锥形钛合金非骨水泥股骨柄全髋关节置换术34例随访一年X线结果分析

目的观察最新一代锥形钛合金非骨水泥股骨柄于术后1年是否稳定及股骨柄周围骨的重构方式。方法对采用最新一代锥形钛合金非骨水泥股骨柄全髋关节置换的34侧髋关节（28例）,进行定期随访,平均随访15个月,对术前、术后近期及术后1年的X线片（股骨部分）进行测量,将测量结果进行统计分析。结果在股骨柄的中1／3普遍存在骨与假体之间的“焊接点”;没有破体移位、“筑基”形成,以及金属颗粒滑脱;除1例外,其余病例出现股骨距的重吸收;27髋出现股骨距松质化;在非涂层部分出现反应线的有19髋;非骨水泥股骨柄固定及稳定评分,平均总分为＋24．1分。结论所有股骨柄于术后1年X线片上都被确认有骨长入。     

Early failure of revision total hip arthroplasty with cemented precoated femoral components: comparison with uncemented components at 2 to 8 years

This is a retrospective analysis of 2 methods of fixation of the femoral component in 86 consecutive revision arthroplasties, for which all clinical and radiographic data were recorded prospectively. There were 56 cemented revisions using precoated femoral components followed for 2 to 8 years (mean, 4 years) and 30 uncemented, proximally porous-coated femoral revisions followed for 2 to 6 years (mean, 4 years). Of the 56 cemented hips, 31 (55%) had a good or excellent clinical result. Rerevision has been performed in 10 hips, and revision of 3 loose femoral components is pending (23%). Radiographic review of 56 femoral components showed that 16 (29%) had probable or definite loosening. Of 30 cementless hips, 24 (80%) had a good or excellent clinical result. There was radiographic bone ingrowth in 22 of 30 hips (73%). Seven hips (23%) had nonprogressive subsidence, and 3 hips (10%) had progressive subsidence or loosening. Rerevision has been performed in only 2 hips (7%). The high rate of loosening (29%) and rerevision (23%) at a mean follow-up of only 4 years suggests that a precoated femoral component may place increased stress at the already damaged bone-cement interface.     

Extensively coated femoral components in revision hip arthroplasty: follow-up study of 23 patients

PURPOSE: To review the outcome of revision hip arthroplasty using extensively coated femoral components. METHODS: We reviewed the results of revision involving 24 extensively porous-coated cementless femoral components in 23 patients, whose mean age was 52.4 years (range, 28.0-79.0 years). Most revisions were performed for aseptic loosening of the previously cemented femoral component. All patients were followed up for a minimum period of 24.0 months (mean, 61.1 months). RESULTS: Of the 24 femoral stems, 20 showed bone ingrowth, 3 showed stable fibrous ingrowth, and one was unstable because of deep infection. Intra-operative anterior femoral diaphyseal perforation occurred in 2 hips during the insertion of straight femoral components of 200 mm. Postoperative radiographs displayed marked cortical erosion in 3 other hips and cortical perforation in one. CONCLUSION: The results from the use of extensively coated femoral components were promising. Nevertheless, anterior cortical perforations were also common, which may be related to more bowing of the femora among the Chinese patients. Caution must be exercised when inserting a long, straight, extensively coated femoral component.     

Free vascularised fibular grafting with OsteoSet?2 demineralised bone matrix versus autograft for large osteonecrotic lesions of the femoral head

The aim of this study was to compare the safety and efficacy of OsteoSet®2 DBM with autologous cancellous bone in free vascularised fibular grafting for the treatment of large osteonecrotic lesions of the femoral head. Twenty-four patients (30 hips) with large osteonecrotic lesions of the femoral head (stage IIC in six hips, stage IIIC in 14, and stage IVC in ten, according to the classification system of Steinberg et al.) underwent free vascularised fibular grafting with OsteoSet®2 DBM. This group was retrospectively matched to a group of 24 patients (30 hips) who underwent free vascularised fibular grafting with autologous cancellous bone during the same time period according to the aetiology, stage, and size of the lesion and the mean preoperative Harris hip score. A prospective case-controlled study was then performed with a mean follow-up duration of 26 months. The results show no statistically significant differences between the two groups in overall clinical outcome or the radiographic assessment. Furthermore, no adverse events related to the use of the OsteoSet®2 DBM were observed. The results demonstrate that OsteoSet®2 DBM combined with autograft bone performs equally as well as that of autologous bone alone. Therefore, OsteoSet®2 DBM can be used as a safe and effective graft extender in free vascularised fibular grafting for large osteonecrotic lesions of the femoral head.     

Cortical strut allografts for the treatment of femoral fractures and deficiencies in revision total hip arthroplasty

Thirty-three hips had revision total hip arthroplasty, using an average of three cortical strut allografts fixed to the femur with cables and followed-up for a mean of 4 years. The indications for strut allografts were ectatic femurs or segmental defects of the femoral diaphysis (22 hips), femoral fractures (10 hips), and severe proximal femoral osteolysis (1 hip). Twenty-one hips had an excellent or good clinical result, 6 had a fair clinical result, and 6 had a poor clinical result. Reoperation was done in six hips, but in only two hips was reoperation related to failure of the allograft. Nine of the 10 femoral fractures repaired with allograft struts healed by 3 to 6 months. Radiographs showed partial or complete bridging of the allograft to host bone with peripheral remodeling and minimal resorption in 30 of 33 hips. Strut allografts, fixed with multiple cables, are an important adjunct to femoral component revision for the restoration of deficient femoral bone stock and in the treatment of periprosthetic femur fractures.     

MRI对坏死股骨头关节软骨的评估

目的研究坏死股骨头关节软骨的MRI表现,以期用MRI表现反映关节软骨的受损程度。方法收集12例股骨头坏死（14髋）的股骨头直视观和对应的MRI表现及相应的X线片表现资料,比较三者在关节软骨的受累情况、软骨下分离及软骨下骨与骨分离的表现。结果相片中所有软骨均有受累,对应MRI中有11髋X线片没有表现。相片中有7髋表现为软骨下分离,对应MRI中有6髋、X线片为4髋。相片中有8髋表现为软骨下骨与骨分离,对应MRI中有8髋、X线片为3髋。结论虽然在软骨下骨与骨分离上有假阳性表现,MRI明显优于X线片,能更好反映关节软骨情况。但是对MRI的表现如何指导临床治疗还需进一步研究。     

Effect of intra-articular lesions on the outcome of periacetabular osteotomy in patients with symptomatic hip dysplasia

In order to clarify how intra-articular lesions influence the survival of a periacetabular osteotomy in patients with dysplasia of the hip, we performed an observational study of 121 patients (121 hips) who underwent a transposition osteotomy of the acetabulum combined with an arthroscopy. Their mean age was 40.2 years (13 to 64) and the mean follow-up was 9.9 years (2 to 18). Labral and cartilage degeneration tended to originate from the anterosuperior part of the acetabulum, followed by the femoral side. In all, eight hips (6.6%) had post-operative progression to Kellgren-Lawrence grade 4 changes, and these hips were associated with the following factors: moderate osteoarthritis, decreased width of the joint space, joint incongruity, and advanced intra-articular lesions (subchondral bone exposure in the cartilage and a full-thickness labral tear). Multivariate analysis indicated subchondral bone exposure on the femoral head as an independent risk factor for progression of osteoarthritis (p = 0.003). In hips with early stage osteoarthritis, femoral subchondral bone exposure was a risk factor for progression of the grade of osteoarthritis. Although the outcome of transposition osteotomy of the acetabulum was satisfactory, post-operative progression of osteoarthritis occurred at a high rate in hips with advanced intra-articular lesions, particularly in those where the degenerative process had reached the point of femoral subchondral bone exposure.     

The effect of partial or full weight bearing ambulation after cementless total hip arthroplasty

The clinical and radiographic results of 46 patients who underwent 50 consecutive primary total hip arthroplasties using a fully porous-coated collared femoral component were determined at a minimum of 2 years' follow-up. Twenty-four patients (25 hips) who were allowed to bear full weight immediately postoperatively were compared with a historical control group of 24 patients (25 hips) who were instructed to bear < or =50 lb of weight for 6 weeks. The average Harris hip score for the partial weight bearing group was 95 compared with 97 for the full weight bearing group. All femoral components in both groups had radiographic evidence of bone ingrowth fixation at the final follow-up. When solid initial fixation is obtained intraoperatively and radiographically using a fully porous-coated (AML) femoral component, it seems that bone ingrowth fixation reliably occurs whether or not a partial or full weight-bearing postoperative protocol is followed.     

Acetabular revision arthroplasty using so-called jumbo cementless components: an average 7-year follow-up study

The optimal technique for acetabular revision surgery in the face of major bone stock deficiency remains controversial. One subset of these problem cases consists of hips that are amenable to reconstruction using a large, hemispherical cementless acetabular component, the so-called jumbo acetabular component. We report the intermediate-term experience of 24 hips in 24 patients who underwent an uncemented acetabular revision using a hemispherical acetabular component of > or = 66 mm diameter. In 16 hips, the femoral component was replaced as well. Of the 18 hips in patients alive after 5 years, 15 were assessed at a mean follow-up of 7.0 years (range, 5.0-10.3 years). The mean final Harris Hip Score was 86 points (range, 45-100 points). No acetabular component had been revised, and none were loose radiographically. In this difficult group, a bimodal distribution resulted. The complication rate was high. In those without infection, the results were excellent.     

Revision total hip arthroplasty with cemented femoral component

We reviewed retrospectively the results of 28 hips (25 patients) after revision of the femoral component with use of a cemented stem, because of aseptic loosening. The mean duration of follow-up was 4.43 years (range 2–12 years). Over the course of the study period, repeat revision was done in 4 hips after an average of 4.45 years. Three hips had a repeat revision of the femoral component because of aseptic loosening and one for a deep infection. The rate of loosening of the femoral component was 32.4% (9 hips) at an average of 5.22 years. The 5-year survival rate was 76.9% with mechanical failure as end point; and 90% with re-revision of femoral component because of aseptic loosening as end point. The cement mantle was the principal factor, which was significantly associated with a better survival rate of femur fixation (P < 0.05). No correlation was noted between quality of bone loss at the time of revision, bone graft or the use of long stems, and the survival rate of femoral component. By improving the cementing technique and in selected patients, the use of cemented femoral stem could be a good alternative for aseptic loosening THA.     

Clinical and radiological outcome of total hip replacement five years after pamidronate therapy. A trial extension

Bisphosphonates reduce peri-prosthetic bone loss in the short term after total hip replacement but the mid- and longer term effects are not known. The aims of this randomised trial were to examine the effect of a single dose of 90 mg of pamidronate on the clinical and radiological outcome and peri-prosthetic bone mineral density in 50 patients (56 hips) over a five-year period, following total hip replacement. At five years, 37 patients (42 hips) returned for assessment. The Harris hip scores were similar in the pamidronate and placebo groups throughout the study. Also at five years, four patients, two from each group had osteolytic lesions on plain radiography. These were located around the acetabular component in three patients and in the femoral calcar in one. The femoral and acetabular peri-prosthetic bone mineral density in the pamidronate group and the control group was similar at five years. Pamidronate given as a single post-operative dose does not appear to influence the clinical outcome or prevent the development of osteolytic lesions at five years after total hip replacement.     

Omnifit cementless total hip arthroplasty. A 10-year average followup.

Seventy-six hips in 67 patients were evaluated an average of 119 months (range, 61-150 months) after total hip arthroplasty with porous coated Omnifit femoral and acetabular components. The patients were young (average age, 45 years), and most were male (67%). Two stems and one cup were revised for aseptic loosening, for aseptic revision rates of 2.6% on the femoral side and 1.3% on the acetabular side. Thigh pain was present in three cases, one of which was activity limiting. Twenty-five (35.7%) hips had evidence of osteolysis confined to proximal Gruen Zone 1 or 7 or to the acetabulum (22 proximal femoral, three both). There were no cases of intramedullary osteolysis in surviving stems. Thirteen (17.1%) hips have undergone reoperation for bone grafting of progressive proximal osteolysis without component revision, at an average 93 months after the total hip arthroplasty. At an average 40 months after reoperation, all stems remain well fixed, and there has been no recurrence of osteolysis of grafted femoral lesions. These results suggest that a circumferentially proximally porous coated femoral component in cementless total hip arthroplasty can provide stable fixation for as long as 12 years after implantation and caseal the canal from distal osteolysis. Serious concerns remain about the incidence of proximal femoral osteolysis.     

Long-term results using the anatomic medullary locking hip prosthesis.

Since the introduction of cementless total hip arthroplasty in the early 1980s, concern has shifted from component loosening toward polyethylene wear and osteolysis. The current review of 223 consecutive unselected Anatomic Medullary Locking femoral and acetabular components extends the followup on a series of patients previously reported on at 5 and 10 years. The purposes are to describe the reasons for revisions and to assess the onset and size of osteolytic lesions, with the hypothesis that osteolysis represents an important cause of loosening. The population included 204 patients (211 hips) with mean followup of 13.9 years (range, 2-18 years). Among them, 122 patients (129 hips) had a minimum 15-year followup. Minimum 2-year radiographs with a mean radiographic followup of 12.2 years (range, 2-18 years) were available for 204 hips (197 patients). Of the entire study group, 39 hips (38 patients) had 44 component revisions, increasing the number of revisions by 24 since this series was reported previously. Twenty-six patients (27 hips) had their first revision surgery more than 10 years after the primary surgery. The most common reason for revision of original components was wear or osteolysis occurring in 22 of the 39 hips (21 of 38 patients). The overall loosening rate was 3.4% (seven of 204) for femoral components and 5.4% (11 of 204) for acetabular components. Twenty-four percent of hips (48 of 204) had evidence of femoral or pelvic osteolytic lesions larger than 1.5 cm2. Femoral osteolysis was not associated with any case of femoral loosening, whereas seven of the 11 loose acetabular components were associated with pelvic lesions larger than 1.5 cm2.     

Impacted cancellous graft plus cement in hip revision

Revision of the femoral component is difficult in the presence of large cavitary defects of the femur. Impaction cancellous grafting used in conjunction with a cemented prosthesis has been recommended as a means of restoring bone stock while providing excellent and durable clinical results. Fifty-seven consecutive femoral revisions were done between 1993 and 1997 in 54 patients (24 men and 30 women) using the impaction grafting technique and a collarless, tapered, polished stem. Strut allografts were used for femoral reinforcement in 40 hips. No patient was lost to followup. One patient had an infection develop and had a resection arthroplasty. Three patients died of causes unrelated to the hip. After 6.3 years the clinical results were excellent. Radiographic evaluation showed no evidence of loosening in any of the 53 surviving hips. Subsidence of 1 to 3 mm was seen in 40 hips and subsidence of 4 to 6 mm was seen in two hips. Cancellous remodeling was observed in 42 hips. The most common complications were postoperative femoral fractures. All six fractures occurred at the distal end of the prosthesis, were not associated with prosthetic loosening, and were treated successfully with open reduction and internal fixation without prosthetic revision. These satisfactory results and the limited subsidence observed in our patients radiographs could be explained by the careful attention to the technical details of the procedure. However, even with the generous use of strut graft augmentation, postoperative femoral fractures remain our most serious complication.     

Major femoral bone loss in revision total hip arthroplasty treated with tapered, porous-coated stems

Clinical results of revision total hip arthroplasty using fully porous-coated tapered titanium stems to treat severe proximal femoral bone loss were evaluated in a retrospective review of 39 patients (45 hips). The bone was reinforced with cables in 39 hips, and in 14 hips strut allografts were added. Fixation was successful in 44 hips, and one hip required revision to treat undetected fracture and migration of the stem. All the others had radiographic evidence of bone attachment. Neither bone atrophy nor reconstitution was noted. Three patients (3 hips) had mild thigh pain, but the others had no pain related to the femoral component. Eight hips dislocated; one resolved and seven had recurrent dislocation that was treated with a constrained acetabular component, capsulorrhaphy, or liner reorientation. Ten patients (12 hips) used a walker and 10 patients (12 hips) used a cane at the last postoperative visit. Whereas fixation was successful with this surgical technique, complications related to deficiency of the soft tissue structures were common.     

A five‐year clinical and radiographic follow‐up of bipolar hip arthroplasty with insertion of a porous‐coated anatomic femoral component without cement

Objective: To evaluate the clinical and radiographic outcomes of bipolar hip arthroplasty with a cementless porous‐coated anatomic femoral component. Methods: Fifty‐nine patients (86 hips) with a minimum 3.5‐year follow‐up were followed up for a mean of 5.2 years (from January 2005 to January 2007). Standard clinical evaluation utilizing the Harris hip score and radiographic evaluation based on the criteria of the Hip Society were used in this prospective study. Radiographic assessment included evaluation of calcar remodeling and pedestal formation. Results: The average age of the patients (24 men and 35 women) at the time of surgery was 71.4 years (range, 69–84 years). The average preoperative Harris hip score was 48.5 ± 4.0 (range, 25–65) points, pain score 15.2 ± 3.9 (range, 0–20) points and functional score 26.7 ± 4.6 (range, 9–40) points. At the time of the latest follow‐up, the average Harris hip score was 96.1 ± 2.1 (range, 67–100) points, pain score 42.6 ± 6.3 (range, 32–54) points and functional score 45.5 ± 4.7 (range, 29–56) points. Five hips (5.81%) had pain in the anterior part of the thigh. Two hips (2.33%) required revision of the femoral component because of aseptic loosening and periprosthetic fracture. Radiographic assessment revealed consistent evidence of proximal bone ingrowth. No completely radiolucent lines were identified, except around stems that had loosened. Twenty‐seven femoral components (31.4%) had associated slight pedestal formation. No osteolytic lesions of the femur were identified. Nonprogressive pelvic osteolysis was identified in four hips, none of the lesions being ≥2 mm in diameter. Conclusion: An anatomically designed prosthesis can provide good clinical results, with low incidence of thigh pain and loosening of the component.     

Particulate bone grafting of osteolytic femoral lesions around stable cementless stems

The purpose of the current study was to evaluate the effect of particulate grafting for proximal femoral osteolysis in the presence of a well-fixed cementless femoral stem at the time of acetabular liner change or revision. Sixteen patients (17 hips) who averaged 51 years of age underwent curettage and packing of proximal femoral osteolytic lesions with cancellous allograft. Modular acetabular liners were changed in 11 patients, acetabular revisions were performed in six patients, and femoral heads were exchanged in all patients. The femoral component was retained in all patients. The majority of patients were asymptomatic before revision surgery. The size of the femoral osteolytic lesions was measured preoperatively and postoperatively with anteroposterior and Lauenstein lateral radiographs of the hip. Preoperatively, the average lesion was 41 x 16 mm on the anteroposterior view and 18 x 7 mm on the lateral view. The average clinical and radiographic followup was 39 and 32 months, respectively, with a minimum followup of 24 months. All but one patient remained asymptomatic during the followup period and no femoral stem showed evidence of loosening. The size of the femoral osteolytic lesion averaged 16 x 6 mm on the anteroposterior view and 6 x 2 mm on the lateral view at most recent followup. In 15 of 17 patients, the size of the femoral lesion had regressed. This technique seems to be a viable means of preventing progressive osteolysis and femoral loosening while preserving bone stock for future reconstruction.     

Revision of failed total hip arthroplasty with a proximal femoral modular cemented stem

We have designed a modular cemented femoral component for revision of failed total hip arthroplasty in which deficiency of the proximal femur is such as to require a variable extrafemoral portion of the stem. We present the results of the first 74 operations in 72 patients; 56 of the patients had grade-3 or grade-4 femoral deficiency as defined by Gustilo and Pasternak and 24 had fractures of the proximal femur, of which 22 were periprosthetic. There was or had been infection in 19 hips. At a mean follow-up of 5 years 9 months (1 to 12 years) nine stems were radiologically loose of which three had been revised. There were no failures in 45 cases in which there was fixation of the distal stem of 10 cm or more. Dislocation occurred in nine patients and there were four cases of infection in the 19 which were, or had been, infected previously. There were no neurovascular complications and no intraoperative femoral fractures. The femoral bone stock improved radiologically in 45 hips of which 29 showed considerable reformation of the proximal femur; 27 remained unchanged and two showed increasing osteoporosis.     

A prospective study of 100 consecutive Harris-Galante porous total hip arthroplasties. 2-5-year results.

This is a prospective study of the authors' first 100 Harris-Galante porous total hip arthroplasties (THA) that were followed for 2-5 years. The mean age of the 83 patients was 43 years. Using the Harris hip rating system, 80% of the hips were rated as excellent, 13% as good, 5% as fair, and 2% as poor at final evaluation. Eighty percent of the hips had no pain, 11% had slight or occasional pain, 8% had activity-related pain, and 1% had moderate pain. Eighty-seven percent of the hips had no limp, 8% had a slight limp, and 5% had a moderate limp. One femoral component, placed as a conversion of a loose bipolar hemiarthroplasty, has been removed for loosening. Two other hips have been reoperated, one for lengthening the femoral neck and one for changing the acetabular liner. There were no problems with acetabular screw fixation and no component migrated. Only two hips had 1 mm nonprogressive radiolucent lines in all three zones. Femoral component subsidence of 3 or more mm was measured in 16 hips, but was progressive in only 1. Radiolucent and radiodense lines were frequently seen in the nonporous coated regions of the femoral stem. Loss of proximal medial femoral bone density was seen in 59% of hips, and calcar resorption was seen in 16% of hips. Although the clinical results of this uncemented implant system were good or excellent in 93% of hips, the high incidence of femoral component subsidence is worrisome.