H/G非骨水泥人工全髋关节置换术后聚乙烯内杯磨损临床研究

目的 对H/G非骨水泥人工全髋关节置换术后聚乙烯内杯的磨损及髋臼周围骨溶解的情况进行总结.方法 我院1991至1995年共进行58例(65髋)H/G非骨水泥人工全髋关节置换,其中35例(40髋)获得10年以上随访.对这35例(40髋)患者获得随访的病例,采用计算机数字化方法测量髋臼聚乙烯内杯的二维线性磨损.结果 35例40髋均有不同程度的磨损,磨损范围2～8 mm,平均磨损为(0.32±0.31)mm/年.10髋聚乙烯磨损超过6 mm,髋臼假体周围的骨溶解严重,并伴有金属假体的移位,其中5髋聚乙烯内杯完伞磨透,金属股骨头与金属髋臼相接触;5髋聚乙烯内杯磨损严重伴明显骨溶解,内杯松动.2髋聚乙烯内杯脱位.共实施翻修手术12例,包括更换聚乙烯内杯和金属股骨头2例、金属闩杯翻修2例、全髋翻修8例.28髋在髋臼侧发现骨溶解,其中14髋股骨侧亦有骨溶解发生.结论 本组病例所观测到的H/G髋臼聚乙烯内杯的磨损程度超过文献所报道,而且由于磨损产生的大量磨屑,导致假体周围出现明显骨溶解,直接影响到假体的稳定.关节置换术后应定期随访,避免出现严重骨溶解后增加翻修手术的困难.     

Complete acetabular cup revision versus isolated liner exchange for polyethylene wear and osteolysis without loosening in cementless total hip arthroplasty

Introduction  

Revision surgery in patients showing polyethylene wear and acetabular osteolysis without visible acetabular cup loosening involves the difficult decision of whether to revise only the liner or both the cup and the liner. The purpose of this study is to compare the outcomes of complete acetabular revision and isolated liner exchange in patients showing wear and osteolysis without loosening.     

Results of the anatomic medullary locking total hip arthroplasty at a minimum of twenty years. A concise follow-up of previous reports

Between October 1982 and December 1984, the senior author performed 223 total hip arthroplasties in 215 patients with use of the anatomic medullary locking hip stem and TriSpike cup. We now report on 119 of these hips at a mean of 22.0 years (range, 20.0 to 25.0 years) after surgery. Of the fifty-six hips with minimum twenty-year follow-up radiographs and the original acetabular component, seventeen (30.4%) had pelvic osteolytic lesions measuring larger than 1.5 cm(2). Of the sixty-eight hips with twenty-year radiographs and the original anatomic medullary locking stem, twenty-five (36.8%) had femoral osteolytic lesions measuring larger than 1.5 cm(2). Acetabular osteolysis was significantly associated with cup loosening (p = 0.006), but the presence of femoral osteolysis was not associated with stem loosening. Kaplan-Meier analysis, with revision for any reason as the end point, revealed that the survival rate at twenty years was 85.8% +/- 5.2% for the acetabular shell and 97.8% +/- 2.2% for the stem. The most common reoperation was polyethylene exchange because of wear or osteolysis.     

Medium-Term Results of Cementation of a Highly Cross-Linked Polyethylene Liner Into a Well-Fixed Acetabular Shell in Revision Hip Arthroplasty

The present study was undertaken to document outcomes of cementation of a highly cross-linked polyethylene (PE) liner into a well-fixed acetabular metal shell in 36 hips. All operations were performed by a single surgeon using only one type of liner. Patients were followed for a mean of 6.1 years (range, 3–8 years). Mean Harris hip score improved from 58 points preoperatively to 91 points postoperatively. There were no cases of PE liner dislodgement or progressive osteolysis. 1 hip (2.8%) required revision surgery for acetabular cup loosening with greater trochanteric fracture. Complications included 1 peroneal nerve palsy and 1 dislocation. The results of this study and previous reports demonstrated that cementation of highly cross-linked PE liner into well-fixed metal shell could provide good midterm durability.     

Management of Polyethylene Wear Associated With a Well-Fixed Modular Cementless Shell During Revision Total Hip Arthroplasty

We identified 128 revision total hip arthroplasties from 1993 to 2005 involving a well-fixed Harris-Galante Porous (HGP)-I or HGP-II acetabular component with minimum 2-year post-revision follow-up. Three treatment cohorts were identified. Of the hips that underwent modular liner exchange at revision, 14 hips (25%) required re-revision of the acetabular component, 8 for liner dislodgement, 3 for osteolysis and poly-wear, 2 for dislocation, and 1 for aseptic loosening. Of the hips that underwent revision of the well-fixed shell, 4 (15%) required subsequent re-revision of the acetabular component; 2 for dislocation and 2 for aseptic loosening. Six hips (27%) in the cemented liner group were re-revised; 4 for dislocation and 2 for loosening. Complete revision of a well-fixed HGP acetabular component is more reliable than liner exchange or liner cementation.     

Dislocation after polyethylene liner exchange in total hip arthroplasty

Little has been published on the outcomes of polyethylene liner exchanges for wear or osteolysis. We assessed 24 patients from our clinic who had an isolated polyethylene liner exchange for wear or osteolysis with retention of the acetabular shell and femoral stem. At a mean 56-month follow-up time, 6 hips (25%) had dislocated. Of these, 2 underwent repeat surgery for recurrent dislocation; 1 had 3 dislocations; 1 had 2 dislocations; and 2 had single dislocations. Seventeen of the remaining patients answered our questionnaire: 13 recovered faster from the polyethylene liner exchange than from the primary arthroplasty; 4 believed that their hips were not as stable, 4 believed the hip did not function as well; and 1 underwent revision for cup loosening. We conclude that polyethylene liner exchanges, with or without femoral head exchange for wear or osteolysis, are associated with a high risk of dislocation and possible decrease in function.     

Ceramic-on-ceramic THA Associated With Fewer Dislocations and Less Muscle Degeneration by Preserving Muscle Progenitors

Background

Dislocation is a common complication after total hip arthroplasty (THA). Although the etiology of dislocation is multifactorial, longer-term changes in muscle such as atrophy may influence the risk of prosthetic dislocation. Biological differences in wear products generated by different bearing surfaces may influence differences in the appearance of periarticular muscle after THA; however, such bearing-associated differences to our knowledge have not been studied in vivo, and few studies have evaluated bearing-associated differences in dislocation risk.

Questions/purposes

(1) Is there a correlation between the postoperative risk of dislocation at revision and the bearing surfaces of the primary arthroplasty? (2) Is there a higher extent of fatty muscle atrophy on CT scan in hips with osteolysis (polyethylene hips) as compared with hips without osteolysis (ceramic-on-ceramic hips)? (3) Are these two abnormalities (bone osteolysis and fatty atrophy) associated with a decrease of mesenchymal stem cells (MSCs) in bone and in muscle?

Methods

We retrospectively evaluated 240 patients (240 hips) who had a THA revision (98% of which, 235 of the 240, were isolated acetabular revisions) and a normal contralateral hip. All patients had received the same implants for the primary arthroplasty (32-mm head) except for bearing surfaces (80 hips with ceramic-on-ceramic, 160 with polyethylene). No differences were noted between the groups in terms of age, sex, body mass index, proportion of patients who had a dislocation after the index arthroplasty but before the revision, and proportion of the patients with stem loosening in addition to acetabular loosening. Indications for revision generally were cup loosening. The revisions in the hips with polyethylene bearings generally had more acetabular bone loss, but the position of the center of the cup and the orientation of the cup were similar after reconstruction in the two groups. Before revision, osteolysis, muscle atrophy, and fatty degeneration were evaluated on CT scan and compared with the contralateral side. Bone muscle progenitors were evaluated by bone marrow MSCs and satellite cells for muscle. At revision, all the hips received the same implants with the same head diameter (32 mm) and a standard liner. Revisions were performed between 1995 and 2005. The followup after revision was at a mean of 14 years (range, 10–20 years) for ceramic revision and 12 years (range, 10–20 years) for polyethylene hips, and there was no differential loss to followup between the groups.

Results

More hips with polyethylene liners at the time of index arthroplasty dislocated after revision than did hips with ceramic liners (18% [29 of 160] compared with 1% [one of 80]; odds ratio, 17.5; 95% confidence interval, 2.3363–130.9100; p = 0.005). For the 80 hips with ceramic-on-ceramic, no osteolysis was detected before revision; there was no muscle fatty degeneration of the gluteus muscles on CT scan or histology. For the 160 hips with polyethylene liners, osteolytic lesions on the acetabulum and femur were observed in 100% of the hips. The increased atrophy of the gluteus muscles observed on CT scan correlated with the increase of osteolysis (r = 0.62; p = 0.012). The surgical limbs in the patients with polyethylene hips as compared with ceramic-on-ceramic hips demonstrated a greater reduction in cross-sectional area (respectively, 11.6% compared with 3%; odds ratio, 3.82; p < 0.001) and radiological density (41% [14.1/34.1] compared with 9%; odds ratio, 6.8; p = 0.006) of gluteus muscles when compared with the contralateral normal side. (41% compared with 9%; odds ratio, 6.8; p = 0.006).

Conclusions

Ceramic bearing surfaces were associated with fewer dislocations after revision than polyethylene bearing surfaces. The reasons of the lower rate of dislocation with ceramic-on-ceramic bearings may be related to observed differences in the periarticular muscles (fat atrophy or not) with the two bearing surfaces.

Level of Evidence

Level III, therapeutic study.     

Primary uncemented Harris-Galante acetabular components in patients 50 years old or younger: results at 10 to 12 years

Seventy-three patients (84 hips) 50 years or younger were treated with primary total hip arthroplasty using the Harris-Galante uncemented acetabular component. At a median followup of 10 years, there were seven acetabular metal shell revisions: five for osteolysis and one each for aseptic loosening and dislocation. There were 10 polyethylene exchanges without metal acetabular shell removal. None of the unrevised acetabular components was radiographically loose, but eight had pelvic osteolysis. The rate of 10-year survival without revision of the acetabular metal shell was 87.9% (95% confidence interval, 80.1%-95.7%). The same rate of survival without revision for aseptic acetabular component loosening was 97.3% (95% confidence interval, 92.9%-100%). Revision for aseptic acetabular loosening or polyethylene liner exchange or both was 84.5% (95% confidence interval, 75.8%-93.4%).     

Clinical and radiographic assessment of cementless acetabular revision with morsellised allografts

The aim of this study was to evaluate the clinical and radiographic results of cementless acetabular revision with deep frozen morsellised allografts. Sixty-one patients (65 hips) underwent acetabular revision using cementless components and deep frozen morsellised allografts. Fifty-seven hips (53 patients) were reviewed at a mean of 105.1 months (range 72–180 months) after revision. The study group included 29 males and 24 females with a mean age of 46.4 years. One cup underwent further revision for aseptic loosening and two were defined as radiographic failures. The mean time for allograft incorporation was 12.5 months (range 6–24 months) after index surgery. The mean Harris hip score of the patients improved from 61.1 points preoperatively to 91.6 points postoperatively. Linear and cavitary osteolysis was observed in two and 12 hips, respectively. The acetabular revision using cementless components with deep frozen morsellized allografts provides favourable clinical and radiographic results, although the initial disease and age may adversely affect the outcomes.