全髋关节股骨侧假体翻修术

目的 报道采用现代骨水泥和非骨水泥技术行全髋关节股骨侧假体翻修手术 26例的疗效。方法 翻修原因 :全髋关节股骨侧假体松动 23例 ,松动伴假体柄端股骨骨折 3例。翻修采用现代骨水泥技术固定者 10例 ,采用长柄股骨侧假体加自体植骨的非骨水泥固定者 16例。结果 骨水泥翻修组 ,平均随访 6年 ,优良 5例 (50％ ),尚可 3例 (30％ ),差 2例 (20％ )。其中再翻修 1例 (10％ );X线表现 :肯定松动 2例 (20％ ),很可能松动 1例 (10％ ),可能松动 5例 (50％ ),无松动 2例 (20％ ),多数患者早期即表现骨水泥－骨界面的广泛 X线透亮带、骨皮质进行性变薄和疏松等征象。非骨水泥翻修组 ,平均随访 5年 ,优 9例 (56％ ),良 6例 (38％ ),尚可 1例 (6％ ),无一例再翻修 ;X线表现 :骨性固定 12例 ,纤维性稳定 4例 ,无一例松动 ,骨皮质密度和厚度均显著增加。结论 非骨水泥翻修术的疗效显著优于骨水泥翻修术 ,自体植骨修复结构性骨缺损并采用长柄多孔表涂假体获得初始稳定 ,是其获得满意疗效的关键。     

股骨皮质骨开窗技术在髋关节翻修术中的应用

目的 探讨股骨前外侧皮质骨开窗技术在髋关节翻修术中取出股骨远端稳定固定骨水泥的价值.方法 2005年5月至2009年6月,共14例(14髋)因各种原因致髋关节置换术后失败患者接受全髋关节翻修手术.其中男性10例,女性4例,年龄54～75岁,平均66岁.翻修原因为股骨头置换术后髋臼磨损5例、全髋关节置换术后假体周围骨溶解并松动6例、骨水泥柄股骨近端骨溶解柄断裂1例、髋臼骨溶解假体松动翻修同时行股骨柄翻修1例,感染后二期翻修时远端骨水泥取出困难1例.14例(14髋)股骨柄均为骨水泥同定.术中按术前计划开窗部位、开窗范围于股骨皮质骨开一长方形骨窗.通过骨窗直视下彻底清除髓腔内稳定固定的骨水泥,修整股骨髓腔.植入翻修柄后将皮质骨开窗骨瓣原位回植,双股钢丝捆绑固定.术后定期随访拍摄x线片.观察皮质骨开窗骨瓣与周围骨愈合情况、骨瓣有无移位、股骨柄有无下沉以及有无捆绑钢丝断裂等.结果 10例患者术后获得随访,平均随访时间24.6个月.股骨皮质骨开窗长度2.5～6.0 cm,平均3.4 cm,宽度0.8～1.4 cm,平均1.2 cm.股骨开窗远端以远部分发生纵形劈裂骨折1例.无术中皮质骨穿孔及股骨干骨折.向远段扩大开窗1例,扩大长度1.5 cm.开窗部位皮质骨骨瓣原位回植选择2～3道双股钢丝固定,平均2.3道.随访期间2例发牛假体柄下沉(平均2.5 mm),无皮质骨瓣移位以及捆绑钢丝断裂,术后3～5个月皮质骨瓣已于周围骨纤维愈合.随访期间无一例因各种原因致再次翻修.结论 股骨皮质骨开窗技术在髋关节翻修术中有助于直视下彻底取出股骨髓腔远端稳定固定的骨水泥,同时不会造成股骨骨丢失、不影响翻修柄植入后的稳定固定.     

逆行击出法在股骨侧假体翻修术中的应用

目的：探讨逆行击出法在股骨侧假体翻修术中的应用及疗效。方法：从1998年12月～2001年12月，采用该法取出股骨柄、骨水泥，行翻修术12例。平均年龄64．5岁。术后随访6～24个月，平均18个月。Harris评分为87．3分。结果：12例患者术后第3d均在双拐辅助下行走，2周后改扶单拐行走，1个月后弃拐行走。结论：本技术在力学上更符合股骨上、中段髓腔上宽下窄的解剖特点。以逆行法取出股骨柄及滞留的骨水泥，能缩短手术时间，省力，对骨质干扰较小，术后恢复快。     

人工髋关节翻修的股骨假体柄的形态及稳定性的临床观察

目的 :根据全髋关节翻修所得资料,分析人工股骨柄在生理应力作用下的状态,讨论延长人工关节使用年限的注意事项,为临床工作积累更多经验。方法:选择53例单侧全髋关节置换术后需要行翻修手术的患者,其中男28例,女25例;平均年龄74.66岁(61~84岁)。人工关节平均使用年限18.24年(3~27年),首次置换术后初始下地负重时间平均11 d(5~16 d),翻修的主要原因为自发松动和外伤。根据患者影像学资料和手术直观所见进行分析,并根据组织学病理做出推断。结果:股骨柄假体在生理应力下存在微动沉降,其二次稳定与股骨柄设计、患者动态、骨质和骨长入性状有关。直柄假体有利于生理性沉降,实现紧密接触的骨长入稳定,可以在患者条件允许下早期负重锻炼。有领假体和结合内固定假体限制股骨柄沉降,其稳定性取决于首次安置时的压配和后期骨长入支撑,对该类患者建议延长非负重时间。结论:根据患者实际情况,选择恰当的股骨假体和下地负重时机可以延长股骨假体的使用年限,减少松动概率。     

嵌压植骨技术在人工全髋关节翻修术中的应用

目的 探讨使用嵌压植骨技术进行全髋关节翻修术的临床效果。方法1998年12月至2003年9月,采用嵌压植骨技术对48例患者72侧髋关节进行了翻修,平均随访时间25个月,采用Harris评分及X线片观察进行临床疗效评定,并统计并发症的发生率。结果Harris评分从术前平均44．6分提高到术后87．4分,术后优良率为达90．3％;无假体松动及下沉;股骨骨折发生率为4．2％;关节脱位率为1．4％,感染率为1．4％。结论嵌压植骨技术是一种有效重建髋关节置换术后松动所致严重骨缺损的方法。采用冻干异体骨植骨及解剖柄股骨假体同样可以获得满意的临床效果。     

非骨水泥长柄假体在髋关节翻修术中的应用

目的回顾性分析非骨水泥全涂层长柄假体在全髋关节翻修术中应用的临床疗效。方法对2006年1月至2011年1月四川大学华西医院收治的采用全涂层长柄假体全髋关节翻修术的53例患者（53髋）进行随访、分析。其中男26例,女27例;年龄49—78岁,平均62岁。股骨假体采用强生（Depuy）公司全涂层长度为165mm的直柄AML假体10例、全涂层165mm的Solution假体19例和203mm带弧度分左右侧的Solution假体24例。比较髋关节术前术后的Harris评分,x线片评价假体柄有无松动下沉及应力遮挡情况。结果53例患者均获随访,随访时间1．8～6．8年,平均4．7年。术前平均Harris评分为37分,最后随访时增加至86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45例股骨柄假体获得骨长人固定。并发症：术后脱位1例,手法复位后未再发生脱位,术后感染1例,假体柄明显下沉1例,后两例患者行再次翻修术,末次随访假体柄稳定。随访X线片显示多数患者骨质改建,密度增加,未发现假体周围有连续亮带及假体柄下沉的患者。结论复杂的股骨侧翻修手术,应尽可能选择非骨水泥长柄假体。特别是股骨干骺端骨质条件差,中段有骨缺损,近端不能获得牢固固定的病例。术中结合同种异体颗粒骨打压植骨处理股骨中上段中重度骨缺损,中期临床疗效良好,远期效果有待随访。     

骨移植在髋关节翻修术修复股骨侧缺损中的应用

目的探讨采用颗粒骨及结构骨植骨技术进行人工髋关节股骨侧假体翻修术的临床效果。方法2001年6月至2005年10月，采用颗粒骨或／和结构骨植骨技术对16例人工髋关节股骨侧假体进行了翻修，平均随访时间39个月，采用Harris评分及X线片观察进行临床疗效评定。结果Harris评分从术前平均41．7分提高到术后82．6分，术后优良率为达87．5％；9例患者无假体松动及下沉；余7例出现不同程度的股骨假体下沉，下沉的高度低于0．5～1cm；所有患者未出现假体松动的症状，无需再次翻修术。结论进行有效骨缺损修复，成功地重建股骨近端的骨结构是人工髋关节股骨侧骨假体翻修的关键。     

采用抗生素骨水泥假体二期翻修治疗人工髋关节感染

目的探讨采用抗生素骨水泥假体二期翻修治疗人工髋关节感染的疗效。方法自1999年6月至2004年10月,14例初次髋关节置换术后感染患者行二期手术。术前Harris评分平均23分。一期手术中将取出的假体彻底清洗,骨水泥垫临时旷置,关节内引流管引流,术后静脉输入抗生素3周后,改为口服抗生素1个月。二期手术于6个月后进行,植入带抗生素骨水泥型假体。结果14例患者均获得随访,随访时间7～26个月,平均18个月。14例患者术后均无感染复发。术后Harris评分平均70分。结论彻底清创、足够间隔期以及二期手术采用抗生素骨水泥假体是有效控制感染复发的有效措施。     

异体皮质骨支撑植骨在髋关节股骨翻修术中的应用

目的探讨异体皮质骨支撑植骨在髋关节股骨翻修术中应用的适应证及临床效果。方法从2001年10月至2007年12月，笔者对41例股骨严重骨缺损的患者在髋关节翻修术中应用了同种异体皮质骨支撑植骨。主要在以下三种情况下使用，一是采用延长股骨粗隆截骨（ETO）取股骨假体，而患者近端骨质疏松或原有严重的骨缺损，采用远端固定假体翻修，为增加股骨近端的强度或增加ETO后股骨近端的稳定性而采用，这类患者共20例；二是在采用打压植骨进行股骨重建时，因为股骨存在有节段性缺损，或因取股骨远端骨水泥而进行股骨开窗造成股骨节段性缺损时，为了封闭骨缺损，使其成为包容性缺损而采用，这类患者共6例；三是在有严重股骨骨质疏松的患者出现股骨骨折时采用，这类患者共15例。笔者进行了平均37个月（6～72个月）的随访。结果所有同种异体皮质骨在术后12个月可以看出有与宿主骨结合的征象，假体固定稳定。未发生感染、排异反应或假体松动征象，髋关节Harris评分从术前平均38分增加到术后的88．1分。结论异体皮质骨支撑植骨在某些股骨翻修情况下有其特殊的需要，能够作为生物接骨板提供机械稳定性和生物稳定性，目前有不可替代的作用。     

异体皮质骨桥接技术在人工髋关节股骨侧翻修中的应用

目的 评价大段异体皮质骨桥接(onlay)技术在人工髋关节股骨侧翻修术中的临床应用情况.方法 自2000年1月,共23例(23侧)髋假体翻修手术中采用了新鲜冷冻异体皮质骨板的桥接技术.手术时患者平均年龄(66.3±6.5)岁.翻修原因:17例为假体无菌性松动,6例为假体松动伴假体周围骨折.根据AAOS骨缺损分型标准:Ⅱ型6例,Ⅲ型11例,Ⅵ型6例.骨缺损严重度均为Ⅲ度.患者接受临床评估,包括Harris评分、疼痛度视觉模拟评分(visual analogue scale,VAS)和满意度VAS.放射学评估假体的稳定性、下沉情况及移植骨的愈合和吸收情况.结果 术后平均随访4.2年,未出现假体失败再翻修.Harris评分由术前平均(32.7±15.5)分上升到术后平均(76.7±9.2)分.疼痛度VAS由术前平均(44.2±12.4)分降为终末随访时的平均(14.5±5.1)分,19例疼痛评分＜20分,优良率82.6%.满意度VAS平均为(76.8±9.2)分,其中14例评分＞80分,优良率为60.9%.放射学结果显示仅1例非骨水泥型假体翻修为纤维连接,2例骨水泥型假体翻修为可疑松动.所有31块移植骨和宿主骨间均获得桥接愈合,24块异体骨出现轻度边缘吸收.结论 大段异体皮质骨的桥接技术可以成功应用于髋关节股骨侧Ⅱ、Ⅲ、Ⅵ型骨缺损的翻修,具有力学支持和恢复骨量的效果,但须注意移植骨和假体的选择.     

An analysis of stably fixed femoral components retained during revision total hip arthroplasty

This study was conducted to analyze the clinical and radiographic results of isolated acetabular revisions during which intact femoral stems were retained. Twenty-nine hips of 26 patients who were followed up for a minimum of 3 years were examined. The average time from primary operation to revision surgery was 9.2 years, and the average follow-up time after revision was 5 years. The average Harris hip scores improved from 56.4 to 89.8 points after revision surgery, and in all cases, the acetabular components and femoral stems were assessed as stable at the final follow-up. The average length of service of the femoral components was 14.2 years. In conclusion, we recommend that isolated acetabular revision be considered in cases with an acetabular component failure and a stable femoral component.     

Femoral revision in hip resurfacing compared with large-bearing metal-on-metal hip arthroplasty

It has been suggested that revision of the femoral component of hip resurfacing after femoral failure would be straightforward and have an outcome comparable to primary total hip arthroplasty (THA). We have compared the outcome of femoral side-only revision resurfacings to the results of primary modular large-bearing metal-on-metal THA. Fourteen consecutive patients underwent revision surgery of the failed femoral component, to a cemented tapered stem (CPT, Zimmer, Warsaw, Indiana) with a large modular metal head (Smith and Nephew Orthopaedics Ltd, Memphis, Tennessee, or Adept, Finsbury Orthopaedics, Surrey, England). The acetabular component was found to be well fixed, well orientated, and was left in situ. The 14 matched patients in the primary THA group received the same components. At a mean follow-up of 49 months (range, 30-60 months), clinical outcome measured using the Oxford and Harris Hip Scores showed no significant difference (P = .11, P = .45, respectively). Operative time and blood loss were comparable for both groups. We conclude that revision of the failed femoral resurfacing component gives excellent results.     

Fashioning of an anterolateral femoral bony lid for revision hip arthroplasty

Objective  Safe removal of a loosened or broken femoral stem together with cement particles and soft tissues. Preparation of the implant bed under direct vision and exact fitting of the new stem. Restoration of pain-free hip motion. Indications  Exchange of loosened or broken femoral stem, its simple extraction being impossible or fraught with complications and time-consuming. Contraindications  Exchange procedures that can be performed without resorting to an anterolateral bony lid. Surgical Technique  Anterolateral approach over the extent of the femoral stem plus cement plug. Fashioning of an anterolateral bony lid (approximately one third of the shaft circumference). The remaining part of the lateral cortex remains undisturbed. If at all possible, a proximal bony ring should be preserved. Distal part of the lid is shaped like a keel. Removal of stem, cement, granulation tissue, and necrotic bone. Reconstruction of the bed for the new femoral stem. All bony cavities are cleaned with a burr and filled with autogenous or allogenic bone. Insertion of revision stem protruding proximally by 1 cm. Closure of the lid. Stabilization with three cerclage wires. Final stable seating of the stem by gentle hammer blows. Results  This approach was used in 49 patients (average age 65 years [26–98 years]). Two patients died of unrelated causes, two could not be reached. The remaining 30 women and 15 men were followed up for 8.4 years (1–14 years). The average Harris hip score improved from 36 to 84 points. All osteotomies consolidated.     

The use of a revision femoral stem to manage a distal femoral periprosthetic fracture in a well-fixed total knee arthroplasty

Managing very distal femoral periprosthetic fracture above a total knee arthroplasty (TKA) is a difficult problem. When a cruciate sacrificing TKA is used, bone stock around the implant is compromised and, therefore, can limit fixation options. We present technique using the revision system femoral stem for the PFC Sigma TKA (Depuy; Leeds, England) to stabilize this particular type of fracture.     

Results of Wagner SL revision stem with impaction bone grafting in revision total hip arthroplasty

Background:

As the number of total hip arthroplasties (THAs) performed increases, so do the number of required revisions. Impaction bone grafting with Wagner SL Revision stem is a good option for managing bone deficiencies arising from aseptic osteolysis. We studied the results of cementless diaphyseal fixation in femoral revision after total hip arthroplasty and whether there was spontaneous regeneration of bone stock in the proximal femur after the use of Wagner SL Revision stem (Zimmer, Warsaw, IN, USA) with impaction bone grafting.

Materials and Methods:

We performed 53 hip revisions using impaction bone grafting and Wagner SL Revision stems in 48 patients; (5 cases were bilateral) for variety of indications ranging from aseptic osteolysis to preiprosthetic fractures. The average age was 59 years (range 44-68 years). There were 42 male and 6 female patients. Four patients died after surgery for reasons unrelated to surgery. 44 patients were available for complete analysis.

Results:

The mean Harris Hip Score was 42 before surgery and improved to 86 by the final followup evaluation at a mean point of 5.5 years. Of the 44 patients, 87% (n=39) had excellent results and 10% (n=5) had good results. The stem survival rate was 98% (n=43).

Conclusion:

Short term results for revision THA with impaction bone grafting and Wagner SL revision stems are encouraging. However, it is necessary to obtain long term results through periodic followup evaluation, as rate of complications may increase in future.     

Early outcome of a modular femoral component in revision total hip arthroplasty

Forty-six hips in 42 patients underwent revision surgery with a modular femoral component (ZMR; Zimmer, Warsaw, Ind). Thirty-nine hips with 2 to 5 years' follow-up were evaluated radiographically and clinically by the Harris hip score and WOMAC pain/stiffness/function scores. The Harris hip score improved from 47.4 to 72.3 (P<.001), with significant improvements in the WOMAC pain/stiffness/function scores. The mean subsidence was 4.4 mm, with 5 hips demonstrating significant subsidence of more than 5 mm. Four hips required reoperation, 1 due to failure of the femoral component. No early complications were encountered regarding the modular junction. Modular, cementless, extensively porous, coated femoral components have demonstrated early clinical and radiographic success. Distal intramedullary fit helps ensure initial stability; proximal modularity further maximizes fit while optimizing hip offset and length.     

Posterior longitudinal split osteotomy for femoral component extraction in revision total hip arthroplasty

We present a technique of single posterior longitudinal split osteotomy. This technique allows the expansion of the proximal femur and easier extraction of uncemented femoral components. Since 1998 we have performed this osteotomy in 12 revision total hip arthroplasties in 11 patients who had either stable fibrous ingrowth or a small amount of bony ingrowth. All were revised to a cemented Exeter stem (Stryker Benoist Gerard, Caen, France). No patient required conversion from a longitudinal split to an extended trochanteric osteotomy. At mean follow-up of 48 months, there were significant improvements in both pain and function. There were no complications due to this technique. Mean in-cement taper engagement (subsidence) was 1.1 mm (range, 0-2 mm). Femoral impaction grafting did not adversely affect the cement mantle or increase in-cement taper engagement. With appropriate patient selection, this is a simple, reliable, and extensile technique to assist in the extraction of uncemented ongrowth femoral components whether hydroxyapatite-coated or not.     

Early failure of unicompartmental knee arthroplasty leading to revision

The most common previously reported modes of failure of unicompartmental knee arthroplasty (UKA) in the first and second decades are polyethylene wear, progression of arthritis, and component loosening. The purpose of this study is to describe an early mechanism of failure of the medial UKA. Thirty-two consecutive revisions from UKA to total knee arthroplasty were retrospectively reviewed. The predominant mode of failure observed in 15 (47%) of 32 knees was medial tibial collapse. Of these, 87% were an all-polyethylene design, and 7 of 15 failed in less than 16 months and required more complex reconstruction with stems, augments, and screws and cement. Increased tibial slope was associated with posterior tibial collapse. In our series, knees that failed by medial tibial collapse had more significant bone defects and required more complex reconstructions than is currently reported in the literature.     

Extensile exposure of the hip for revision arthroplasty

The authors describe a lateral approach to the hip without trochanteric osteotomy that allows sufficient access to the femur and acetabulum for revision total hip arthroplasty. When bone loss is extensive, this approach permits massive autograft/allograft arthroplasty of the proximal femur and acetabulum. This approach follows anatomic muscle planes, maintains abductor function, and allows wound closure with a viable muscle cuff around the acetabulum and upper femur. The exposure is adequate for anatomic placement of components and correction of leg length discrepancy.