经骨盆内髋臼周围截骨术治疗成人髋臼发育不良

目的介绍经髂腹股沟入路在骨盆内壁行伯尔尼髋臼周围截骨术治疗成人髋臼发育不良。方法1997年10月～2001年4月,共有51例患者(53髋)因髋臼发育不良造成髋关节疼痛而接受经髂腹股沟入路髋臼周围截骨术(Berneseperiacetabularosteotomy)。患者平均年龄30.6岁(13～48岁,其中1例13岁患者的髋臼骨骺已完全闭合),男∶女=1∶10。术前患者平均疼痛3.4年(3个月～15年);髋关节活动度正常或基本正常(235°～360°,平均300°)。术前X线片显示CE角?15°～15°,平均1.1°;臼顶倾斜角为15°～55°,平均28°;髋关节间隙正常或轻度狭窄。53%的髋关节伴有不同程度的半脱位(Shenton线不连续)。结果24例(24髋)有12～38个月(平均26个月)的随访结果。24髋术后疼痛明显减轻,髋关节活动度保持正常。Harris评分从术前平均79.8分(64～83分)提高到术后平均93.8分(75～100分)。术后CE角平均为40°(20°～60°),臼顶倾斜角平均为9°(0°～20°),Shenton线不连续率降为33%。术中及术后并发症包括股神经损伤1例,膀胱功能障碍1例,切口疝2例。结论骨盆内髋臼周围截骨术治疗成人髋臼发育不良可以获得良好疗效。该术式的特点为:在保持骨盆环和髋外展肌完整的基础上,可以最大限度地改善髋关节畸形,恢复髋关节的解剖关系。患者术后髋关节功能恢     

改良Bernese髋臼周围截骨术治疗成人髋臼发育不良

[目的]介绍经改良的经髂腹股沟入路在骨盆内壁行Bemese髋臼周围截骨术治疗成人髋臼发育不良.[方法] 10例髋关节发育不良造成髋关节疼痛的患者行髂腹股沟入路髋臼周围截骨术,并对原截骨方法进行适当改良.患者平均年龄29岁,术前患者平均疼痛2.5年,髋关节活动度正常或基本正常,髋关节间隙正常或轻度狭窄.术前术后均测量CE角和AC角及Harris评分.[结果]术后10例经12 ～28个月(平均20个月)的随访.髋术后疼痛明显减轻,髋关节活动度保持正常.术后CE角和AC角及Harri评分明显改善,术中术后无明显并发症发生.[结论]骨盆内髋臼周围截骨术治疗成人髋臼发育不良可以获得良好疗效.     

计算机辅助下Chiari骨盆截骨和股骨短缩旋转截骨治疗儿童髋臼发育不良并髋关节脱位的初步应用

目的评估计算机辅助设计下Chiari骨盆截骨和股骨短缩旋转截骨治疗儿童髋臼发育不良并髋关节脱位的术前评估、手术设计以及术后效果分析的可行性。方法自2007年7月～2009年4月,在12例(12髋)Chiari髋臼周围截骨和股骨短缩旋转截骨术中使用基于三维CT重建的计算机辅助技术。其中男7例(7髋),女5例(5髋);年龄3～12岁,平均6岁。术前行髋关节螺旋CT扫描并进行三维重建,使用"三维辅助截面"技术对股骨头覆盖程度进行评估。通过该程序对Chiari髋臼周围截骨和股骨短缩旋转截骨术进行模拟操作,记录模拟手术中髋臼截骨块内移的距离及股骨短缩距离与旋转角度,作为实际手术的参考。术后复查髋关节X线片,对手术效果进行分析。结果 12髋术前外侧CE角平均为13.5°(8～23°),臼顶倾斜角平均为37.7°(18～50°),股骨前倾角为87.2°(81～95°),三维辅助截面的股骨头实际覆盖率平均为9%(0%～20%)。术后平均外侧CE角为33.1°(23～49°),臼顶倾斜角为13.1°(11～21°),三维辅助截面的股骨头实际覆盖面积平均为91.4%(85%～94%),股骨前倾角为13.5°(13～25°)。结论计算机辅助技术对Chiari骨盆截骨和股骨短缩旋转截骨的术前设计具有较高的准确率和可信度,能够直观、立体地再现髋臼发育不良的畸形特点;模拟截骨操作可使术者了解合适的截骨位置和旋转角度,以指导实际的截骨手术。     

改良骨盆三联截骨术治疗成人髋臼发育不良临床研究

目的 探讨改良骨盆三联截骨术治疗成人髋臼发育不良的临床疗效.方法 回顾性分析2005年7月至2011年6月期间20例(22髋)成人髋臼发育不良患者经改良骨盆三联截骨术治疗的资料.患者年龄19～49岁,平均36.18±9.80岁.采用X线片测量CE角及Sharp角,经Harris髋关节功能评分评价术后功能恢复情况.结果 所有患者均获随访1～6年,平均2.6年.术后主要症状、体征均得到明显改善.Harris髋关节功能评分由术前平均74.36±5.01分上升至术后平均89.86±5.65分(P＜0.05).CE角由术前平均4.77±4.44°改善至术后平均29.68±4.75°,平均改善24.91°(P＜0.05).Sharp角由术前平均52.91±5.83°改善至术后平均35.23±3.35°,平均改善17.68°(P＜0.05).结论 改良骨盆三联截骨术是治疗成人髋臼发育不良的有效方法.     

经髋臼基底三联截骨术治疗青少年髋臼发育不良

目的: 介绍经髋臼基底三联截骨术治疗青少年髋臼发育不良。方法: 2000年 3月~2004年 2月改进Tǒnnis术式, 设计经髋臼基底三联截骨治疗 22例患者。术前X线片显示:CE角为-25~15°, 平均 8. 4°; Sharp角为 45 ~70°, 平均 58. 6°: 臼头指数为 31% ~76%, 平均 61. 4%; ACP角为100~170°, 平均 139. 8°。CT片示: 髋臼前CE角大于正常, 髋臼前断面角和前倾角小于正常。CT三维重建示: 前、后外侧壁边缘角, 外侧髋臼倾斜角均大于正常, 水平面髋臼旋转角小于正常。结果: 16例 ( 16髋 ) 有 12 ~30个月(平均 20个月) 的随访结果。X线片示: CE角平均 32. 6°(15~52°), 比术前增大约 25°; Sharp角平均 41. 5°(38~46°), 减小约 18°; 臼头指数平均 81. 6% (69% ~89% ), 增大约 20%; ACP角平均 171. 1° ( 140 ~180°), 增大约31°。CT示: 髋臼前CE角和前倾角变小, 髋臼前断面变大。CT三维重建示: 髋臼前、后外侧壁边缘角变小, 外侧髋臼倾斜角变小, 水平面髋臼旋转角变大。结论: 经髋臼基底三联截骨术治疗青少年髋臼发育不良能够获得满意疗效。     

Chiari截骨加盖螺钉固定术治疗髋臼发育不良(附56例临床分析)

[目的]介绍一种Chiari截骨、植骨加盖螺钉固定术治疗各种原因引起的髋臼发育不良.[方法]从1982年10月～2001年10月在吉林大学第一医院骨科共有63髋(56例患者)因髋臼发育不良而行Chiari截骨、植骨加盖螺钉固定术.患者年龄为8～42岁,平均20.7岁.术前X线片显示Wiberg CE角平均4°,髋臼覆盖率平均60%,Sharp角平均51°,髋臼角平均为27°,除2例外均有不同程度的半脱位(Shenton线不连续).[结果]37髋(32例患者)有6个月～8年的随访结果,平均45个月,其中30髋疼痛明显改善,术后X线片显示Wiberg CE角平均44°,Sharp角平均37°,髋臼角平均12°.Harris评分从术前平均76.3分,提高到术后平均89分.术后并发症包括2髋骨块被吸收.[结论]Chiari截骨、植骨加盖螺钉固定术较适合治疗各种原因引起的髋臼发育不良.     

影响髋臼周围截骨术结果的术前因素分析

[目的]探讨术前因素对髋臼周围截骨术结果的影响.[方法]2002～2006年接受髋臼周围截骨术的56例髋关节发育不良患者,共56髋,平均随访2.7年.定义髋臼周围截骨术后WOMAC疼痛评分在10分(中度疼痛)以上和(或)术后Tnnis分期显示骨关节炎有进展的患者为不满意组,其余为满意组.比较满意组和不满意组之间术前疼痛和影像学表现等评估指标的差异性.[结果]56髋中,不满意组病例数为10髋.其余46髋为满意组.比较满意组和不满意组之间各术前评估指标见年龄、外侧CE角、前方CE角、臼顶倾斜角,无组间差异性,而WOMAC疼痛评分、Shenton' s线连续性、T(o)nnis分期有显著性差异.满意组术后和术前WOMAC评分有显著性差异.满意组和不满意组之间CE角和臼顶倾斜角在术后没有差异性.[结论]髋臼周围截骨术可以有效地改善髋臼覆盖情况,缓解患者疼痛症状.髋臼发育不良继发骨关节炎术前就较严重的患者,髋臼截骨术后结果不满意率较高.     

髋臼旋转截骨术治疗髋臼发育不良

目的探讨髋臼旋转截骨术治疗髋臼发育不良的疗效。方法应用髋臼旋转截骨术治疗髋臼发育不良16例（18髋）,截骨线距臼周缘2 cm,做穹隆状截骨,凿断后再用弧度骨凿将髋臼向前外下方旋转。髋臼矫正到较正常位置后,截骨间隙呈楔形状,用类似间隙大小的楔形同种异体骨块嵌入,并用可注射状人工骨填满间隙,最后用2枚可吸收螺钉固定。测定并比较术前和术后JOA评分、CE角和Sharp角。结果16例均获随访,时间442个月。术后摄片髋关节复位位置好,股骨头及髋臼形状基本正常。髋臼旋转截骨及植入骨块2个月后骨性愈合,6个月后髋关节功能恢复正常17髋,较差1髋,无患髋的骨性关节炎病变继续恶化。JOA评分：术前为75.2分±3.1分,术后为93.5分±3.5分;CE角：术前为15.8°±1.3°,术后为33.4°±1.7°;Sharp角：术前为47.3°±2.5°,术后为29.8°±2.1°。JOA评分术后增加18.3分;CE角增加17.6°,Sharp角减少17.5°,差异有统计学意义（P〈0.05）。结论髋臼旋转截骨术可矫正头臼间异常的匹配关系,使疼痛得到缓解,并使骨性关节炎的过程得到有效遏制,是治疗髋臼发育不良合并早、中期骨性关节炎的理想术式。     

伯尔尼髋臼周围截骨术对严重髋臼发育不良的治疗

目的 研究和分析使用伯尔尼髋臼周围截骨术治疗严重髋臼发育不良的中期临床和影像学结果.方法 1997年10月至2002年12月对18例(20髋)严重髋臼发育不良(Severin分级Ⅳb级)的患者接受了伯尔尼髋臼周围截骨术.患者手术时平均年龄21岁,平均随访时间6.2年.本组患者术前患髋均已出现疼痛,术前功能位片显示关节面吻合.术后影像学评价畸形的矫正范围,截骨处的愈合情况及关节炎的进展.临床结果和髋关节功能由Harris评分进行评价,术前Harris评分平均78.5分.结果 比较术前和术后X线片,外侧中心边缘角(CE角)、前方CE角和臼顶倾斜角均有显著改善.所有髂骨截骨均愈合.患者术后末次随访Harris评分平均91.1分.18例患者中的14例对手术效果表示满意.20髋中16髋临床结果优.但有5髋存在畸形矫正不足.结论 伯尔尼髋臼周围截骨术是治疗严重髋臼发育不良的有效术式.这一截骨术可以在各个平面对严重的骨缺损进行矫正,中期临床结果令人满意.     

髋臼周围截骨治疗成人髋关节发育不良

目的 探讨髋臼周围截骨治疗成人髋关节发育不良的手术适应证及疗效.方法 25例成人髋关节发育不良患者接受经改良Smith-Peterson人路的髋臼周围截骨术,女19例,男6例;年龄18～45岁,平均25.5岁.均为单侧发病,左侧14例,右侧11例.3例有既往手术史,2例Chari截骨术、1例Salter截骨术.髋关节骨关节炎T(o)nnis 0期13例、Ⅰ期9例、Ⅱ期3例.Shenton线不连续18例.髋臼外侧CE角4.57°±7.39°,前侧CE角0.95°±6.02°,髋臼顶倾斜角32.50°±5.96°,股骨头超出指数38.11%±5.70%,Harris髋关节评分(75.32±7.51)分.结果 全部患者随访2.0～7.5年,平均4.5年.3例髋关节骨关节炎T(o)nnis Ⅰ期者改善为0期,2例T(o)nnisⅡ期者改善为Ⅰ期,1例T(o)nnis Ⅰ期者进展为Ⅱ期.Shenton线不连续减少为10例.外侧CE角29.07°±5.81°,前侧CE角29.52°±4.51°,髋臼顶倾斜角19.17°±4.95°,股骨头超出指数24.20%±4.83%,Harris髋关节评分(84.88±4.88)分,与术前比较差异均有统计学意义.16例出现股外侧皮神经支配区感觉麻木,其中9例自行恢复,7例残留永久性麻木.1例出现髋关节周围Brooker Ⅰ型异位骨化.结论 经改良Smith-Peterson人路行髋臼周围截骨治疗成人髋关节发育不良可有效增加髋臼包容,改善关节功能,阻止髋臼周围硬化和囊性变,保持关节间隙,延缓骨关节炎进展.     

Cementless acetabular reconstruction after acetabular fracture.

BACKGROUND: Total hip arthroplasty in patients with posttraumatic arthritis has produced results inferior to those in patients with nontraumatic arthritis. The use of cementless acetabular reconstruction, however, has not been extensively studied in this clinical context. Our purpose was to compare the intermediate-term results of total hip arthroplasty with a cementless acetabular component in patients with posttraumatic arthritis with those of the same procedure in patients with nontraumatic arthritis. We also compared the results of arthroplasty in patients who had had prior operative treatment of their acetabular fracture with those in patients who had had prior closed treatment of their acetabular fracture. METHODS: Thirty total hip arthroplasties were performed with use of a cementless hemispheric, fiber-metal-mesh-coated acetabular component for the treatment of posttraumatic osteoarthritis after acetabular fracture. The median interval between the fracture and the arthroplasty was thirty-seven months (range, eight to 444 months). The average age at the time of the arthroplasty was fifty-one years (range, twenty-six to eighty-six years), and the average duration of follow-up was sixty-three months (range, twenty-four to 140 months). Fifteen patients had had prior open reduction and internal fixation of their acetabular fracture (open-reduction group), and fifteen patients had had closed treatment of the acetabular fracture (closed-treatment group). The results of these thirty hip reconstructions were compared with the intermediate-term results of 204 consecutive primary total hip arthroplasties with cementless acetabular reconstruction in patients with nontraumatic arthritis. RESULTS: Operative time (p < 0.001), blood loss (p < 0.001), and perioperative transfusion requirements (p < 0.001) were greater in the patients with posttraumatic arthritis than they were in the patients with nontraumatic arthritis. Of the patients with posttraumatic arthritis, those who had had open reduction and internal fixation of their acetabular fracture had a significantly longer index procedure (p = 0.01), greater blood loss (p = 0.008), and a higher transfusion requirement (p = 0.049) than those in whom the fracture had been treated by closed methods. Eight of the fifteen patients with a previous open reduction and internal fixation required an elevated acetabular liner compared with one of the fifteen patients who had been treated by closed means (p = 0.005). Two of the fifteen patients with a previous open reduction and internal fixation required bone-grafting of acetabular defects compared with seven of the fifteen patients treated by closed means (p = 0.04). The thirty patients treated for posttraumatic arthritis had an average preoperative Harris hip score of 41 points, which increased to 88 points at the time of follow-up; there was no significant difference between the open-reduction and closed-treatment groups (p = 0.39). Twenty-seven patients (90%) had a good or excellent result. There were no dislocations or deep infections. The Kaplan-Meier ten-year survival rate, with revision or radiographic loosening as the end point, was 97%. These results were similar to those of the patients who underwent primary total hip arthroplasty for nontraumatic arthritis. CONCLUSIONS: The intermediate-term clinical results of total hip arthroplasty with cementless acetabular reconstruction for posttraumatic osteoarthritis after acetabular fracture were similar to those after the same procedure for nontraumatic arthritis, regardless of whether the acetabular fracture had been internally fixed initially. However, total hip arthroplasty after acetabular fracture was a longer procedure with greater blood loss, especially in patients with previous open reduction and internal fixation. Previous open reduction and internal fixation predisposed the hip to more intraoperative instability but less bone deficiency.     

Uncemented acetabular components for arthritis after acetabular fracture

The purpose of the current study was to evaluate the results of uncemented acetabular components used to treat posttraumatic arthritis after acetabular fracture at a minimum of 10 years. Thirty-four hips in 33 patients (mean age, 49.7 years, range, 19-78 years) were treated from 1984 to 1990 at one institution with a total hip arthroplasty using an uncemented titanium porous-coated socket. Four patients died before 10 years (all with implants intact). Nine patients had the acetabulum revised: four had the shell and liner revised (one for loosening, one for loosening and dislocation, and two for osteolysis) and five had the liner alone revised (three for polyethylene wear and two for dislocation). All patients with unrevised hip replacements who were alive and patients who were not lost to followup had no or minimal pain at final followup (range, 10-16 years); no components were radiographically loose. Uncemented sockets had a low rate of loosening in this challenging patient population, but polyethylene wear and osteolysis were problematic.     

Revision of failure acetabular components with cementless acetabular components

Outcomes of cemented acetabular components show unacceptably high rates of loosening over the short-term, and increased failure over the long term. The use of uncemented acetabular components with porous coatings and supplemental screw fixation has improved the success rates of revision surgery with bone loss. Intermediate follow-up results of uncemented acetabular components for revision surgery suggest excellent outcomes with superior fixation compared with cemented components. Use of large components that rely on the posterior column and acetabular dome for fixation appear to function satisfactorily, even in a significantly bone deficient acetabulum.     

Results for a custom acetabular component for acetabular deficiency

We report our experience with a triflanged titanium cementless custom-made acetabular implant in the management of complex major acetabular deficiency for revision total hip arthroplasty in 27 patients. The mean follow-up period was 58 months (range, 48-72 months). There were 9 men and 18 women. Clinical assessment was performed using Charnley's modification of the Merle d'Aubigne and Postel scoring system. Radiographic assessment was carried out using the DeLee and Charnley grading system. All patients had improved hip scores at latest examination. Six patients (22%) had complications. Two patients (7.4%) required further revision surgery. This procedure is technically demanding and has a high complication rate. Until better long-term results are shown, this procedure should be restricted to patients for whom a Girdlestone pseudarthrosis is the only surgical alternative.     

Periprosthetic acetabular bone loss using a constrained acetabular component

We describe two patients with a constrained acetabular component who required treatment for recurrent dislocation showing postoperative periprosthetic acetabular bone loss. These hips required revision surgery and demonstrated considerable bone loss caused by the migrated acetabular component. Impingement may have occurred with increased stress at the bone-prosthesis interface, and the sharp ends of screws with a metal shell may have gradually plowed up the acetabular bone. These failures illustrate the potential risk of using a constrained acetabular component.     

The acetabular teardrop and its relevance to acetabular migration

Five pelvises were photographed, roentgenographed, and sequentially sectioned or reamed to determine the location and appearance of the acetabular teardrop figure. The teardrop is located inferomedially in the acetabulum, just superior to the obturator foramen. The lateral lip is the exterior, and the medial lip is the interior of the acetabular wall. The ilioischial line projects over the medial acetabulum only fortuitously on the straight anteroposterior (AP) roentgenogram. Because of parallax, the relationship between the ilioischial line and the teardrop changes for views varying as little as 10 degrees in horizontal obliquity from the true AP roentgenogram. Because the teardrop comprises a well-defined, constant portion of the medial acetabular wall whereas the ilioischial line does not, the authors recommend using the acetabular teardrop rather than the ilioischial line for the detection and measurement of medial and superior acetabular migration.     

环髋臼截骨成形术治疗陈旧性髋臼骨折

目的: 探讨治疗陈旧性难以复位的髋臼骨折的新方法。方法: 本组 6例, 男 5例, 女 1例, 年龄平均 33岁 (22~55岁), 骨折时间平均 3个月 (2 5~3 5个月), 骨折类型为骨盆环骨折并髋臼骨折, 髋臼骨折并中心性脱位或移位, 采用环髋臼内移截骨成形术。结果: 随访平均 3年 (1~6年), 关节无痛, 关节活动度及步态恢复正常。恢复原来工作。X线示关节间隙正常, 无股骨头坏死。髋臼指数 18°(16 ~22°), CE角平均 32°(28 ~35°)。优 5例, 良 1例。病人满意率 100%。结论: 治疗陈旧性难以复位的髋臼骨折可以应用环髋臼内移截骨成形术, 符合生物力学原则。     

The Kerboull acetabular reinforcement device in major acetabular reconstructions

Sixty consecutive revision total hip arthroplasties were performed with bulk allograft bone supported by the Kerboull reinforcement acetabular device in 53 patients from 1980 to 1987. The average age of the patients at the time of hip revision was 57.7 years. Acetabular bone loss according to the American Academy of Orthopaedic Surgeons grading system was Type III for 48 hips in 41 patients and Type IV for 12 hips in 12 patients. Three failures, defined as radiologic loosening of the socket, revised or not, were reported in this series at a mean 8-year followup. Eight patients died of unrelated causes at a mean of 5 years. No patient was lost to followup. The mean followup of the series was 10 years +/- 3 years. The mean preoperative Merle d'Aubigné hip functional score was 11.7 +/- 2.4 versus 17.4 +/- 0.6 at the latest followup. Consolidation of the graft was considered completed in all 60 hips and occurred by 12 months. Remodeling of the graft proceeded for 3 to 4 years. The survival rate at 13 years was 92.1% +/- 5% using loosening of the acetabular component as the end point. This study indicated that acetabular allograft reconstructions reinforced by the Kerboull acetabular device were able to provide satisfactory long-term clinical and radiologic results.     

Total hip replacement and acetabular bone grafting to acetabular dysplasia

We have described the problems of deficient acetabular and femoral bone stock in the Japanese total hip prosthesis patients. From the mechanical viewpoint, coverage of the ultra-high-molecular-weight-polyethylene (UHMWPE) socket with bone graft is a prerequisite for preventing socket loosening. Use of a larger diameter UHMWPE cup in combination with new grafting techniques is highly desirable for reasons of creep reduction and minimal wear. From 1984 on, we reported on about 300 cases of dysplasia, high dislocation, RA and osteonecrosis of the hip. Depending on the severity of the problems, various configurations of femoral-head and neck bone grafts and hydroxyapatite particles (100-300 microns in diameter) in combination with bone cement were used. Bone resorption was seen only in the non-weight bearing regions of the graft. With our interface bioactive bone cement and grafting techniques, some of the problems of radiolucent zones and socket wear common to such difficult cases are believed to have been overcome.