Cementless total hip arthroplasty with femoral head bone grafting for hip dysplasia

Femoral head bone grafting was required to augment acetabular bone stock in 19 cases of hip dysplasia treated with cementless total hip arthroplasty. All acetabular grafts provided mechanical support for the cementless acetabular component. Radiographic evaluation of the fixation of the femoral components at an average of 3 years after surgery revealed an optimum appearance in all cases. All porous-coated acetabular components remained stable, but only one of six (17%) nonporous threaded acetabular components maintained stability. One threaded acetabular component has been revised for symptomatic loosening. Acetabular graft healing was suspected in 18 of 19 cases (95%). Significant graft resorption was observed only in the cases with unstable threaded acetabular components. The clinical scores were high. Cementless total hip arthroplasty with structural acetabular grafting and porous acetabular components appears to produce satisfactory short-term results.     

Total Hip Arthroplasty in Patients with Crowe III/IV Developmental Dysplasia of the Hip: Acetabular Morphology and Reconstruction Techniques

The severe anatomic deformities render acetabular reconstruction as one of the greatest challenges in total hip arthroplasty (THA) for patients with Crowe III/IV developmental dysplasia of the hip (DDH). Thorough understanding of acetabular morphology and bone defect is the basis of acetabular reconstruction techniques. Researchers have proposed either true acetabulum position reconstruction or high hip center (HHC) position reconstruction. The former can obtain the optimal hip biomechanics, including bulk femoral head autograft, acetabular medial wall displacement osteotomy, and acetabular component medialization, while the latter is relatively easy for hip reduction, as it can avoid neurovascular lesions and obtain more bone coverage; however, it cannot achieve good hip biomechanics. Both techniques have their own advantages and disadvantages. Although there is no consensus on which approach is better, most researchers suggest the true acetabulum position reconstruction. Based on the various acetabular deformities in DDH patients, evaluation of acetabular morphology, bone defect, and bone stock using the 3D image and acetabular component simulation techniques, as well as the soft tissue tension around the hip joint, individualized acetabular reconstruction plans can be formulated and appropriate techniques can be selected to acquire desired clinical outcomes.     

High hip center in revision arthroplasty

What is the effect of superior placement of the acetabulum in complex hip reconstruction? Twenty-two patients (23 cases) had revision hip arthroplasty with superiorly placed porous-coated components without bone-grafts. Cemented femoral components were used in 21 cases and ingrowth components in 2. The average vertical height (corrected for magnification) was 36.8 mm from the interteardrop line, compared to a contralateral normal height of 12.1 mm. Three patients were deceased. The remaining 19 patients (20 hips) had a minimum 2-year follow-up period (average, 35 months). Fourteen hips had two or more previous surgeries. Seven acetabular components had thin (< 1 mm), nonprogressive, incomplete radiolucent lines. One acetabulum had a complete 1 mm radiolucent line in an asymptomatic patient. The remaining 12 acetabular components had no evidence of radiolucent lines and none of the acetabular components migrated. One hip with a cemented femoral component had evidence of possible loosening. Two cemented femoral components had evidence of definite loosening, one with minimal clinical symptoms and the other was revised to a long stem at 14 months after revision. Of the two ingrown femoral components, one had initial subsidence of 1.5 cm and both had thigh pain. All other patients had improved from their preoperative status; however, 4 of 20 hips had moderate to severe pain. Superior cup position did not result in concomitant lateral position. With a shortterm follow-up period however, vertical displacement alone resulted in high loosening rates, with 25% for the femur and 5% for the acetabulum.     

Efficacy of alumina ceramic heads for cemented total hip arthroplasty.

Fifty-seven cemented total hip arthroplasties (THAs) were reviewed in cases of osteoarthrosis secondary to congenital dysplasia or dislocation. The bearing surface of the prosthesis used in this series consists of a polyethylene acetabular component on an alumina ceramic head. All acetabular components were positioned at the same level as the original acetabulum, and an autologous femoral head graft was performed for 18 hips. The follow-up period ranged from five to eight years, averaging six years two months. The latest survey showed excellent and good results for 53 hips (92.9%). Four acetabular components (7%) and two femoral components (3.5%) showed roentgenographic evidence of loosening. Only one hip (1.8%) had to be treated with revision surgery for femoral component loosening. None of the cases suffered a broken ceramic head. The use of a total hip prosthesis with an alumina ceramic head in THA is likely to lead to excellent results for patients with osteoarthrosis of the hip.     

Cementless total hip replacement using second-generation components: a 12- to 16-year follow-up

We reviewed 123 second-generation uncemented total hip replacements performed on 115 patients by a single surgeon between 1993 and 1994. The acetabular component used in all cases was a fully porous-coated threaded hemispheric titanium shell (T-Tap ST) with a calcium ion stearate-free, isostatically compression-moulded polyethylene liner. The titanium femoral component used was a Taperloc with a reduced distal stem. No patient was lost to follow-up. Complete clinical and radiological follow-up was obtained for all 123 hips at a mean of 14 years (12 to 16). One femoral component was revised after a fracture, and three acetabular components for aseptic loosening. No additional femoral or acetabular components were judged loose by radiological criteria. Mild proximal femoral osteolysis was identified in two hips and minor acetabular osteolysis was present in four. The mean rate of penetration of the femoral head was 0.036 mm/year (0.000 to 0.227). These findings suggest that refinements in component design may be associated with excellent long-term fixation in cementless primary total hip replacement.     

Porous surface replacement of the hip with chamfer cylinder design

Fifty-seven porous surface replacements (PSR) were performed in 53 patients (36 men and 17 women) with a mean age of 54 years (range, 19-75 years). Follow-up examination times ranged from one year to 2.5 years with 33 patients having follow-up periods of at least two years. Preoperative diagnoses were osteoarthritis (OA), 37; osteonecrosis (ON), six; dysplasia, nine; rheumatoid ankylosing spondylitis, three; and other, two. Sixteen hips had metal-backed acrylic-fixed THARIES (total hip articular replacement by internal eccentric shells) acetabular sockets, nine hips had a cobalt chrome hemispherical beaded acetabular component with adjuvant screws, and 32 hips had a chamfer-cylinder designed acetabulum. Pain relief has been immediate and more complete than with acrylic-fixed or biologic-in-growth stem-type replacements with comparable walking and function improvements. There have been no major systemic complications, sepsis, or loosening. There have been two transient peroneal nerve palsies and three trochanteric fibrous unions. There has been one subluxation requiring reoperation. Histologic sections of the removed femoral surface component showed excellent (90%) bone ingrowth. Circumferential progressive radiolucencies developed at the bone-cement interface by one year in all of the 16 acrylic-fixed acetabular components. Reaming or seating defects were noted in 25% of the patients on postoperative radiographs. Serial radiographic analyses demonstrate progressive narrowing of all of the chamfered cylinder design and less in hemispherical design with screw fixation. These observations are encouraging and suggest healing of the bone-component interface with bony trabeculae in the porous-coated acetabular design. This new surface replacement (SR) of the hip uses porous-ingrowth fixation to overcome the major disadvantages of acrylic-fixed SR which are as follows: (1) excessive acetabular reaming, (2) poor long-term fixation, and (3) difficulty with acetabular revision.     

全髋关节置换术治疗成人髋关节发育不良的髋臼重建

目的探讨全髋关节置换术治疗成人髋关节发育不良（DDH）时不同方式髋臼重建对疗效的影响。方法 2000年1月至2007年10月,36例（44髋）先天性髋臼发育不良患者进行了全髋关节置换。年龄42～65岁,平均48岁。术前Harris评分平均为49.9分,双下肢长度差异平均为1.8 cm,髋关节平均活动度：屈曲59.6°,外展21.6°,内收13.9°,外旋10°,内旋8.2°。术中臼杯均安装于真臼处,髋臼内移14髋,髋臼内陷成形术18髋,自体股骨头结构性植骨12髋。髋臼侧均选用非骨水泥型假体。疗效评价：根据Harris评分分为优、良、可、差四级。结果所有患者均获得随访,随访时间1.8～9.2年,平均5.1年。平均Harris评分由术前的49.9分恢复到术后的90.1分,两者比较有统计学差异（P〈0.01,t=28.807）,其中评定为优23髋、良17髋、可4髋,术后优良率达90.9%。术后髋关节平均活动度：屈曲105°,外展35°,内收15.8°,外旋45°,内旋15°。本组病例无肺栓塞、深静脉血栓形成、感染等并发症发生。X线检查示假体无松动移位,无翻修病例。结论全髋关节置换术治疗成人髋臼发育不良采用恰当的髋臼重建结合非骨水泥型髋臼假体可获得满意中远期疗效。     

High placement of porous-coated acetabular components in complex total hip arthroplasty

The authors retrospectively evaluated the results of 56 hips in 51 patients with an acetabular deficiency who had a total hip arthroplasty with a porous-coated, cementless acetabular component implanted at a high hip center. Forty-nine cases were revisions and seven were primary operations. The mean height of the hip center was 43 mm above the interteardrop line compared to 14 mm for the anatomic center, threefold higher than normal. In contrast, the mean horizontal locus was reduced compared to normal (33 vs 37 mm for the anatomic center). Sixteen acetabular components were small (46–48 mm o.d.) and eight were miniature (40–44 mm o.d.). Despite superior placement of the acetabular component, 32 limbs were lengthened by the procedure. The mean preoperative Harris hip score was 51 (range, 28–93). At a mean follow-up period of 40 months (range, 24–64 months), the mean Harris hip score was 86 (range, 36–100). In 23 hips no radiolucent lines were present at the interface of the bone to the porous mesh, and 33 hips had a thin (0.5 mm), nonprogressive radiolucent line in one or more zones. No acetabular component had migrated and no problems occurred with the screws. Four hips (3 revisions and 1 primary operation) had a complete radiolucent line on one oblique view of the acetabulum. No acetabular component has been revised for loosening. These short-term data suggest that under circumstances in which the acetabulum cannot be reconstructed at the anatomic level without a major structural bone-graft, superior placement of the porous-coated acetabular component against viable host-bone at a higher level than normal may be an acceptable alternative.     

Noncemented porous-coated anatomic total hip arthroplasty

In 1984, as an alternate to the acrylic fixation of the components of total hip arthroplasty, the use of an uncemented porous-coated anatomic (PCA) hip system with a beaded porous coating to achieve biologic fixation was initiated. Since then, 44 patients with cementless acetabular components and 35 patients with cementless femoral components have been followed for a minimum of 24 months and an average of 37 months. Harris hip scores averaged 90.5 at most recent follow-up intervals. No reoperations were necessary for failures of fixation or change in position of the acetabular component. Ominous roentgenographic signs such as progressive bead shedding, progressive radiolucencies, or progressive component migration have not occurred. Two femoral component revisions have been necessary: one for intractable pain and one for pain and roentgenographic loosening. Although thigh pain has been prevalent (20%), all patients have been accommodated and have retained stable hip scores. Progressive radiolucencies and progressive implant subsidence have been rare occurrences. The authors continue to use the cementless acetabular component in all cases of total hip arthroplasty in which initial stability can be obtained. It is their preference to cement the femoral component in patients over 65 or when initial stability cannot be achieved.     

人工髋关节置换术后翻修病例分析

目的分析人工髋关节置换术后翻修的原因,评价全髋翻修术的临床效果。方法本组33例34髋。初次关节置换类型:全髋置换21例,双杯髋关节置换1例,人工股骨头置换11例。翻修原因:无菌性松动23例24髋,髋臼位置不良1例1髋,股骨头置换后髋臼磨损5例5髋,感染4例4髋。翻修距初次手术时间:1年以内5髋,1～2年1髋,5～10年18髋,10～13年10髋。翻修假体类型:非骨水泥型假体20髋,混合型假体7髋,骨水泥型假体7髋。结果平均随访3.5年。1例术后半年发生股骨柄松动进行再翻修,其余病例假体保留,优良率为82.4%。结论翻修的最常见原因为无菌性松动,人工股骨头置换时髋臼磨损也是翻修原因之一,对较年轻的股骨颈骨折患者,如行假体置换,最好采用全髋关节置换。翻修术采用非骨水泥型假体较好。     

Severity of hip dysplasia and loosening of the socket in cemented total hip replacement. A long-term follow-up

We have assessed the long-term results of 292 cemented total hip replacements which were performed for developmental dysplasia of the hip in 206 patients. The mean age of the patients at operation was 42.6 years (15.9 to 79.5) and most (202) were women. The severity of dysplasia was graded according to both the Crowe and the Hartofilakidis classifications. A 22.25-mm Charnley head was always used and the acetabular components were inserted with cement into the true acetabulum. Bone grafting of the acetabulum, using the patient's own femoral head, was performed on 48 occasions. At a mean follow-up of 15.7 years (2.2 to 31.2) the overall survival of the acetabular component was 78%. The main cause of revision was aseptic loosening (88.3%). The rate of survival at 20 years based on the Hartofilakidis classification was 76% in the dysplastic, 55% in the low-dislocation and 12% in the high-dislocation groups and on the Crowe classification, 72.7% for group I, 70.7% for group II, 36.7% for group III and 15.6% for group IV. There was no statistical correlation between bone grafting of the acetabulum and survival of the acetabular component. This study has shown a higher rate of failure of the acetabular component with increasing severity of hip dysplasia.     

成人发育性髋关节发育不良的全髋关节置换的治疗

对于继发有创伤性髋关节炎且临床症状明显的成人发育性髋关节发育不良(DDH)患者,人工全髋关节置换(THR)是首选治疗方法。此类患者的髋臼及股骨解剖结构的异常具有特殊性,包括髋臼浅小、股骨头较小、股骨干近端髓腔狭窄等,因此其THR也与一般的THR有很大的区别且具有很高的难度。本文主要综述了对DDH的治疗很重要的临床分型,其THR尤其是髋臼重建、股骨假体的安放等过程中的难点以及解决方法。     

Assessment of complex hip deformity using three-dimensional CT image

We used three-dimensional computed tomography (CT) to define the bony configuration of the acetabulum and the proximal femur and their relationship to complicated and/or neglected congenital hip dislocations and Legg-Calvé-Perthes disease. Three-dimensional CT was useful for preoperative planning and postoperative evaluation of hips with complex deformities, which were often difficult to assess by means of plain radiographs or conventional two-dimensional CT. The coverage of the femoral head under the acetabular roof and the severity of the hip dysplasia could be assessed easily with three dimensional CT, and acetabular and femoral torsion could be measured.     

人工全髋关节置换术治疗化脓性髋关节炎后遗骨关节病的研究进展

目的总结人工全髋关节置换术(total hip arthroplasty,THA)治疗化脓性髋关节炎后遗骨关节病的研究进展。方法广泛查阅国内外近年相关文献,就THA治疗化脓性髋关节炎后遗骨关节病的时机、髋臼侧及股骨侧处理方法以及假体类型选择等方面进行总结分析。结果THA是治疗化脓性髋关节感染后遗骨关节病的有效手段,为避免感染复发,建议感染静止期达10年以上时手术。此类患者可能存在髋臼侧发育不良,髋臼覆盖率差,行THA时可选择高位造臼、髋臼内陷截骨、结构性植骨、Cage、钽金属垫块或3D打印假体等方式处理;股骨侧可能存在股骨髓腔细小、股骨颈前倾角增大、颈干角增大、大转子延长和骨质差等问题,行THA时可通过股骨截骨及选择合适型号假体进行处理。化脓性髋关节炎后遗骨关节病患者多较年轻,为获得更好的远期假体生存率,首选非骨水泥型假体。结论THA可有效治疗化脓性髋关节炎后遗骨关节病,但手术难度大、手术并发症相对较多,术者应有充分认识。     

Types of persistent dysplasia in congenital dislocation of the hip.

This article reports five types of persistent bony dysplasia in patients with congenital dislocation of the hip (CDH), suggests the pathogeneses, and discusses the treatment options. We consider the five types to be (1) maldirected acetabulum, (2) capacious acetabulum, (3) false acetabulum, (4) lateralized acetabulum, and (5) femoral deformity. The maldirected acetabulum persists when the acetabulum continues to face forward and laterally. The capacious acetabulum arises from joint instability; capsular laxity permits the proximal femur to slide within the acetabulum. The false acetabulum results from an ectopic fibrocartilaginous cavity in the pelvis created by the subluxated or dislocated femoral head.44 The lateralized acetabulum occurs with ossification of the cotyloid cavity from longstanding lateral subluxation or dislocation or premature closure of the triradiate cartilage. Femoral deformities include valgus and anteversion of the femoral neck, capital femoral physeal growth arrest, discrepancy between the greater trochanter and the femoral head, and femoral head asphericity. After clinical and radiographic evaluation, we believe that an understanding of the pathogeneses and types of dysplasia will facilitate appropriate treatment programs. Treatments consist of acetabular redirection, acetabular reconstruction, femoral osteotomies, and salvage procedures.     

Long-term results of the cementless porous-coated anatomic total hip prosthesis

Between January 1984 and January 1986, 131 porous-coated anatomic total hip replacements were performed in 119 consecutive patients. Of these, 100 patients (110 hips) who were alive at a minimum of 18 years after replacement were included in the study. The mean age of the patients at surgery was 48.4 years and that of surviving patients at the latest follow-up was 67.8 years. The mean duration of the clinical and radiological follow-up was 19.4 years (18 to 20). The mean Harris hip score initially improved from 55 points before to 95 points at two years after operation, but subsequently decreased to 91 points after six years, 87 points after 11.2 years, and 85 points after 19.4 years. At the final follow-up, 23 hips (18%) of the entire cohort and 21% of survivors had undergone revision because of loosening or osteolysis of the acetabular component and eight hips (6%) of the entire cohort and 7% of survivors for loosening or osteolysis of the femoral component. Only four femoral components (4%) were revised for isolated aseptic loosening without osteolysis and two (2%) for recurrent dislocation. On the basis of these long-term results, the porous-coated anatomic femoral component survived for a minimum of 18 years after operation while the acetabular component was less durable. The findings identify the principles of uncemented joint replacement which can be applied to current practice.     

全髋关节置换术中髋臼意外的处理

目的 探讨全髋置换术中髋臼意外的处理方法。方法 回顾性分析11例13髋全髋置换术中出现的髋臼假体床骨质不足、缺损,利用截除的股骨头自体植骨进行修补或重建,对髋臼顶被锉穿盆腔出血,采用填塞止血并用股骨头松质骨骨泥填塞后重建。结果 随访6个月～3年,通过临床和放射学评定,优良率达84.62％,无髋臼假体松动及移位。结论 利用自体股骨头移植修复、重建置换术中出现意外的髋臼,可以获得较满意的结果。     

Total hip arthroplasty in the treatment of developmental dysplasia of the hip

Total hip arthroplasty (THA) is the preferred treatment for patients with severe arthritis of the hip secondary to developmental hip dislocation or dysplasia. However, THA may be difficult due to bone and soft tissue problems that arise from hip dislocation or dysplasia. Another problem is that patients are usually young, which may affect the long-term survival of the prosthesis. Either cemented or uncemented components can be used depending on bone structure and bone stock. Uncemented components are more preferable because of the young age of the patients. From a biomechanical standpoint, the placement of the acetabular component in its true anatomical location is the main goal for survival and better functional results of THA. To ascertain the stability of the acetabular component, superior grafting, controlled medial wall perforation (medialization), or giving the position of a high hip center may be used. On the femoral side, various femoral components may be used with or without a shortening osteotomy. In this article, reconstruction options for developmental hip dysplasia are discussed depending on acetabular and femoral features of the deformity.     

A second-generation cementless total hip arthroplasty mean 9-year results

Two hundred fifty-eight primary total hip arthroplasties in 231 patients were implanted using a circumferentially, proximally porous-coated, collared femoral component and a cementless, hemispherical, porous-coated acetabular component and followed up for a mean of 9 years (5-14 years). Four femoral components were revised (2 stems for infection and 2 stems for aseptic loosening). One additional femoral component was radiographically loose at last follow-up. Nine hips underwent acetabular revision (4 for instability, 2 for infection, 2 for loosening, and 1 for osteolysis). Ten-year survivorship with revision or loosening of any component as the end point was 92%; with femoral component aseptic loosening as end point, survivorship was 98%; with acetabular aseptic loosening as the end point, survivorship was 99%. Osteolysis was identified in 26 hips (13%).     

全髋关节置换术治疗Crowe Ⅳ型髋关节发育不良患者及围手术期并发症分析

目的:探讨人工全髋关节置换术治疗Crowe Ⅳ型成人髋关节发育不良的疗效及围手术期并发症。方法:2000年3月至2010年3月,对19例(23髋)Crowe Ⅳ型成人髋关节发育不良患者进行人工全髋关节置换术,其中男5例,女14例;年龄41～72岁,平均61.3岁。髋臼侧采用小臼杯结合髋臼内陷技术安置臼杯假体,股骨侧采用粗隆下短缩截骨放置股骨假体。采用Harris评分评价术后髋关节功能。结果:所有患者获随访,时间1～8年,平均4.2年,术后X线片显示髋臼假体均位于真臼内,无髋臼假体松动。股骨侧截骨处均骨性愈合。Harris评分由术前平均(34.0±6.9)分提高至末次随访的(85.0±7.5)分。发生围手术期并发症11例,包括股骨劈裂骨折3例,神经并发症3例,截骨延迟愈合2例,术后脱位3例。结论:采用小臼杯、假体内陷技术、股骨短缩截骨对Crowe Ⅳ型DDH患者行全髋关节置换可以重建关节功能,恢复下肢长度,早期疗效满意,但并发症发生率高。后期疗效有待进一步观察。