植骨在全髋置换翻修术中修复髋臼缺损的应用

翻修术（Revision）国内曾称二次或重复手术、修整手术等，是指关节因各种原因行人工关节置换术后，因磨损或其它原因导致其松动、下沉，需再次进行关节置换。由于临床上髋关节置换术开展最多，翻修术也是应用最多的。国外自上世纪60年代中期开展人工髋关节置换术，随着前期置换关节使用寿命的结束，需要行翻修术的患者日益增多。有数据显示美国人工髋关节置换手术中约10％为翻修术。我国自上世纪70年代开展人工髋关节置换术，随着人工髋关节置换术的不断普及，需要行全髋翻修的患者逐年增加。     

髋关节置换翻修术骨质缺损的处理

探讨全髋关节置换术后翻修术骨质缺损处理方式的选择。对29例病人（29髋）行髋关节置换术后翻修术;其中骨水泥型假体置换3例,非骨水泥型假体置换26例;3例为Synergy＋Reflection假体,余为CLS＋ALLOFIT假体。患者伤口均一期愈合,无术后早期感染征象。随访25例25髋,平均随访时间58个月。关节局部疼痛缓解,活动功能满意;术后随访X线片示：骨质愈合好,未见明显的骨质吸收征象。Harris评分,术前平均36.8分,术后平均93.2分。翻修距初次全髋关节置换平均13.7年。髋臼部骨质缺损,在髋臼覆盖大于80%的情况下可不植骨;若髋臼覆盖大于50%、小于80%,行颗粒性植骨结合结构植骨;髋臼覆盖的比例低于50%,结构植骨往往能获得较好的效果。股骨侧骨质缺损,打压颗粒植骨结合异体皮质骨板效果满意。     

双锥面螺旋髋臼在髋关节置换术后髋臼侧翻修术中的应用

目的探讨双锥面螺旋髋臼假体在初次人工全髋关节髋臼侧翻修术中的临床应用效果。方法对1996年7月~2010年8月收治的25例初次行全髋关节置换术后假体松动的患者行双锥面螺旋髋臼翻修。患者男性6例,女性19例,年龄57~81岁,平均(69.0±0.2)岁。Harris评分16~57分,平均43分。患者术前均行X线,CT等影像学检查,术中彻底清理髋臼并根据骨缺损情况行同种异体颗粒松质骨打压植骨。术后随访评价依据Harris评分系统,根据坎贝尔手术学所提供的诊断标准判断影像学上假体是否松动。结果术后切口均一期愈合,经过3~14年,平均4年的随防,髋关节功能良好,未发现髋臼假体松动,按Harris评分标准,优16例,良6例,可3例,优良率为95%。结论运用双锥面螺旋髋臼假体对初次行全髋关节置换术后松动的患进行翻修治疗,固定可靠、愈合快、能早期功能锻炼、并发症少、功能满意,是一种确切可靠的方法。     

人性化护理在人工肩关节置换术患者中的应用

目的 对于人性化护理在某医院人工肩关节置换术患者的应用进行探索.方法 选择1009年3月～2010年7月在某医院收治的人工肩关节置换术的患者100例,年龄22～64岁,平均41.8岁.,对其进行人性化护理.结果 100例患者经过上诉人性化护理之后,显效(症状较治疗前明显减轻)83例(83%),有效(症状有所减轻)14例(14%),无效(治疗前后临床症状无改善)3例(3%),总有效率97%.结论 该医院人工肩关节置换术患者的人性化护理效果良好.     

人工全髋关节置换术和翻修术后并发异位骨化的风险因素分析

目的:探讨人工全髋关节置换术(THA)和翻修术后异位骨化(HO)形成的影响因素、临床特点、创伤机制和预防方法.方法:我院2004年1月～2010年12月行THA及翻修术287例,其中男98例,女189例;年龄56~72岁,平均63岁.其中≤65岁140例,＞65岁147例;THA 257例,翻修术30例.所有患者术后均口服阿斯匹林50 mg/d×30 d.两位骨科医师根据患者术前和术后双髋关节正、侧位X线摄片,按Brooker分级标准评定HO产生情况.按Harris评分标准评定髋关节功能.结果:本组287例均随访1 a以上,共有45例发生HO(15.68%),其中Brooker I型29例(64.44%),BrookerⅡ型14例(31.11%),BrookerⅢ型2例(4.44%),未发现BrookerⅣ型.HO发生率在男性为23.47%、女性11.64%,≤65岁10.71%、＞65岁20.41%,初次THA后10.89%、翻修术后56.67%,不同性别、年龄、术式间比较,差异均有统计学意义(P＜0.05).结论:在THA及翻修术后应常规预防HO;对HO形成的高危因素如翻修手术,围手术期应尽早采取干预措施.     

生物型假体在髋关节翻修术中的应用

目的:通过资料分析了解生物型假体应用于髋关节翻修手术的研究进展.方法:收集并分析国内外最新的相关资料,总结生物型髋关节假体设计特点及其用于翻修手术的适应证、禁忌证、手术注意事项及其随访研究结果.结果:用于髋关节翻修的生物型假体目前仍以金属-聚乙烯或陶瓷-聚乙烯界面为主,金属-金属以及陶瓷-陶瓷等新型界面的临床效果尚需时间的考验.股骨骨量的评估是选择生物型假体翻修的主要参考指标.在髋关节翻修手术中,生物型假体表现出良好的早、中期疗效,长期随访研究报道较少.结论:生物型假体在髋关节翻修术中表现出良好的应用前景.     

全髋关节置换治疗股骨颈骨折内固定失败的临床研究

目的探讨应用全髋关节置换术(Total hip arthroplasty,THA)治疗股骨颈骨折内固定失败后疗效。方法回顾性分析自2007年1月~2012年12月应用THA治疗股骨颈骨折内固定失败22例,男17例,女5例,年龄25~60岁,平均(48±7.0)岁。内固定失败表现:螺钉取出后股骨头坏死10例,股骨头坏死并螺钉松动、断裂7例,术后骨折不愈合3例,骨折不愈合并股骨头坏死2例。内固定术后至行THA时间10个月~9年,平均32.5个月。患者均采用生物型固定假体,其中18例选择近端固定的股骨假体柄,4例选择髓腔匹配的假体柄。采用Harris评分比较患者术前及随访时的患髋功能。结果本组随访24~60个月,平均32.2个月。术前髋关节功能Harris评分28~50分,平均(35±4.0)分。术后末次随访评分为84~97分,平均(89±5.0)分,其中优12例,良9例,中1例,差0例,优良率为95.4%。术后髋关节功能评分较术前明显提高,差异有统计学意义(P0.05)。结论股骨颈骨折内固定失败后行THA能有效改善髋关节功能,提高患者的生活质量,是一种有效的挽救性手术。     

氨甲环酸关节腔内注射对全膝关节置换术后隐性失血的影响

目的探讨氨甲环酸关节腔内注射对全膝关节置换术后隐性失血的影响。方法选取2012年6月~2014年12月在我院行单侧全膝关节置换术治疗的60例患者为研究对象。男性14例,女性46例,年龄58~77岁,平均66.7岁,病程6~15年,平均9.1年。手术及麻醉均由同一组医生完成。将符合条件的患者随机分为2组,试验组(氨甲环酸组)30例,切口缝合完毕后将氨甲环酸1 g稀释至50 m L生理盐水中,用注射器沿引流管注入关节腔内。对照组30例,直接将50 m L生理盐水沿引流管注入关节腔内。比较二组患者术后显性失血量、隐性失血量、异体输血人数、输血比率。结果术后试验组与对照组显性失血量分别为389m L(170~505m L)和628m L(225~874m L),差异有统计学意义(0.05)。术后试验组与对照组隐性失血量分别为514 m L(374~819 m L)和917 m L(542~1297 m L),差异有统计学意义(0.05)。两组术后凝血机制无显著性差异。术后试验组输血人数及输血比率明显小于对照组,差异有统计学意义(0.05)。结论膝关节腔内应用氨甲环酸能够有效地降低全膝关节置换术后患者的显性失血量和隐性失血量,减少术后异体输血的可能性,局部使用方便,未发现不良反应。     

人工髋关节置换后感染二期翻修中的彻底清创

背景：感染是人工全髋关节置换后灾难性的并发症,其诊断标准尚未统一,治疗方案亦存在争议。髋关节置换后感染灶的清除彻底与否决定能否重建关节并恢复关节功能。 目的：分析髋关节置换后感染二期翻修过程中彻底清创的经验及疗效。 方法：2008年8月至2013年1月解放军南京军区南京总医院骨科收治23例(24髋)髋关节置换后感染病例,均符合共识性的诊断标准,修复方案分两期,一期彻底清创加含抗生素骨水泥间隔置入;二期行关节重建,若间隔期感染持续存在,可以重复清创,待感染彻底控制后行关节重建。翻修后随访期间行髋关节功能Harris评分,并评估感染控制情况。 结果与结论：所有患者均获得随访,随访时间1-5年,治疗前Harris评分平均为36.5分(27-45分),二期翻修后Harris评分平均为88.6分(76-98分),且均无感染复发,感染控制率达100%。提示二期翻修是治疗髋关节置换后感染的有效方法,彻底清创可起到至关重要的作用,能有效控制感染复发,提高假体稳定性,从而重建关节功能。  中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

屈髋屈膝体位在Crowe IV型DDH非短缩截骨全髋置换避免坐骨神经损伤的应用

目的探讨发育性髋关节高脱位(Developmental Dysplasia of the Hip,DDH)真臼重建非短缩截骨全髋置换术中避免坐骨神经损伤的有效方法。方法 20髋Crowe IV型DDH者,采用真臼重建非短缩截骨全髋置换,股骨头旋转中心上移42~68mm(48.65±7.28)mm,术中应用Outside-in全关节囊切除,复位时内收20°,屈髋60°,屈膝90°。复位后外展30°,屈髋60°屈,膝90°。麻醉恢复后,根据患者对患肢远端疼痛和麻木的耐受逐渐伸直。应用Harris评分评估髋关节功能。结果所有病人都获得12~108月随访,最后一次Harris评分(87.3±10.6),术前Harris评分35分(7~58分),术前术后比较有显著性差异。1髋坐骨神经术中损伤,3髋坐骨神经术后损伤,最终神经损伤均完全恢复。结论 Crowe IV型DDH全髋置换真臼重建非短缩截骨屈髋外展屈膝位能成功减少坐骨神经损伤。     

Reverse total shoulder arthroplasty

Reverse total shoulder arthroplasty designs have gained popularity over the last few years due to their satisfactory functional results in patients with cuff‐tear arthropathy and other difficult reconstructive shoulder problems. These semiconstrained prostheses improve stability and active elevation in the absence of a functional rotator cuff by coupling a spherical glenoid component with a concave humeral component and increasing deltoid tension. Understanding the anatomy of the shoulder is critical in order to ensure secure fixation of the glenoid component, explore uncemented options for humeral component fixation, and determine the ideal soft‐tissue tension to provide the best functional outcome without increasing the risk of complications. Key anatomic elements to be considered for the successful implantation of a reverse prosthesis include the orientation and size of the glenoid vault, the scapular regions with better bone stock (coracoid, spine of the scapula), the internal geometry of the humeral medullary canal, and the effects of reverse arthroplasty on the deltoid and brachial plexus. Clin. Anat. 22:172–182, 2009. © 2008 Wiley‐Liss, Inc.     

Long-term results of revision total knee arthroplasty using a rotating hinge implant

BackgroundRotating hinge implants are commonly used in revision total knee arthroplasty (TKA) in the setting of significant ligamentous instability or bone deficiency. These highly constrained implants have been associated with variable clinical outcomes and uncertain long-term survivorship. The aim of this study is to establish long-term functional outcomes, radiographic results, and survivorship after revision TKA with a rotating hinge implant.MethodThis is a retrospective study of prospectively collected data of 41 consecutive patients undergoing revision TKA with rotating hinge components and minimum 10-years follow-up. The study included 22 females (53.7%) and 19 males (46.3%) with a mean age of 66.6 ± 8.5 years. Clinical outcomes recorded included the Oxford Knee Score (OKS) preoperatively and at latest follow-up. Range of motion, implant survivorship, and complications were also recorded. Predefined radiological outcomes were obtained using plain radiographs.ResultsThere was a significant improvement in OKS after revision TKA with a rotating hinge implant compared to preoperative scores (40.7 ± 4.2 vs. 21.4 ± 4.9 respectively, p < 0.001). At latest follow-up, mean range of motion was 111.5° ± 9.3° and mean overall limb alignment was 0.2° ± 2.0° varus. Implant survivorship at minimum 10-year follow-up was 90.2%. Radiographic lucent lines were observed in 14 patients (34.1%).ConclusionRevision TKA with a rotating hinge implant leads to satisfactory clinical outcomes and very good implant survivorship at long-term follow-up. Surgeons should have a low threshold to use these versatile implants in complex revision knee arthroplasty.     

The oxford knee score minimal clinically important difference for revision total knee arthroplasty

BackgroundMinimal clinically important difference (MCID) is crucial for interpreting meaningful improvements in patient-reported outcome measures (PROMs). No previous study has evaluated the MCID for the Oxford Knee Score (OKS) in revision total knee arthroplasty (TKA). This study aimed to propose the OKS MCID for revision TKA.MethodsProspectively collected data from 191 patients who underwent revision TKA at a single institution was analysed. Clinical assessment was performed preoperatively and at 2 years using OKS and Short-Form 36 Physical Component Score (SF-36 PCS). MCID was evaluated with a three-pronged methodology, using (1) anchor-based method with linear regression, (2) anchor-based method with receiver operating characteristic (ROC) and area under curve (AUC), (3) distribution-based method with standard deviation (SD). The anchors used were improvement in SF-36 PCS ≥ 12, patient satisfaction, and implant survivorship following revision TKA.ResultsThe MCID determined by anchor-based linear regression method using improvements in SF-36 PCS was 4.9 points. The MCID determined by anchor-based ROC was 10.5 points for satisfaction (AUC = 74.8%) and 13.5 points for implant survivorship (AUC = 73.7%). The MCID determined by distribution-based method of 0.5 SD was 4.7.ConclusionThe proposed MCID for OKS following revision TKA is 4.9 points. Patients who achieve an improvement in OKS of at least 10.5–13.5 points by 2 years are likely to be satisfied with their surgery and not require a subsequent re-revision TKA. Patients undergoing revision TKA should aim for an improvement in OKS of at least 10.5–13.5 points as a target score.     

弹力绷带加压包扎联合低分子肝素对全髋关节置换患者下肢深静脉血栓的影响

目的探讨弹力绷带下肢加压包扎联合低分子肝素(Low molecular weight heparin,LMWH)预防全髋关节置换(Total hip arthroplasty,THA)患者下肢深静脉血栓(Deep venous thrombosis,DVT)的临床效果。方法回归分析2014年1月~2015年10月初次行全髋关节置换病例120例,所有患者皆使用低分子肝素抗凝以预防血栓形成,根据术后下肢是否采用弹力绷带加压包扎分为观察组和对照组。记录并观察术前血小板(Platelet,PLT)、活化部分凝血活酶时间(Activated partial thromboplastin time,APTT)、凝血酶原时间(Prothrombin time,PT)、甘油三酯(Triglyceride,TG)、纤维蛋白原(Fibrinogen,FIB)、总胆固醇(Cholesterol,CHOL)、手术时间及术后引流量;采用彩色多普勒检查评估深静脉血栓形成情况。结果两组患者基线特征一致,具有可比性。术前两组PLT、APTT、PT、TG、FIB、CHOL及手术时间比较,差异无显著性意义(0.05)。观察组术后引流量高于对照组,但两组比较,差异无显著性意义(0.05)。术后深静脉血栓形成观察组少于对照组,但两组经卡方检验,差异无显著性意义(0.05)。结论弹力绷带下肢加压包扎联合低分子肝素预防THA术后深静脉血栓形成与单独使用低分子肝素比较无明显统计学差异,其是否能够明显减少DVT数量尚需扩大样本量进行深入研究。     

Hinged versus CCK revision arthroplasty for the stiff total knee

Background

Total knee arthroplasty (TKA) remains the gold standard for end-stage knee osteoarthritis. The prevalence of stiffness after this procedure described in literature varies from 1.3% to 5.3%. The causes of arthrofibrosis after total knee arthroplasty are multifactorial. Revision TKA is a successful procedure when performed for loosening, instability, mechanical implant failure, or infection. The results of revision TKA for idiopathic arthrofibrosis and stiffening are however less favorable.

Angiosarcoma after revision total knee arthroplasty

BackgroundHemarthrosis after total knee arthroplasty (TKA) is a relatively rare complication. Although most cases are effectively treated with conservative therapy, some cases require angiographic embolization or surgical intervention. Angiosarcoma is a rare malignant tumor derived from the vascular endothelium with neovascular hyperplasia and mainly arises in the skin and superficial soft tissue, and less frequently in deep soft tissue and bone. Although malignant neoplasms such as angiosarcoma in the vicinity of orthopedic implants were reported, the causal relationship between development of the malignant tumor and the orthopedic implant is widely debated in the literature.Case presentationWe report the case of a 68-year-old female with angiosarcoma that developed in the knee joint 2 years after revision TKA. The patient exhibited severe persistent bleeding, which reached 1000–1400 ml per day for 4 months. Histological analysis of the synovial tissue in the knee joint showed large cells with nuclear atypia. Immunohistochemical staining showed cells that were positive for CD31, CD34, and D2-40, and she was diagnosed with angiosarcoma. The patient underwent an amputation at the level of the thigh, and her general condition immediately improved after the operation. The patient did not exhibit bleeding from the site of amputation, and no local recurrence or distant metastases were detected 1 year after the amputation.ConclusionsTo the best of our knowledge, this represents the first report of angiosarcoma 2 years after revision TKA. Further careful follow up is needed, given the high-grade malignancy.     

胫骨近端几何形态分析与再置换胫骨组件的设计研究

目的良好的胫骨组件与胫骨截骨平面配合,可提高人工关节组件的稳定性,同时可避免组件沉陷或松脱。目前国内市售的人工关节多由欧美进口,这些胫骨组件尺寸不符合国人的需求,在膝关节置换手术时,胫骨的外形轮廓会随着骨切除不同深度而改变,使得再置换胫骨组件与截骨平面较难有良好的覆盖。该研究将台湾人胫骨近端的几何形状应用于胫骨基座与胫骨填补块(tibial augmentation)设计的参考,以提高胫骨组件与截骨平面的涵盖率。方法利用50例退化性关节炎患者之病肢,通过计算机断层扫描重建胫骨近端3D模型,以取得胫骨外型参数。测量胫骨平台下方4、7、10、13、16mm处的5个截骨平面。测量参数包含截骨平面的前后侧(AP)长度,内外侧(ML)宽度,以及前外侧(AL)、后外侧(PL)、前内侧(AM)与后内侧(PM)之圆弧半径。结果结果显示平均AP47.4mm(40.4-52.9mm)、ML69.0mm(59.6-79.1mm)、AL30.0mm(18-38mm)、PL20.0mm(10-25mm)、AM28.7mm(18-36mm)、PM17.9mm(11-23mm)。将测量结果与市售的胫骨之间尺寸进行分析,进口假体PFCSigma与Zimmer Nexgen所提供的尺寸较适合国人。结论身高与AP、ML尺寸呈高相关性,而国人体型较欧美矮小,人种间身高上的差异,可能就是导致市售假体与国人胫骨截面尺寸不合的原因。通过测量资料,针对国人规划5款假体尺寸,应可提高涵盖率,减少尺寸不合导致植入物沉陷的发生机率。     

肱骨近端解剖测量在人工肩关节置换中的意义

目的:为人工肩关节置换治疗肱骨近端粉碎性骨折、假体设计提供参考数值。方法:对68例成人干燥肱骨标本进行观测分析。结果:肱骨头横径:左侧(40.67±1.90)mm,右侧(40.49±1.36)mm;肱骨头纵径:左侧(44.54±1.31)mm,右侧(43.45±1.48)mm;肱骨头后倾角:左侧(26.59±1.36)°,右侧(26.85±1.61)°;头结节距(肱骨头最高点至大结节最高点的垂直距离):左侧(6.63±1.13)mm,右侧(6.80±1.02)mm;颈干角:左侧(134.320±3.49)°,右侧(135.58±1.50)°。结论:(1)假体头直径在(40～45)mm,后倾角30°左右,假体高度应该高于大肱骨结节6～8mm;(2)人工肩关节置换应该考虑选择适合的假体高度、后倾角度、假体头的大小等,这与患者肩关节功能重建、并发症的发生密切相关。     

Annual revision rates of partial versus total knee arthroplasty: A comparative meta-analysis

Background

Utilization of unicompartmental knee arthroplasty (UKA) and patellofemoral arthroplasty (PFA) as alternatives to total knee arthroplasty (TKA) for unicompartmental knee osteoarthritis (OA) has increased. However, no single resource consolidates survivorship data between TKA and partial resurfacing options for each variant of unicompartmental OA. This meta-analysis compared survivorship between TKA and medial UKA (MUKA), lateral UKA (LUKA) and PFA using annual revision rate as a standardized metric.