需要解决的问题。通过临床及放射学检查，观察分析假体松动的表现与过程，对于人工髋关节置换术后假体松动的及时临床处理及预防均有指导意义。本对人工髋关节置换术后假体无菌性松动的临床及影像学评估方法进行了回顾和分析，指出临床及各影像学评估方法的意义，提出正确的评估原则。     

基质金属蛋白酶及其组织抑制剂与全髋关节置换术后假体无菌性松动中的关系

全髋关节置换术能有效重建髋关节功能 ,减轻疼痛 ,提高生活质量。随着假体设计改进 ,骨水泥技术提高 ,人工关节假体无菌性松动已日益成为影响人工关节使用寿命的主要因素。目前文献[1] 已证实假体周围界膜的存在 ,普遍认为该界膜具有生物学活性并在假体松动中起重要作用。其中基质金属蛋白酶与其组织抑制剂的相互作用关系在假体松动中越来越为人们所重视。1　基质金属蛋白酶 (ＭａｔｒｉｘＭｅｔａｌｌｏｐｒｏｔｅｉｎａｓｅｓ,ＭＭＰｓ)ＭＭＰｓ是一组结构中含Ｚｎ2 + 和Ｃａ2 + 的蛋白水解酶家族 ,目前至少有 16个成员。根据其作用底物不…     

髋关节置换后假体无菌性松动机制研究

髋关节置换包括全髋和半髋置换,是治疗髋关节严重病损的有效手段,但假体松动作为术后晚期出现的并发症是手术失败的主要原因.早期假体松动归因于应力遮挡引起的骨质重新塑形,晚期假体松动的原因主要是假体微动和磨损碎屑诱导骨溶解.近年研究发现假体松动与运动后假体摩擦产热、吸烟、滑液中IGF-I水平等有关.该文就近几年关于髋关节置换后假体发生无菌性松动的可能发生机制作一综述.     

全髋关节置换术后病人假体松动机制的分析

目的 :根据松动假体周围骨溶解情况分析各种机制在假体松动过程中的作用。方法 :自 1991年 8月～ 2 0 0 1年十一年期间我院行全髋关节置换术 132例病人 ,共计 137髋。失访 31例 ,2例高龄病人死于与手术无关内科疾病。剩余 99例病人 (10 2髋 )年龄范围 :35～ 78岁 ,平均年龄 6 1.5岁。平均随访时间 6 .9年。其中 4 3髋出现假体松动 ,1髋假体松动由感染引起 ,余下 4 2髋为无菌型松动 ,并伴不同程度骨溶解。将假体周围骨溶解根据形态分为衬性骨溶解和扩张性骨溶解。按 Delee & Charnley髋臼分区和 Gruen近端股骨分区标准进行假体周围骨溶解发生率的影像分析。结果 :髋臼侧扩张性骨溶解 区的发生率最高 ,为 6 9% ,骨水泥固定组与非骨水泥固定组在扩张性骨溶解发生率有显著差异 (P<0 .0 5 ) ,非骨水泥固定组各区发生率较高 ;分别为 6 8%、79% ,骨水泥固定组与非骨水泥固定组在溶骨发生率无显著差异 (P>0 .0 5 )。衬性骨溶解髋臼侧发生率 区最高 ,股骨柄侧衬性骨溶解发生率由高至低为 区、 区、 区、 区 ,两种固定形式假体周围衬性骨溶解的发生率无显著差异 (P>0 .0 5 )。结论 :磨屑诱导的炎症性骨溶解在假体松动过程中起主导作用 ,而股骨侧骨溶解的发生以应力遮挡和假体早期微动等机械力学因素为前提     

假体柄长度与股骨远端肿瘤术后假体无菌性松动的关系

目的 探究假体柄长度对股骨远端肿瘤膝关节假体置换术后假体无菌性松动的影响。方法 选择自2015年6月至2021年6月于四川友谊医院行膝关节假体置换术的164例股骨远端肿瘤患者作为研究对象,根据术后随访2～8年期间假体无菌性松动情况将患者分为未松动组和松动组。未松动组126例,男71例,女55例;年龄25～69岁,平均(47.69±5.48)岁。松动组38例,男24例,女14例;年龄27～70岁,平均(46.12±5.33)岁。比较两组患者的临床资料。采用Kaplan-Meier法分析假体柄长度与假体使用寿命的关系;采用随机森林算法及多因素Logistic回归分析影响患者术后假体无菌性松动的因素;相关性E值法分析研究结果的敏感性;限制性立方样条图分析假体柄长度与患者术后假体无菌性松动的剂量-效应关系;建立预测模型并评价其预测效能。结果 Kaplan-Meier法分析结果显示,假体柄长度与假体使用寿命有关(P<0.001);下肢力线距膝关节中心距离增加是患者术后假体无菌性松动的危险因素(P<0.05),假体柄长度、髓腔柄与股骨直径比值、机械轴股骨远端外侧角、术后髋-膝-踝角增加...     

成纤维细胞在全髋关节置换术后无菌性松动中的潜在作用

全髋关节置换术可明显减轻病人的疼痛，改善患者的关节功能，提高病人的生活质量。然而，置换术后晚期假体无菌性松动已日益成为影响人工关节使用寿命的主要因素。许多文献已证实，假体周围往往存在一层膜性组织，这层膜性组织具有生物活性并在假体松动中起着重要的作用。...     

肿瘤型假体无菌性松动翻修术后疗效观察

目的探讨采用普通长柄假体或同种异体骨假体复合物(allograft-prosthesis composite,APC)翻修治疗肿瘤型假体无菌性松动的疗效。方法 2002年1月-2008年6月,收治14例肿瘤型假体无菌性松动患者。男8例,女6例;年龄21～70岁,平均43.9岁。肿瘤部位:股骨远端8例,股骨近端2例,胫骨近端4例。假体置换术后6～31年出现患肢疼痛,负重和行走时加重;6例出现患肢短缩畸形。术前参照美国骨与软组织肿瘤协会(MSTS)功能评分系统行关节功能评分为(16.36±1.50)分。X线片检查见假体明显松动和下沉。出现症状至入院时间为3～9年,平均4.5年。7例骨量严重丢失(骨皮质厚度减少>50%)、假体下沉>2 cm、假体穿破骨皮质或即将穿破骨皮质者采用APC翻修;7例骨量丢失不严重(骨皮质厚度减少<50%)者,采用订制普通长柄假体翻修。结果患者切口均Ⅰ期愈合;2例出现腓总神经一过性麻木,对症治疗后3个月内恢复。患者术后均获随访,随访时间2年2个月～7年,平均3.6年。翻修术后患者术前疼痛症状均缓解,关节功能改善。术后12个月MSTS功能评分为(23.43±2.56)分,与术前比较差异有统计学意义(t=8.910,P=0.024)。X线片检查示,术后12个月2例采用普通长柄假体翻修患者出现骨水泥周围无症状透亮线,无假体松动和周围感染等并发症;其余患者未见明显异常。结论肿瘤型假体无菌性松动后再次行翻修重建肢体功能可行,根据患者骨量丢失情况选择APC或普通长柄假体翻修,可获较好疗效。     

髋关节置换术后并发症的研究进展

人工髋关节置换术是严重髋关节疾患的有效治疗手段，它能有效地恢复肢体功能，提高生活质量，但术后可能发生多种并发症，如感染、假体脱位、神经血管损伤、假体穿凿、骨折、疼痛、深静脉血栓、假体松动、异位骨化等，如何有效地诊断、预防和治疗术后并发症一直是临床关注的焦点。本文对并发症中的假体脱位、血栓栓塞、无菌性松动和异位骨化的研究进展予以介绍。     

Bone mineral density and biochemical markers of bone turnover in aseptic loosening after total hip arthroplasty.

The aims of this study were to determine whether subjects with aseptic loosening after total hip arthroplasty (THA) have regional differences in periprosthetic bone mineral density (BMD) and systemic biochemical markers of bone turnover compared to subjects with successful implants.Proximal femoral and pelvic BMD were measured by dual energy X-ray absorptiometry and bone turnover markers were assayed in 49 subjects 12.6+/-4.3 (mean+/-SD) years after cemented THA. Femoral BMD was lower in Gruen zones 2, 5, 6, and 7 in subjects with a loose femoral implant (n=17) compared to those (n=32) with fixed femoral implants (P<0.05 all comparisons). This BMD difference was greatest (-31%, P=0.02) in the proximal and medial region of the femur. Subjects with femoral loosening had higher levels of the bone resorption marker N-telopeptides of type-I collagen (P=0.02) than those with a fixed femoral implant. No differences in pelvic BMD or bone turnover markers were found between subjects with loose (n=18) versus fixed (n=31) pelvic implants.This study suggests that failure of femoral components after cemented THA is associated with region-specific decreases in BMD and an increase in urinary excretion of N-telopeptide cross-links of type-I collagen. These surrogate outcome markers may be of value in monitoring response to antiresorptive therapies used to treat periprosthetic osteolysis, although the diagnosis of aseptic loosening remains clinical and radiological.     

依据Paprosky分型股骨侧假体无菌性松动的处理策略

目的研究全髋关节置换术后假体无菌性松动的治疗方法及疗效,探讨股骨侧假体无菌性松动的治疗原则。方法回顾性分析自2000-01—2014-12诊治的24例股骨侧假体无菌性松动,记录手术前后VAS评分、Harris评分。影像学指标包括假体松动表现、Paprosky分型、假体内翻角、Barrack分级、植骨方式、内固定位置、并发症情况等。结果所有患者均获平均15.3(13~68)个月随访。术前VAS评分平均为8.9(7.2~10)分,末次随访VAS评分4.3(2~10)分,与术前有较大改善,差异有统计学意义(t=2.361,P=0.027)。术前Harris评分平均为32.5(12~54)分,末次随访时为60.8(36~82)分,差异有统计学意义(t=2.213,P=0.032)。所有患者初次置换为骨水泥型股骨柄假体,22例透亮线位于骨水泥-骨界面间。翻修手术采用生物型翻修假体,骨水泥残留1例。术前Paprosky分型,Ⅰ型4例(16.7%),Ⅱ型6例(25%),ⅢA型8例(33.3%),ⅢB型4例(16.7%),无Ⅳ型。术中根据不同分型应用结构性植骨及打压植骨,术后骨长入良好。结论股骨侧假体无菌性松动的处理原则需要对患者骨质缺损、初次置换方式及质量等方面因素进行综合考虑。其处理以翻修手术为主,需根据不同骨缺损类型选择植骨方式及翻修方法。     

Increased interleukin-8 (IL-8) expression is related to aseptic loosening of total hip replacement

Aseptic loosening is an increasing problem in total hip replacement (THR). Chronic inflammatory reaction against implant wear particle results in collageno- and osteolysis, leading to loosening of the implant. Cytokines are known to play a major role in this particular inflammatory process [10]. The aim of the present study was to examine interleukin-8 (IL-8) in the synovial-like interface membrane (SLIM) and pseudocapsular tissue of THRs and to compare it to normal knee synovial membrane. Eleven patients suffering from aseptically loosened THRs were included. All the SLIM and pseudocapsular tissue samples were obtained during revision operations. Ten control samples of normal synovium were collected per arthroscopy from the superior recessus of the knee. For immunohistochemical IL-8 detection, polyclonal mouse anti-human immunoglobulin (Ig)G₁ IL-8-primary antibody was used with the alkaline phosphatase anti-alkaline phosphatase (APAAP) method. Results were quantitated using the Vidas image analysis system. The highest count levels (mean ± SEM) were detected in SLIM tissue (386 ± 82 cells/mm²). The difference was statistically significant compared with pseudocapsular tissue (193 ± 36 cells/mm²) and control samples (18 ± 5 cells/mm²). Count levels in control tissue were on average 5% of the SLIM tissues values. The present study determines for the first time the cellular origin of IL-8 in aseptically loosened THRs and also quantitates the IL-8-producing cells in the periprosthetic tissue. The results reveal a high rise in IL-8 concentration in SLIM and in synovial tissues. This finding moves us one step forward in solving the complex network of multiple factors affecting loosening of hip implants. Received: 10 November 1998     

Role of free radicals in aseptic loosening of hip arthroplasty.

Fibrous pseudocapsule around hip implants is an invariable finding at revision operations and is believed to release inflammatory mediators that stimulate bone resorption. Reactive oxygen species have been proposed to be causative factors in various disorders with tissue fibrosis. We were interested in investigating whether aseptic loosening is connected with high oxidative stress, and in showing the underlying mechanism of periprosthetic fibrosis and its role in loosening. Levels of oxidative stress markers reduced (GSH) and oxidized (GSSG) gluthatione and malondialdehyde (MDA) were assayed in 28 loose hips and in 12 stable hips revised for high rate of wear and osteolysis. Collagen in the periprosthetic tissues was measured as hydroxyproline content. Osteolysis and polyethylene wear were graded. Increased oxidative stress measured by low GSH/GSSG ratio as well as by increased MDA level was established in patients compared to controls. Oxidative stress markers intercorrelated significantly. MDA and both GSH and GSSG levels correlated significantly with hydroxyproline level. Levels of GSSG and MDA were higher in hips with greater polyethylene wear. The results suggest that high oxidative stress may play a role in formation of a fibrous membrane observed at revision of loose hips. The fibrous pseudocapsule is probably related to high intraarticular pressure and expansion of the effective joint space. This study may elicit some aspects of the pathogenesis of aseptic hip loosening and aid in future investigations aiming at prevention of this complication.     

Total hip arthroplasty with a ribbed anatomic HA coated stem

In total hip arthroplasty, a straight stem seems to provide better results than an anatomic one. A new generation of anatomic stems is under evaluation, so the follow-up is still short and cannot compare with studies of straight stems. The clinical and radiographic results of 176 patients who underwent 189 primary total hip arthroplasties using an anatomic, collared, proximally hydroxyapatite (HA)-coated femoral component were prospectively determined from 1 to 6 years follow-up. The stem is ribbed in the metaphyseal region, allowing to decrease the elasticity modulus, to augment the surface for bone ingrowth and to preserve the space needed for the circulation of the inner half side of the corticalis. The average postoperative Harris hip score was 96.7 points. All femoral components had radiographic evidence of bone ingrowth fixation at the final follow-up. There were no cases of loosening for any reason. The strength of the study is limited by the short follow-up, but our preliminary excellent clinical results with stable bone ingrowth fixation allow us to continue to use this stem following patients over time.     

Revision total hip arthroplasty with cemented femoral component

We reviewed retrospectively the results of 28 hips (25 patients) after revision of the femoral component with use of a cemented stem, because of aseptic loosening. The mean duration of follow-up was 4.43 years (range 2–12 years). Over the course of the study period, repeat revision was done in 4 hips after an average of 4.45 years. Three hips had a repeat revision of the femoral component because of aseptic loosening and one for a deep infection. The rate of loosening of the femoral component was 32.4% (9 hips) at an average of 5.22 years. The 5-year survival rate was 76.9% with mechanical failure as end point; and 90% with re-revision of femoral component because of aseptic loosening as end point. The cement mantle was the principal factor, which was significantly associated with a better survival rate of femur fixation (P < 0.05). No correlation was noted between quality of bone loss at the time of revision, bone graft or the use of long stems, and the survival rate of femoral component. By improving the cementing technique and in selected patients, the use of cemented femoral stem could be a good alternative for aseptic loosening THA.     

Computer-aided reconstruction of hip joint in revision arthroplasty

Geometric revision reconstruction of the hip joint of a female patient is presented. Because of extensive bone resorption and strong bone obstruction, we decided to employ a custom–made prosthesis not only in the pelvis but also in the femur. The custom prosthesis design and manufacturing processes were carried out with the aid of computed tomography (CT), a system of tomographic image processing, a computer–aided design (CAD) system and a computer–aided manufacturing (CAM) system. The process included tomographic measurements of the patient’s hip joint, conversion of the CT images, geometrical modelling of the femur and pelvis in the CAD system, prostheses design, virtual simulation of the reconstructed acetabulum, determination of prosthesis matching, and manufacturing on a CNC machine. The outcome of this engineering process was a total hip arthroplasty (THA) surgical operation.