加强杯联合植骨技术修复翻修术中巨大髋臼骨缺损

[目的]介绍加强杯联合植骨技术在髋关节翻修手术中巨大髋臼骨缺损的修复应用。[方法]回顾分析2002—2007年，8例在翻修术中存在严重髋臼骨缺损患者，按D’Antonio分类：ⅡB型1例，ⅡC型2例，Ⅲ型5例；加强杯联合颗粒打压植骨3例，加强杯联合颗粒骨植骨＋结构性植骨5例；术后进行临床评估及X线评估。[结果]术后平均随访时间2．7年（6—49个月），未出现假体失败而需要再次翻修病例，植骨组织未见明显骨吸收。Harris评分系统评估患者髋关节功能，术后平均提高47分。[结论]采用颗粒骨打压植骨技术修复腔隙性骨缺损，结构性植骨恢复髋臼后方结构的完整，提高局部骨量，增加假体的骨性接触面，同时利用加强杯固定植骨组织，稳定假体，该方法可有效修复髋臼侧的巨大骨缺损。     

颗粒骨打压植骨结合多孔非骨水泥臼杯在AAOSⅢ型髋臼大面积骨缺损翻修中的应用

背景：颗粒骨打压植骨是修复髋臼骨缺损的重要方法,对大面积髋臼骨缺损采用打压植骨结合非骨水泥臼杯重建仍然存在争议。目的：探讨同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术修复AAOSⅢ型髋臼大面积骨缺损的方法及近期疗效。方法：随访2005年6月至2010年4月收治的28例（28髋）AA0SⅢ型髋臼大面积骨缺损患者。男18例,女10例,年龄34-74岁,平均53．8岁。髋关节置换术后感染醐翻修9例,骨溶解及髋臼假体松动翻修19例。本组AAOSⅢ型髋臼骨缺损面积大,术中见髋臼骨缺损超过髋臼关节面的50％。全部采用同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术。术后定期随访,观察臼杯有无松动、植入骨与宿主骨整合情况,髋关节功能评分采用Harris评分。结果：28例均获得随访,术后随访时间为13-70个月,平均43个月。Harris评分由术前32-48分,平均41分,提高至末次随访时86-95分,平均90分。28例髋臼假体均固定牢固无松动征象,植入骨逐渐与宿主骨整合,无感染及坐骨神经损伤。结论：在获得臼杯初始稳定固定的情况下,大面积颗粒骨打压植骨（臼杯与宿主骨接触面积〈50％）结合多孔非骨水泥臼杯髋臼重建术修复AAOSⅢ型髋臼大面积骨缺损近期疗效较好,远期疗效尚待进一步随访。     

Hydroxyapatite block for reconstruction of severe dysplasia or acetabular bone defects in total hip arthroplasty: operative technique and clinical outcome

Fourteen hips in 14 patients (all female; average age, 64 years) with severe bone defects due to developmental dysplasia of the hip or migration of the socket were treated with hydroxyapatite block with impacted morselized bone graft in conjunction with a cemented socket. All patients were followed clinically in a prospective fashion, and radiographs were analyzed retrospectively. One initial patient had 17-year follow-up, whereas the remaining 13 patients had follow-up between 4 and 6.5 years. No acetabular components were revised, including the socket of a 17-year postoperative case that remains rigidly fixed and supported by the graft and hydroxyapatite block with only mild polyethylene wear and minor osteolysis. Osteointegration and good clinical outcome were achieved in all cases by reconstruction with this technique in total hip arthroplasty.     

全髋关节翻修术中髋臼骨缺损的处理方法

目的探讨全髋关节翻修术中对于髋臼骨缺损重建的方法及其术后疗效。方法回顾性分析自2007-03—2011-12的75例（76髋）全髋关节翻修术,髋臼骨缺损根据Paprosky分型：Ⅰ型9髋,ⅡA型21髋,ⅡB型18髋,ⅡC型11髋,ⅢA型10髋,ⅢB型7髋。髋臼骨缺损采用不同方式修复,术后定期随访。采用髋关节功能Harris评分评估髋关节功能,根据X线片判断假体是否松动、植骨是否融合。结果 75例（76髋）均获得平均36（16~73）个月随访。术后12个月不同类型骨缺损患者髋关节功能Harris评分较术前明显提高,差异有统计学意义（P〈0.05）。术后症状和关节功能明显改善,未出现髋臼骨折、感染、下肢深静脉血栓形成、坐骨神经损伤等严重并发症。X线片可见移植骨与宿主骨质交界处有连续性骨小梁通过,假体未见松动迹象。结论髋臼假体无菌性松动及骨溶解是需要进行全髋关节翻修的主要原因,而髋臼骨缺损Paprosky分型法对髋臼翻修重建方法有指导意义,正确选择假体类型及合理选择植骨方式是全髋关节翻修术后取得满意疗效的保证。     

One-stage revision of infected total hip arthroplasty with bone graft

There are many different opinions in the literature regarding the best procedure for revision of infected hip arthroplasty and hence in achieving long-term stabilization of a new implant. Thirty-two patients with 32 loose and infected total hip arthroplasties underwent revision with a bone graft in a 1-stage procedure. The bone graft was used in the acetabulum and femur in 25 patients, in the acetabulum alone in 4 patients and in the femur alone in 3 patients. A metal mesh was necessary in 15 patients to contain the morselized bone graft. At the time of surgical revision, 9 patients had a draining sinus, 6 had a closed sinus, and 17 had never had sinuses in the surgical wound. Antibiotic therapy was administered intravenously and orally for 6 months. Mean follow-up was 103 months (range, 63-183 months), and infection recurred in 2 (6.2%) cases. Further studies are necessary, and continuation of this method is justified.     

Acyclic acetabular roof reconstruction for severe superior segmental acetabular bone loss in 2-stage surgery for infected hip arthroplasty

Ensuring the stability of a cemented PROSTALAC cup (Depuy, Warsaw, Ind) in the presence of severe superior acetabular segmental deficiency is critical to the success of the first-stage surgery. We present an illustrative case and the surgical technique required to achieve this.     

Cemented hip revision surgery in severe acetabular defects using a semirigid acetabular reinforcement ring--a 5- to 25-year follow-up study

Between 1978 and 1998, a total of 38 consecutive acetabular component revisions were performed in 38 patients. Average age was 67 years, and 87% of patients had severe uncontained segmental acetabular defects of more than 50%. We describe the operative technique of acetabular component revisions performed with bone grafting and a steel, semirigid acetabular reinforcement ring (Eichler), and long-term results are presented. After an average of 11.2 years follow-up, 1 cup was revised after 0.8 years for mechanical loosening, but the ring remained stably fixed. Remodeling (partial) of autografts occurred in all cases. The average HHS was 72.5. The Eichler reinforcement ring is a viable option for segmental acetabular defects in revision hip surgery, allows for restoration of pelvic bone, and makes future revisions feasible.     

Removal of the acetabular component minimizing destruction of the bone bed

Removal of a well-fixed acetabular component can be difficult and may produce destruction of the acetabular bone bed. The authors describe a technique for removal of such a component with minimal bone destruction that involves the use of an offset punch and breaking the fixation interface in tension. This technique obviates the need for prying at the interface and fracturing the bone bed.     

Technique for access to the posterosuperior iliac spine for local bone graft during total hip arthroplasty

A technique of local acquisition of large amounts of autogenous bone graft during revision total hip arthroplasty is described. Eleven such procedures in ten patients are described, with average total blood loss (intraoperative and postoperative) of 2,610 ml. No adverse wound or operative complications related to bone graft acquisition occurred.     

Evaluation of a porous tantalum uncemented acetabular cup in revision total hip arthroplasty: clinical and radiological results of 60 hips

Long-term survival of the acetabular component in revision total hip arthroplasty (THA) is determined by initial implant stability and bone ingrowth. Highly porous Trabecular Metal (TM, Zimmer, Inc, Warsaw, Ind) facilitates ingrowth and may be an ideal material for revision THA. The outcome and survivorship of a TM, nonmodular, uncemented acetabular cup were assessed in 60 consecutive patients undergoing revision THA (mean follow-up, 42 months; range, 14-68 months). Most (55/60) acetabular cups were implanted without screw fixation. Mean Harris Hips Scores improved from 74.8 preoperatively to 94.4 at last follow-up. Serial radiographs demonstrated excellent bone apposition and bone graft incorporation. Complications were limited to 7 cases of dislocation and 1 revision for aseptic loosening. The TM acetabular cup appears suitable for use in revision THA and warrants further study.     

Impaction grafting using a cemented porous-coated modular acetabular component

Reconstruction of major acetabular defects continues to challenge surgeons. There are many surgical options for these situations, including oversized hemispherical cups, oblong cups, acetabular cages, bulk allografts, and impaction allografting. We present the case of a modification to the impaction grafting technique for acetabular reconstruction. In our case, a porous-coated modular titanium acetabular component was cemented in place instead of an all-polyethylene acetabular component, which is the standard technique for impaction grafting reconstruction. The use of the modular component allowed a greater number of surgical options at the time of surgery. At 5 years from surgery, the patient has a successful reconstruction and the radiographs continue to look excellent.     

Acetabular revision using a total acetabular allograft

The most challenging aspect of an acetabular revision is the management of severe bone loss, which compromises implant fixation and stability. We present a case of failed acetabular revision with extensive bone loss (Paprosky Type 3b) in a 50-year-old woman with rheumatoid arthritis, which was treated using total acetabular allograft. At a follow-up of 1 year and 3 months, the allograft had united with the host bone. This is the first report of the use of a total acetabular allograft for revision total hip arthroplasty in India. The total acetabular allograft allows the placement of the component closer to the normal hip center, provides initial stability for the acetabular component, and restores bone stock to the host pelvis.     

Revision total hip arthroplasty for pelvic osteolysis with well-fixed cementless cup

Treatment of pelvic osteolysis after total hip arthroplasty (THA) remains controversial. Clinical and radiographic outcomes of revision THA were evaluated in 62 hips with pelvic osteolysis and well-fixed cementless cups. The patients' mean age was 50.9 years, and the mean interval from primary to revision THA was 9.7 years. For revision, cementless cups were used in 51 hips, and cemented cups in 11 with acetabular reinforcement rings in 9. The mean duration of follow-up after revision THA was 5.9 years (range, 3.0-9.7 years). At final follow-up, the average Harris Hip Score was 92.4, and there was no radiographic complication except for 1 with change of inclination. Revision THA for pelvic osteolysis with well-fixed cementless cups showed favorable outcomes, and it can be preferentially used in young patients.     

Trabecular metal acetabular revision system (cup-cage construct) to address the massive acetabular defects in revision arthroplasty

The increasing number of total hip replacements in the younger clique has added to the demand for revision procedures. Revision situations are often encountered with infection, loss of bone stock and bone defects. There are various methods of reconstruction of acetabular defects. The management options of type 3B Paprosky acetabular defects are limited with allograft and conventional cages. Trabecular metal technology has evolved to address these bone defects. Trabecular metal acetabular revision system (TMARS) cup-cage construct is a new technique to address massive acetabular defects. We describe a case of failed hip reconstruction done for a Giant cell tumour of proximal femur managed by a two stage procedure, initial debridement and second stage reconstruction of acetabulum with TMARS cup-cage construct and femur with allograft prosthesis composite.     

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.     

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.     

打压植骨结合金属网重建全髋关节翻修术中髋臼侧严重骨缺损

[目的]探讨在全髋关节翻修术中使用打压植骨技术结合金属网重建严重髋臼骨缺损的方法和效果。[方法]2001年12月至2006年1月应用打压植骨技术结合金属网重建严重髋臼侧骨缺损的患者共有21例21髋,男6例,女15例;翻修时平均年龄为51.9岁（38-77岁）。采用美国骨科医师协会（AAOS）分型,本组患者骨缺损均为AAOSⅢ型（混合型骨缺损）。采用金属网将非包容性骨缺损转变为包容性骨缺损,然后采用7-10 mm的深低温冷冻骨颗粒,使用打压植骨技术恢复骨量,重建髋关节的正常解剖形态,使用骨水泥将聚乙烯臼杯固定于理想的生物力学位置。拍摄术后3 d、3个月、1年及每年随访时的双髋正位片,以泪滴为参照,观察聚乙烯臼杯位置的变化及骨水泥层透亮线的变化,并进行Harris髋关节评分比较。[结果]平均随访2.8年（1-5年）,Harris评分从术前平均46.4分提高到术后81.3分,未发现臼杯松动病例。术后1例脱位,1例有坐骨神经受损症状。[结论]在髋关节翻修术中采用打压植骨技术并结合应用金属网的方法能较好地重建髋臼侧严重骨缺损,恢复骨量,辅助髋臼安放在理想的生物力学位置,并能提供良好的早期稳定性。     

Total hip arthroplasty for posttraumatic arthritis after acetabular fracture

Total hip arthroplasty (THA) outcomes for posttraumatic arthritis after acetabular fracture have yielded inferior results compared to primary nontraumatic THA. Recently, improved results have been demonstrated using cementless acetabular reconstruction. Thirty-two patients underwent THA for posttraumatic arthritis after acetabular fracture; 24 were treated with open reduction internal fixation, and 8 were managed conservatively. Time from fracture to THA was 36 months (6-227 months). Average follow-up was 4.7 years (2.0-9.7 years). Harris Hip score increased from 28 (0-56) to 82 points (20-100). Six patients required revision. Five-year survival with revision, loosening, dislocation, or infection as an end point was 79%. Survival for aseptic acetabular loosening was 97%. Revision surgery correlated with nonanatomic restoration of the hip center and a history of infection (P < .05). Despite obvious challenges, advances in fracture management and cementless acetabular fixation in THA demonstrate improved results for posttraumatic arthritis following acetabular fracture.     

Improving acetabular cup orientation in total hip arthroplasty by using smartphone technology

Acetabular cup placement in total hip arthroplasty is often difficult to assess, especially in the lateral position and using the posterior approach. Conventional techniques and computer-assisted surgery are the 2 most popular methods for proper placement of the acetabular cup in Lewinnek's safe zone of orientation (anteversion 15° ± 10° and lateral inclination 40° ± 10°). We developed a system that uses the accelerometer and camera function of the iPhone. A level indicator application and protractor application were downloaded to the iPhone and used to improve acetabular cup placement. This system has proven to be accurate and quick. Our series of 50 prospective cases showed good results with all our acetabular cups being placed within a narrow range in the safe zone and with less than 5% difference between the preoperative, intraoperative, and postoperative acetabular inclinations.     

Redefining revision total hip arthroplasty based on hospital admission status

This study examined patient demographics, length of hospital stay, and discharge disposition in those undergoing nonelective revision total hip arthroplasty (rTHA) vs elective rTHA. Data from 23 000 patients with hip revisions from 2005 through 2007 were extracted from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database. We examined patient admission status, demographics, length of stay, and discharge location. We found that patients undergoing nonelective rTHA were older, were female, had more comorbidities, stayed an excess of 1.61 days in the hospital, and required a skilled care facility after discharge compared with those undergoing elective rTHA. We found that rTHA outcomes varied based on patient hospital admission status. Patients who elected to have rTHA had less comorbidities, cost, and likelihood of being discharged into a skilled care facility.