Fracture of ceramic heads in total hip replacement

After introduction of ceramics in total hip replacement, there have been several studies on wear and fracture of the femoral head component. Though reports on fractures are few, we saw four fractures within 2 months. In all patients, a cementless hip prosthesis by four different surgeons was implanted between 3/2001 and 2/2004. In three patients, a ceramic-on-polyethylene pair and in one, a ceramic-on-ceramic pair was used. Only one patient suffered an adequate trauma. The mean survival of the ceramic head was 27 months (11–42). In two patients with polyethylene inlays, the inlay showed signs of wear out due to the fractured head. All four revision surgeries had a good outcome with satisfying results and no complications. Though we observe the postoperative development after implantation of ceramic components closely, we still believe that ceramics in total hip replacement in young and active patients are indicated with good long term results.     

Zirconia陶瓷头-聚乙烯全髋关节的长期随访

目的: 通过对 28例 (30髋) zirconia-聚乙烯全髋关节的长期随访, 了解Zirconia陶瓷头的实际临床使用效果。方法: 用Harris评分分别评价术前和最后一次随访时髋关节功能。比较术后 1年及最后随访时的X线片, 记录假体松动、假体周围骨溶解、透亮线、及股骨矩吸收情况。根据Liv ermore的方法测量聚乙烯杯的磨损率。比较有骨溶解发生的髋关节与无骨溶解发生的髋关节的聚乙烯磨损率有无差别。结果: 共有 24例 (26髋) 获长期随访, 平均随访 9年 ( 6 ~13年 )。术前平均Harris评分 46分 ( 20 ~78分 ),最后随访时平均Harris评分 86分 (48~98分)。13髋 (50% ) 有假体周围的骨溶解发生。有 10髋 (38% ) 因髋臼假体的松动或髋臼周围骨溶解而接受翻修手术。平均聚乙烯髋臼磨损率为 0. 118mm/年。结论: 在本组研究病例中, 其髋臼磨损率并不比文献报道的传统的金属头低。而临床平均 9年翻修率更达 38%。其临床实际效果有待更深入的研究。     

Dislocation after revision of hemiarthroplasty to total hip replacement

Over a 3-year period, nine hemiarthroplasties were revised to total hip arthroplasty. The hemiarthroplasties were all performed for an original diagnosis of subcapital fracture, and the revisions were for a variety of indications including instability, loosening and acetabular erosion. Four of the revised prostheses subsequently dislocated, and one has recurrent subluxation. This dislocation rate of 50% is higher than previously reported. Factors contributing to this are discussed. These include: previous strokes, advanced age, difficulty complying with instructions, and a hip capsule not contracted by osteoarthritis. Preventative factors are discussed. It is imperative to treat this group of patients differently from those having other hip arthroplasties, and to consider prophylactic bracing post-operatively. The capsule or pseudo-capsule should be preserved wherever possible.     

Revision total hip arthroplasty for metal-on-metal failure

Metal-on-metal (MoM) arthroplasty systems became popular in the early-2000s due to presumed advantages of improved wear characteristics and superior stability. However, subsequent reports of abnormal soft-tissue reactions to MoM implants and national registry data reporting high failure rates raised concerns. Early outcomes of revision total hip arthroplasty (THA) for adverse reaction to metal debris (ARMD) were poor, leading to development of surveillance programs and a trend towards early revision surgery. Patients with MoM arthroplasties require surveillance, comprehensive history and physical examination, imaging with ultrasound or magnetic resonance imaging (MRI), and laboratory evaluation including metal ion levels. Operative strategies for revision THA vary from exchange of modular components to extensive debridement and reconstruction with revision components. Surgeons should be aware of the increased risks of dislocation and infection following revision THA for ARMD. However, there is growing evidence that early revision surgery prior to extensive soft tissue destruction results in improved outcomes and decreased re-operation rates. It is estimated that >1 million MoM articulations have been implanted, with a large proportion still in situ. It is imperative to understand the aetiology, presentation, and management strategies for these patients to optimise their clinical outcomes.     

小切口全髋关节置换术近期随访观察

[目的]探讨前外侧小切口全髋关节置换术的适应证及临床效果。[方法]自2002年5月-2005年3月，采用前外侧小切口人工全髋关节置换术治疗年龄65～88岁的股骨颈囊内骨折23例，股骨头无菌性坏死11例。[结果]前外侧小切口平均长度7．5cm，手术时间平均75min，平均出血量205ml，无输血及使用镇痛药物，无脱位、感染、深静脉栓塞等并发症。平均随访18个月，X线片未见假体松动下沉表现，Harris评分为92．1分。[结论]前外侧小切口全髋关节置换术适用于髋关节无畸形、髋臼和股骨近端无明显骨质缺损、骨质疏松及过度肥胖的患者。合理的切口及精确的操作可减少手术创伤，有利于功能恢复。     

数字化术前计划在人工髋关节翻修髋臼重建术中的初步应用评估

目的探讨数字化术前计划在提高全髋关节翻修中髋臼旋转中心精确重建中的应用价值。方法对人工髋关节翻修髋臼旋转中心重建病例进行数字化术前计划。患者男3例,女4例,年龄平均72.1岁（56～83岁）。以非手术正常侧髋臼旋转中心为标准,以双侧骨盆泪滴下缘连线及骨盆中垂线为参照基准线设定翻修侧髋关节旋转中心水平及垂直位置距离,制定重建方案。比较计划与手术实际间髋臼中心的吻合程度。结果术前做计划与术后真实情况的差值间无明显差异（t水平=0.416,P水平=0.692;t垂直=0.399,P垂直=0.704）。结论数字化术前计划可为术中内植物及骨重建的组合选择提供更多有用信息,使因骨缺损所致移位的髋臼旋转中心恢复解剖位置,有利于患肢的长度及偏心距的恢复。     

MicroHip: a minimally invasive procedure for total hip replacement surgery. A modified Smith-Peterson approach

Abstract: In this article we present the surgical technique of our anterior minimally invasive approach to the hip joint. This is aligned along an interneural plane and makes the approach truly minimally invasive. This technique is performed in a lateral decubitus position on a normal operating table; there is not a need for a specific orthopaedic or fracture table. As leg traction is not necessary, this enables the approach to be used routinely. Most of the instruments used for this procedure are standard instruments, only the acetabular reamers and positioners are angulated and specifically designed. The angled instruments (MI – minimally invasive) are especially useful when performing hip replacement in obese patients. An excellent view of both the acetabulum and the proximal femur can be obtained through an incision of only 6-8 cm, using this MI approach. The approach follows the interval between the tensor fascia lata muscle and the sartorius muscle using a section of the anterior iliofemoral approach described by Smith-Peterson. No tendon or muscle is cut or detached. The joint capsule is split and preserved in toto. The hip joint is not dislocated and we perform the osteotomy of the femoral neck in-situ. To date we have performed over 500 MicroHip™ operations. We have not observed any nerve lesions or fractures of the trochanter. Our experience to date shows that the method we have developed allows us to operate reliably on virtually any patient. Preliminary results also show that important factors like length of stay, pain, blood loss and return to work can be reduced significantly. The MicroHip™ technique is being used by more and more different clinics all over the world and can be applied with success after suitable training.     

Fracture of a ceramic liner in a total hip arthroplasty with a sandwich cup

Alumina ceramic-on-ceramic total hip arthroplasty (THA) has been widely used due to its advantages such as low wear, scratch resistance, wettable surface and relatively low biological reactivity of the wear particles. Nevertheless, this material in THA still persists to be one of the major concerns about the risk of fracture, due to its brittleness. Many authors have reported a fracture of the ceramic head but few reported a fracture of the ceramic acetabular insert. In order to reduce the rigidity of the ceramic-on-ceramic coupling and prevent an impingement between the rim of the ceramic liner and the metal neck of the femoral stem, a modular acetabular component with a sandwich insertion (alumina/polyethylene/titanium) was proposed. We report the fracture of the ceramic acetabular liner of such a ceramic sandwich cup due to a slightly retroverted position of the cup that causes an impingement between the femoral stem and the rim of the insert. The fracture occurred 3 years after the operation without trauma. At revision the entire cup was replaced using a polyethylene liner without inner ceramic liner.     

Current trends in revision of total hip arthroplasty

Summary Total hip arthroplasty has brought pain relief and mobility to many patients, but load bearing implants may fail and the resulting problems must be tackled early and with vigour. The primary operation offers the best chance of success, and revision may only ever be considered a salvage procedure. Patients with total hip arthroplasty must be offered facilities for an indefinite follow-up. Revision surgery is not to be undertaken lightly or on an occasional basis, and the lessons learned from such procedures must be used for the benefit of the patients undergoing primary operation.

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Résumé L'arthroplastie totale de la hanche a apporté à de nombreux malades l'indolence et la mobilité, mais la fixation des implants prothétiques peut se détériorer et les problèmes qui en résultent doivent être abordés sans retard ni pusillanimité. La première opération offre les meilleures chances de succès et la révision ne peut être considerée que comme une intervention de rattrapage. On doit faire en sorte que les patients porteurs d'une prothèse totale de hanche puissent bénéficier d'une surveillance continue. La chirurgie de reprise ne doit pas être effectuée à la légère et de façon non réglée et les enseignements qu'on peut en tirer bénéficieront aux malades qui subissent la première opération.

     

陶瓷-陶瓷人工髋关节初步应用结果

目的　研究陶瓷型人工髋关节的中短期应用结果 ,以探讨这种假体的临床应用价值。方法　对人工全髋关节置换术 332例 345髋进行随访 ,其中陶瓷 -陶瓷非骨水泥型假体 31例 33髋 ,生物型固定超高分子聚乙烯 -钴铬钼合金全髋假体 30 1例31 2髋。应用Harris评分进行功能评价 ,应用股骨Gruen与髋臼Delee-Charnly分区方法进行影像学评价。结果　Harris评分两组患者之间未见显著性差异 ,但是影象学上 ,超高分子聚乙烯 -钴铬钼合金假体的松动范围或程度要大于或多于陶瓷 -陶瓷假体。结论　对于年轻患者 ,新型的陶瓷 -陶瓷假体中短期效果良好 ,影象学松动率明显低于超高分子聚乙烯 -钴铬钼合金假体。但是由于其价格昂贵 ,使用范围受到限制。而且远期结果有待于临床观察     

全髋关节置换术治疗强直性脊柱炎晚期严重髋关节固定畸形12例

强直性脊柱炎有 30 %髋关节受累[1] ,但是髋关节伸直固定在 0°～ 10°位 ,屈曲固定在 80°～ 10 0°位较罕见。我院自 1999年 5月 - 2 0 0 2年 7月采用全髋关节置换术治疗此类疾患 12例 ,疗效满意 ,现报告如下。1　临床资料本组 12例 (均为双髋 ) ,男 9例 ,女 3例 ;年龄30～ 4 0岁 6例 ,4 1～ 5 0岁 4例 ,5 1岁以上的 2例。伸直固定在 0°～ 10°位 4例 ,屈曲固定在 80°～ 10 0°8例 ;国产材料 5例 ,进口材料 7例。术前术髋症状、体征X线检查结果 :不能伸屈活动 ,无行走蹲坐功能 ,所有患者生活均不能自理 ,关节活动度屈曲 0°、伸 0°、…     

人工髋关节置换术后翻修原因分析

目的:分析人工髋关节置换术后翻修的原因,并评价其疗效。方法:本组30例(31髋)行人工髋关节置换术后翻修术,男12例,女18例,平均年龄63.1岁(47~74岁)。初次关节置换类型:全髋置换19例(20髋),人工股骨头置换11例。翻修原因:3例(3髋)为感染性松动,余均为无菌性松动。翻修距初次手术时间:1年以内1髋,2~3年3髋,8~10年21髋,10~15年6髋。翻修假体类型:均为混合型假体,国产12例(12髋),进口18例(19髋)。X线评价包括翻修前骨缺损,翻修前后的下肢长度,股骨偏心距,前倾角。临床功能评价采用Harris评分。结果:30例均获随访,平均随访时间4.1年,术后所有患者双下肢基本等长(差距小于1 cm)。偏心距、前倾角、颈干角恢复至初次手术前水平,术后3个月均完全负重,髋关节疼痛除2例外其余完全缓解,至最后1次随访时,按Harris评分,优16髋,良10髋,可4髋,差1髋。无感染及髋关节脱位发生。结论:翻修的常见原因为无菌性松动、髋臼磨损和感染性松动;髋关节翻修是一种近期疗效满意的方法。     

人工髋关节翻修术72例探讨

目的探讨人工髋关节置换术后失败的原因,骨缺损的处理、假体的选择及根据,观察翻修的术后疗效。方法2000年1月～2008年6月,本组共对72例患者进行了人工髋关节翻修术。翻修术所置换的假体包括,普通金属杯加内衬45例,大头臼杯15例,Cage加聚乙烯臼杯9例,聚乙烯臼杯3例;普通柄43例(其中12例应用骨水泥固定),加长柄29例(其中5例应用骨水泥固定,7例为组合型柄)。39例假体柄取出容易,20例假体柄取出困难。13例假体臼、17例假体柄使用骨水泥固定,其中10例臼及柄均使用骨水泥固定;55例假体臼、32例假体柄植骨,其中28例假体臼及柄均植骨。结果平均随访31.7个月。Harris评分:术前平均39.4(9～58)分,术后平均92.0(65～99)分。无感染或脱位患者。结论(1)无菌性松动、关节感染和医源性错误是人工髋关节翻修的主要原因;(2)股骨假体柄取出困难和严重骨质缺损是髋关节翻修术中常见的难题;(3)应用松质骨骨块、颗粒骨和骨屑混合打压植骨,尽量多用自体骨填补缺损,而少用异体骨、人工骨或骨水泥;(4)假体的选择主要依据是骨质缺损的程度。     

活动性髋关节结核一期病灶清除全髋关节置换28例报告

目的 探讨活动性髋关节结核一期病灶清除全髋关节置换的可行性及其临床疗效.方法 回顾性分析2007年1月至2010年10月期间接受一期病灶清除全髋关节置换治疗的28例晚期活动性髋关节结核患者的相关资料,男17例,女11例;年龄18～72岁,平均36岁.8例单纯关节内脓肿,20例合并关节周围脓肿;均有髋臼及股骨头骨破坏.术前红细胞沉降率为28～102 mm/1 h,平均52 mm/1 h;C反应蛋白为11～73 mg/L,平均38 mg/L.9例合并肺结核,1例合并脊柱结核,术前抗结核治疗时间平均7周(3～32周).所有患者术中均彻底清除髋关节周围脓肿、髋臼死骨,将切除的股骨头颈清除病灶组织后置于体积分数75％酒精浸泡5 min,用生理盐水冲洗,用于骨缺损区植骨,采用非骨水泥型假体置换.病理检查证实为髋关节结核.术后系统抗结核治疗18个月.结果 28例患者均获得随访,随访时间24～56个月,平均37个月.所有患者切口一期愈合,红细胞沉降率恢复正常时间平均为3.3个月(2～5个月),C反应蛋白恢复正常时间平均为2.1个月(1～3个月).髋关节Harris评分从(30.214±9.350)分改善至(90.535±6.746)分.1例患者术后13个月自行停用抗结核化疗后结核复发,术后56个月随访时患者能行走,股骨柄和髋臼杯无松动,目前保留假体密切随访中.结论 活动性全髋关节结核在有效抗结核化疗的基础上行一期病灶清除全髋关节置换可获得较好的临床疗效.     

Serious metallosis of a metal head due to fragmented ceramic screws in a cemented THA

We reported a rare revision case necessitated by massive metallosis of a metal head due to a fragmented ceramic screw which had been extraarticularily used in the primary THA here and reviewed previous literature about metallosis of metal heads associated with ceramic materials. The ceramic screw had been used for the fixation of a bone graft and reattachment of the greater trochanter in the primary THA. Scanning electron microscope analysis revealed large alumina ceramic particles embedded on the bearing surface of the polyethylene. It has previously been pointed out that metallosis of an inner head occurred in bipolar case due to a fracture of the ceramic screws in contact with a proximally migrated outer head. However, this case showed that if a ceramic screw fragmented even though it was used outside of the hip joint, the fragments could migrate into bearing surface and cause serious metallosis of the metal head. Thus, we recommend that surgeons should pay special attention to the radiographic signs of ceramic failure or metallosis such as a change of the metal head contour, if an aseptic loosening or severe osteolysis is observed in a THA in which ceramic materials were used near the hip joint. And, when a surgical revision is planned, the surgeon should be prepared to exchange with a new ceramic head.     

Revision total hip replacement: predictors of blood loss, transfusion requirements, and length of hospitalisation

Background  

Revision total hip replacement (THR) is associated with increased blood loss and extended hospitalization.     

Revision total elbow replacement

The range of general and specific adverse event in total elbow arthroplasty is similar in principle and practice to all other revision prosthetic arthroplasty but with three particular challenges: loss of humeral and ulnar bone stock; insufficiency of the extensor ‘mechanism’; and the management of the ulnar nerve. Total elbow replacement is presently performed for the management of complex non-reconstructable distal humeral fractures in osteoporotic bone, for post-traumatic arthropathy, and for medically managed inflammatory arthritides in which metaphyseal bone architecture is often preserved while the articular surface is degenerate. In all these conditions the patient often presents for revision total elbow arthroplasty with relevant co-morbidities and relevant musculoskeletal dysfunction (for example: ipsilateral shoulder, wrist, thumb or hand dysfunction).Infection is a universal concern for revision arthroplasty but where the soft tissue ‘envelope’ is compromised and already limited, as in the proximal forearm, it is difficult to eradicate, particularly in immunocompromised patients.Bone loss compromises subsequent implantation of a revision prosthesis, while failure to restore the working lengths of the humerus and ulna reduces the strength of the flexor and extensor compartment muscles for elbow motion.Failure to restore the continuity of the triceps aponeurosis - antebrachial fascia and triceps medial head-olecranon components of the extensor ‘mechanism’ also compromises extensor power. Prior triceps-dividing surgical approaches will determine the elasticity, and therefore pliability, of the extensor ‘mechanism’: this will have a role in determining how much gain in length of the humeral side can be safely achieved.The ulnar nerve, and its management during elbow arthroplasty, is a source of frequent concern, particularly for revision of an elbow arthroplasty undertaken for distal non-reconstructable humeral articular fractures or post-traumatic arthropathy, in which the position of the ulnar nerve is never anatomic. For these reasons revision total elbow replacement (RTER) is challenging: it requires experience with surgical exposures of the elbow including the major nerve trunks, familiarity with the restoration of bone stock, a range of prostheses and techniques for prosthetic implantation, the ability to achieve adequate soft tissue cover and primary closure, and a logical approach to individualised rehabilitation.     

Clostridial infection in total hip joint replacement: a report of two cases.

Two cases of clostridial cellulitis are presented in patients who had Charnley total hip joint replacement for severe osteoarthritis. Early deep infection can be a major problem in this operation, and is usually due to Staphylococcus aureus.     

全髋置换术中聚乙烯内衬的安装

自1963年Ｃｈａｒｎｌｅｙ首先报道全髋关节置换术治疗类风湿性髋关节炎以来,该手术取得了长足的发展。不仅假体设计、制作工艺不断得到改进,而且手术技术也日臻完善。超高分子量聚乙烯髋臼假体与金属股骨头所组合的人工关节被认为是最佳的优化组合,目前在临床上广泛应用。其中大多数非骨水泥固定的人工髋臼是金属外壳与可拆卸的超高分子量聚乙烯所组成。一般聚乙烯内衬与金属壳非常密贴,镶嵌牢靠,有锁定结构,安装时应该很容易〔1〕。临床上有时遇到内衬安装非常困难的情况,而在国内的工具书和文献上却少有报道。笔者曾经遇到4例,现报道如下…