Arthrography of painful hips following arthroplasty: digital versus plain film subtraction

Digital and manual subtraction images obtained during the arthrographic evaluation of 78 painful hip prostheses were reviewed retrospectively. Revision arthroplasty was performed in 53 of these cases, and the arthrographic and surgical findings were correlated. The digital and manual subtraction images were evaluated without knowledge of the surgical results using established criteria for component loosening. Digital subtraction arthrography of the femoral component demonstrated a 96% sensitivity and 100% specificity for the diagnosis of component loosening. Sensitivity and specificity for acetabular component loosening were 83% and 80%, respectively. Plain film subtraction of the femoral component demonstrated a 79% sensitivity and 100% specificity; the sensitivity and specificity for the acetabular component were 75% and 80%, respectively. The difference between detection of femoral component loosening on digital as opposed to manual subtraction images was statistically significant (P<0.05). This study demonstrates that digital subtraction improves the evaluation of femoral component loosening in painful hip prostheses.     

全髋关节置换术后股骨皮质的肥厚反应

目的 观察全髋转换术后股骨皮质的肥厚反应及其临床意义。方法 １９９３年１月～１９９５年８月,应用同一设计的骨水泥和非骨水泥股骨假体,共施行２４６髋全髋关节转换术。骨水泥组１１７髋,平均随访４．５年;非骨水泥组１２９髋,平均随访４．１年。结果骨水泥组无一例有股骨皮质肥厚,髋关节功能优良率８８．９％,无一例假体松体;非骨水泥组３６髋（２７．９％）出现股骨远侧皮质肥厚反应,髋关节功能优良率９５．３％,假     

Digital subtraction arthrography in preoperative evaluation of painful total hip arthroplasty

 Objective. The objective of this clinical study was to define the diagnostic value of plain radiography, digital subtraction arthrography and two-phase bone scintigraphy in patients with clinically loose or infected hip prostheses. Design. Digital subtraction arthrograms, scintigrams and plain radiographs of 70 consecutive patients who underwent revision hip arthroplasty were scored individually and in masked fashion for the presence or absence of features indicating loosening of femoral and/or acetabular components. The operative findings acted as the gold standard. Results. Digital subtraction arthrography was best (P<0.001) for predicting a loose acetabular component, while no significant additional predictive value was found for plain radiographs (P=0.24) and scintigraphy (P=0.27). Digital subtraction arthrography was also the most important modality for predicting a loose femoral component (P=0.001), while the plain radiograph was of significant (P=0.04) additional value and scintigraphy was of no additional value (P=0.13) on multivariate analysis. Conclusion. Digital subtraction arthrography gives the best results in the prediction of loosening of acetabular and femoral components. Plain radiographs give additional information on loosening of the femoral component, but scintigraphy offers no additional advantage.     

99Tcm-MDP显像用于人工髋关节置换术后关节感染的鉴别诊断

目的 探讨99Tcm-MDP显像用于髋关节置换术后关节感染与无菌性假体松动鉴别诊断的适合方法.方法 回顾性分析2008年2月至2011年8月间74例人工髋关节置换术后出现关节疼痛的患者资料,其中男32例,女42例,年龄(64.3±11.2)岁.所有患者均行99Tcm-MDP血流、血池和骨骼三时相显像及血清C反应蛋白和血红细胞沉降率测定.99Tcm-MDP显像分别以假体周围软组织放射性浓聚、假体周围骨骼放射性浓聚或两者同时存在作为关节感染的诊断依据;无上述阳性表现者即认为关节疼痛由无菌性假体松动所致.依据最终临床诊断,采用x2检验比较99Tcm-MDP显像中骨骼相、血流-血池相、血清学检查结果间诊断效能的差异.结果 74例患者中,有症状关节74个,其中感染关节24个,无菌性假体松动50个.诊断关节感染的灵敏度和特异性:血流-血池相分别为91.7％(22/24)和90.0％ (45/50),骨骼相分别为70.8％ (17/24)和48.0％ (24/50),血清C反应蛋白分别为62.5％ (15/24)和78.0％ (39/50),血红细胞沉降率分别为62.5％ (15/24)和76.0％ (38/50).血流-血池相对假体周围感染诊断的准确性优于单纯骨显像[90.5％ (67/74)和55.4％ (41/74);x2=23.159,P＜0.001],也优于血清C反应蛋白[73.0％(54/74) ;x2 =7.656,P＜0.05]和血红细胞沉降率[71.6％(53/74);x2 =8.633,P＜0.05]检测.结论 在髋关节置换术后关节感染与无菌性假体松动鉴别诊断中,99Tcm-MDP血流-血池相具有较高的临床价值,建议作为常规检查方法.     

全涂层表面微孔股骨假体在人工全髋关节翻修术中的应用

目的评价全涂层股骨假体在人工髋关节翻修术后的X线表现和临床效果。方法自1999年1月至2003年12月，对15例患者15髋采用全涂层表面微孔股骨柄假体进行全髋关节翻修术。男6例，女9例；年龄58～82岁，平均66岁。翻修原因：无菌性假体松动10例，感染性松动2例，假体松动、股骨骨折2例，股骨假体位置不良1例。所有患者均采用Harris髋关节评分和手术前、术后定期X线评价。结果15例患者均获随访，随访时问1～5年，平均2．3年。术前平均Harris评分为42分，最后随访时增加至89分。所有患者均在术后3个月后完全负重，原有髋关节疼痛缓解。在最后随访时，有14例股骨柄假体获得骨长入固定，有1例获得稳定的纤维固定。并发症包括股骨干骨折2例，其中1例为股骨柄尖端处无移位骨裂，1例为股骨假体柄远端穿出股骨皮质，术后脱位1例。本组中无假体固定失败的患者。无一例患者发生感染。结论全涂层非骨水泥股骨假体是髋关节翻修股骨侧的良好选择，近期X线和临床效果满意，对个子矮小的患者选用加长翻修柄应慎重。     

采用锥形股骨柄生物学固定对高龄患者行全髋置换术后的骨改建及临床疗效

目的 探讨采用锥形股骨柄假体生物学固定对高龄患者行全髋关节置换术(total hip arthroplsty,THA)后的假体周围骨改建及中期临床疗效.方法 随机选取2003年1月-2005年1月采用锥形股骨柄假体生物学固定行THA的高龄患者(70～90岁)30例(34髋).对术后及随访X线片的影像学资料、术后及随访中采用双能X线骨密度仪(DEXA)测量的手术前、后假体周围骨密度资料进行分析,临床疗效采用Harris标准评定,并以Kaplan-Meier法评价股骨假体的使用寿命.结果 4例死于肺癌,余26例(30髋)获5～7年(平均6年)随访.术后X线片测量显示12髋1年内假体下沉＜1.5 mm,无假体松动.增生性骨反应见于Gruen 2,3,4,5,6,11,12区;吸收性骨反应见于1,7区.DEXA检查显示骨密度增加在2,3,4,5区,骨密度减少主要发生在1,6,7区.术后6个月内,2,5区的骨密度增加速度最快(P＜0.05),2年后各区骨密度改变趋于稳定(P＞0.05).术后1年内的假体周围总骨密度减少较多(P＜0.05),手术2年后的假体周围总骨密度基本无改变(P＞0.05),只是骨量从股骨近端到远端呈区域性重新分布.髋关节功能Harris评分从术前38.56±8.21提高至最近随访时的86.32±6.01,假体6年存留率达100%.结论采用锥形股骨柄假体生物学固定对高龄患者行THA后的假体周围具有良好的骨改建模式,且中期临床效果良好.     

骨水泥股骨柄和非骨水泥臼杯在首次全髋关节置换术中的应用

目的 随访一组采用同一类型骨水泥型股骨假体和非骨水泥型髋臼假体组合在首次人工全髋关节置换术中的应用，并探讨该种混合型假体对于全身健康情况和骨质质量一般较差的老年患者的适用情况。方法 共有75例患者84髋得到临床和影像学随访，平均年龄为67．9岁。其中老龄股骨颈骨折患者41例41髋，平均年龄72．1岁。随访时间为4．1年。随访内容包括患者的健康状况、手术方法、术后恢复情况以及对于骨形态、骨水泥固定质量和假体稳定性的判断。结果 2例股骨假体发生无菌性松动，臼杯则未见骨溶解或松动征象。未出现骨水泥相关的术中或术后死亡，各类全身性疾病在围手术期无加重表现。41例股骨颈骨折患者术后Harris评分为81.1分。股骨近端骨形态A型17髋（20％），B型47髋（56％），C型20髋（24％）。骨水泥固定质量分别为A级31髋（37％），B级40髋（48％），C级13髋（15％）。结论 混合型人工关节置换术的短期随访结果良好；混合型人工关节的术后即时稳定性有利于老年患者的康复；在手术中必须应用现代骨水泥技术。     

人工全髋关节不稳定的影响因素及防治

目的 探讨人工髋关节不稳定的影响因素，以期防止人工全髋关节置换术后髋关节脱位。方法 1995—2005年收治人工关节置换术后脱位患者19例，其中男8例，女11例；年龄54—78岁，平均62．1岁。原发病包括股骨颈骨折4例，病理性股骨颈骨折1例，先天性髋关节脱位5例，骨性关节炎4例，股骨头无菌性坏死2例，人工关节翻修术后3例。8例患者采用闭合复位石膏固定3—6周，1例在闭合复位时死亡，10例在闭合复位失败后或有明确脱位原因的患者，采用手术切开复位。结果 8例患者采用闭合复位、石膏固定3—6周后获得成功。2例患者经闭合复位后再次失败，采用手术切开复位获得成功。8例闭合复位不成功直接手术切开复位获得成功。术后随诊2年，未再出现脱位现象。术后髋关节Harris评分平均82分（72—96分）。结论 人工全髋关节脱位由多种因素造成，强调以预防为主，全面分析和研究患者的具体情况，制定相应的方案，使关节周围组织张力、关节位置和头臼间的匹配关系达到最佳，并选用合适的假体，才能彻底避免髋关节不稳定的发生。     

复杂人工髋关节置换术35例

目的 探讨复杂人工髋关节置换术的经验。方法 回顾分析复杂人工髋关节置换术35例，其中人工髋关节术后感染12例，髋臼畸形10例，股骨短缩畸形5例，髋关节骨性强直8例。结果 本组手术全部成功，术后无感染发生。随访3个月－6年，平均2年8个月。1例死亡，生存的34例对手术结果满意。结论 （1）感染的髋关节手术不宜单纯清创，应取出原关节行I期或Ⅱ期翻修术，万古霉素骨水泥在翻修术中有利于感染的控制。（2）植骨以自体颗粒骨植骨较好，建议大块植骨时应辅以颗粒骨，并尽量选用钉板系统固定。（3）手术难度大，术前准备要求缌、全面，以随时处理可能出现的并发症，并制定多个预案，手术中及时发现并纠正各种意外。     

全髋关节置换术后异位骨化的X线观察

目的了解人工髓关节置换术（totalhiparthroplasty,简称THA）后异位骨化的发病情况及其X线表现。方法对333例（352个髋关节）接受THA的病例作了术后X线随访，时间最短者1年，最长者12年。按Brooker分级法加以分级记录，并与性别、年龄、手术原因等作了比较。结果在随访X线片上共发现异位骨化69例，检出率20.7％，男性较女性检出率高7.2％，但与年龄关系不大。85．5％（59例）的异位骨化出现在术后1年内，但也有迟至术后8年者(1例）。按Brooker分级方法，85．0％均属Ⅰ-Ⅲ级，Ⅳ级者仅15％。因强直性脊柱炎手术而发生严重异位骨化者要较其他病因为多。在X线片上早期的骨化皆位于髋关节外侧，以后在内侧也逐渐出现，形态各异以条片状为多，即使在Ⅳ期时仍以髓关节外侧骨化数量为多。结论异位骨化是THA术后常见的并发症，X线平片是诊断本病最简便经济的方法，也是临床确定治疗方案的主要依据。     

Shoulder,hip, and knee arthrography needle placement using fluoroscopic guidance: practice patterns of musculoskeletal radiologists in North America

Objective  The aim of this study was to evaluate the range of techniques used by radiologists performing shoulder, hip, and knee arthrography using fluoroscopic guidance. Materials and methods  Questionnaires on shoulder, hip, and knee arthrography were distributed to radiologists at a national radiology meeting. We enquired regarding years of experience, preferred approaches, needle gauge, gadolinium dilution, and volume injected. For each approach, the radiologist was asked their starting and end needle position based on a numbered and lettered grid superimposed on a radiograph. Results  Sixty-eight questionnaires were returned. Sixty-eight radiologists performed shoulder and hip arthrography, and 65 performed knee arthrograms. Mean experience was 13.5 and 12.8 years, respectively. For magnetic resonance arthrography, a gadolinium dilution of 1/200 was used by 69–71%. For shoulder arthrography, an anterior approach was preferred by 65/68 (96%). The most common site of needle end position, for anterior and posterior approaches, was immediately lateral to the humeral cortex. A 22-gauge needle was used by 46/66 (70%). Mean injected volume was 12.7 ml (5–30). For hip arthrography, an anterior approach was preferred by 51/68 (75%). The most common site of needle end position, for anterior and lateral approaches, was along the lateral femoral head/neck junction. A 22-gauge needle was used by 53/68 (78%). Mean injected volume was 11.5 ml (5–20). For knee arthrography, a lateral approach was preferred by 41/64 (64%). The most common site of needle end position, for lateral and medial approaches, was mid-patellofemoral joint level. A 22-gauge needle was used by 36/65 (56%). Mean injected volume was 28.2 ml (5–60). Conclusion  Arthrographic approaches for the shoulder, hip, and knee vary among radiologists over a wide range of experience levels. No grants were received for this study and no conflicts of interest to report.     

Computed tomography arthrography in traumatic hip dislocation

The newer diagnostic modalities such as computed tomography and magnetic resonance imaging are becoming increasingly used in the evaluation of joint trauma. The combination of computed tomography and arthrography can also be of significant diagnostic value in certain specific situations. In our case report, we describe its use in post-traumatic recurrent hip dislocation and its value, not only in depicting a posterior capsular tear, but also in the diagnosis of an internal joint derangement which may contribute to incongruous reduction of the hip joint.     

帕瑞昔布钠对全膝全髋关节置换术后镇痛的疗效分析

目的 评价帕瑞昔布钠对全膝关节置换术(total knee arthroplasty,TKA)和全髋关节置换术(total hip arthroplasty,THA)术后的镇痛效果. 方法 本研究为前瞻性、随机、双盲研究,由同一组医师完成101例TKA患者和105例THA患者,根据镇痛方式分为三组:(1)术中静脉注射帕瑞昔布钠组;(2)术中关节局部注射帕瑞昔布钠组;(3)对照组.比较术后三组的视觉模拟疼痛评分(VAS)、关节活动度(ROM)、术后直腿抬高能力和恶心、呕吐等并发症的发生率. 结果 术中静脉注射帕瑞昔布钠组和术中关节局部注射帕瑞昔布钠组在术后各时段的VAS评分和术后24 h ROM及直腿抬高能力的差异无统计学意义(P＞0.05),但均明显优于对照组(P＜0.05).使用帕瑞昔布钠后恶心、呕吐等并发症的发生率没有显著增加. 结论 术中静脉注射和术中关节局部注射帕瑞昔布钠对TKA和THA术后的镇痛效果确切,有利于患者关节功能的迅速康复,且操作简便、实用,是TKA和THA镇痛的有效方法之一.     

全髋关节假体安装参数的优化组合

目的 研究满足日常生活活动范围条件下,全髋关节假体安装参数优化组合及髋臼安装角度安全范围.方法 建立人工全髋关节三维可视化计算机模型,将髋关节屈曲≥110°、屈曲90°内旋≥30°、后伸≥30°、外旋≥40°定义为日常生活活动范围一般标准;将屈曲≥120°、屈曲90°内旋≥45°、后伸≥30°、外旋≥40°定义为严格标准,头颈直径比变化范围为2～2.92,假体颈前倾角变化范围为0°～30°,髋臼假体外展角变化范围为10°～60°,髋臼前倾角变化范围为0°～70°,计算满足上述两种活动标准,臼杯外展角每变化5°,相应的髋臼假体前倾角,颈干角设定为135°.髋臼前倾角和外展角组合的安全范围定义为满足上述活动范围而没有杯颈撞击的面积.应用SAS6.12统计软件对数据进行分析.结果 髋臼角度安全范围随着头颈比增大而增大;严格标准下的安全范围比一般标准的小.颈干角135°、一般标准活动度,髋臼前倾角平均值与外展角的和加0.816倍颈前倾角等于84.76°;严格标准活动度,髋臼前倾角平均值与外展角的和加0.873倍颈前倾角等于92.04°.结论 大的头颈直径比明显增大髋臼角安全范围的面积.髋关节活动范围要求越高,髋臼角安全范围就越小,但可以通过增大头颈比来纠正.一般标准和严格标准活动度,髋臼前倾角平均值与外展角的和(Y)与颈前倾角(X)的组合分别可通过公式进行估计:Y1=-0.816X1+84.76(R2=0.993),Y2=-0.873X2 +92.04(R2=0.999).     

Ultrasonography after hip arthroplasty

Ultrasonography was performed in 55 patients who had total Charnley hip arthroplasties. Effusions were identified in 19 patients and confirmed in all but 3 by arthrocentesis or at surgery. Aspirations were performed in 5 and demonstrated infection in 2. It is concluded that ultrasound is a valuable noninvasive method for assessing painful hip arthroplasty. It can demonstrate the presence of effusion, which should be aspirated to exclude infection.     

股骨头缺血坏死非骨水泥型全髋关节置换后生活质量评估与Harris评分的相关性研究

目的评估非骨水泥型人工全髋关节置换术（THA）治疗股骨头缺血坏死术后患者的生活质量。方法对我院1998年1月-2001年3月采用非骨水泥假体行THA治疗股骨头缺血性坏死患者71例（80髋）进行至少5年（或直至死亡）的随访。所有入选患者均在术前行Harris评分。随访时再对其进行Harris评分和评估健康相关生活质量的SF-36简明健康状况调查量表（the MOS 36-item short form health survey，SF-36）评分，并与四川省居民的生活质量参考值相比较，分析Harris评分与SF-36各项评分之间的相关性。结果共54例（62髋）患者获得至少5年的随访，Harris评分从术前平均44分（21～50分）提高到最新随访时平均92．4分（80～100分）（P〈0．01）。但最新随访时的SF-36评分除了躯体疼痛、情感职能和精神健康外，其余各项得分均较一般人群的参考值低（P〈0．05）。Harris评分与SF-36生理功能和躯体疼痛项评分有相关性（r=0．657，P〈0．01；r=0．524，P〈0．05），但与SF-36其他方面评分相关性不强（P〈0．05，或无相关性（P〉0．05）。结论股骨头缺血坏死患者在接受非骨水泥型THA治疗后，虽然其生理功能和疼痛缓解等生理健康方面的情况能得到较好的恢复，但是术后的生活质量还不理想；Harris评分不能有效地反映出患者除生理功能和疼痛以外其他一些生活质量方面的情况。因此，有必要将SF-36评分引入到全髋关节置换术的疗效评估中，对患者术后的生活质量加以关注。     

非感染性人工髋关节翻修术28例

目的探讨非感染性人工髋关节翻修的原因、术中常见的困难及对策。方法1994年1月-2004年12月收治的28例中，男17例，女11例；年龄42～87岁，平均65．5岁。左侧13髋，右侧15髋似体松动14例、臼松动11例，柄松动3例；股骨侧假体下沉4例；髋臼磨透3例；股骨柄似体过长3例；合并股骨假体周围骨折1例；股骨柄穿通皮质1例；头臼不匹配1例；臼后倾1例。股骨柄假体15例取出顺利，13例取出困难，结果翻修成功27例。失败1例。全部患者经6个月-8年随访，平均3年7个月、Harris评分术前平均为45分，随访时评分平均为84分。结论（1）无菌性松动和医源性错误是非感染性人工髋关节翻修的主要原因；（2）人工关节翻修手术难度大，术前要做好周密的准备，没有手术经验的医师尽量不要尝试；（3）股骨柄假体取出困难是髋关节翻修中常见的难题，骨水泥型更为突出；（4）术后科学的康复锻炼对功能恢复十分重要.     

MRI as a problem-solving tool in unexplained failed total hip replacement following conventional assessment

Objective To evaluate MRI as a problem-solving tool for patients with an unexplained failed total hip replacement following conventional radiological assessment. Methods and materials Patients’ informed consent was obtained in all cases. Institutional review board approval was obtained. Twenty-eight patients with unexplained failed total hip replacements following conventional radiological assessment underwent additional MR imaging with an optimised turbo-spin echo sequence. Images were reviewed by two musculoskeletal radiologists by consensus and compared with findings at surgery, or following response to image-guided intervention or clinical follow-up. Results Of the 28 patients, MRI revealed an unsuspected diagnosis explaining the cause of prosthesis failure in 15 patients. In eight of 15 patients in this group, subsequent minimally invasive image-guided intervention obviated the need for revision total hip replacement. No cause for prosthesis failure was identified in 13 patients. Discussion MRI may be successfully undertaken in patients following total hip replacement, and, when performed, it frequently leads to an unsuspected diagnosis, allowing informed patient treatment. In this study it allowed the identification of an unsuspected diagnosis in over 50% of cases. The authors state that they have no financial relationships to disclose.