全髋关节置换术后股骨假体周围Vancouver B型骨折治疗的随访研究

目的 探讨全髋关节置换术后股骨假体周围Vancouver B型骨折治疗方法的选择,总结同种异体皮质骨板移植重建股骨假体周围骨折的临床效果.方法 22例全髋关节置换术后股骨假体周围骨折患者,男7例,女15例;年龄平均65岁(53～75岁).Vancouver分类B1型5例,B2型4例,B3型13例.B1型骨折采用异体皮质骨板移植加钢丝环扎治疗;B2型骨折选择加长股骨柄翻修;B3型骨折选择骨水泥柄翻修,加同种异体皮质骨板移植和钢丝环扎同定.所有患者均获得随访,随访时间平均67个月(37～95个月).采用Harris髋关节功能评分、X线片、外周血T淋巴细胞亚群、抗体免疫复合物检测 和核素骨显像对治疗结果进行评价.结果 22例患者骨折全部愈合,21例患者能自由行走,1例需要助 行器帮助.末次随访Harris评分平均89分(79～93分).患者未发生免疫排斥反应;术后3个月,骨折愈合,术后12个月,移植骨板与宿主骨骨性愈合,股骨皮质厚度增加3～5mm;核素骨显像骨板移植区放射性核素分布较对侧浓集.3例患者移植骨板出现部分吸收现象.术后2年.骨板与宿主骨融合,移植骨板吸收停止.结论 针对股骨假体周围骨折不同类型分别采取不同方法治疗能够取得较好疗效,同种异体皮质骨板移植在维持骨折稳定性、促进骨折愈合、增加局部骨量和改善骨强度方面有较好疗效.     

同种异体皮质骨板移植免疫学研究

目的: 探讨实验动物和患者接受不同方法处理的同种异体皮质骨板移植后宿主免疫学反应。方法: 48只山羊接受分别经过 -70℃深低温冷冻 4周、 -70℃深低温冷冻 4周 48℃环氧乙烷灭菌、-70℃深低温冷冻 4周 25kGyγ射线辐照处理的同种异体皮质骨板移植,对照组移植异体山羊新鲜皮质骨板。7例髋关节置换术后股骨假体周围骨折患者, 接受深低温冷冻和环氧乙烷处理同种异体皮质骨板移植重建股骨骨折。检测实验动物外周血CD4 、CD8 以及患者外周血T淋巴细胞亚群、抗体、补体和循环免疫复合物。结果: 新鲜骨板移植组CD4 明显升高, 术后 6周达到顶峰。除深低温组术后 6周CD4 升高外, 深低温冷冻、深低温冷冻 环氧乙烷及深低温冷冻 γ射线辐照组T淋巴细胞亚群无明显改变。患者T淋巴细胞亚群、抗体和免疫复合物正常, 切口无感染。结论: 新鲜同种异体皮质骨板具有抗原性, 移植后诱发宿主免疫排斥反应; 深低温冷冻、深冻 环氧乙烷和深冻 γ射线辐照处理同种异体皮质骨板移植受体无明显免疫排斥反应。     

同种异体皮质骨板移植

1　引　言195 1年Kreutz报道用冻干同种异体皮质骨板移植治疗骨折,2 0世纪80年代中期,同种异体皮质骨板移植开始应用于人工关节外科,重建股骨骨溶解和假体周围骨折[1] 。近年来人们对同种异体皮质骨板移植组织学、X线表现、临床应用以及并发症等方面进行了广泛研究,本文就相关文献做一综述。2　同种异体皮质骨板移植的生物学行为用任何方法保存的异体骨移植后必须经受宿主骨的爬行替代而存活。节断性同种异体皮质骨移植的爬行替代沿移植骨长轴进行,骨修复在宿主骨与移植骨交界处最活跃,然后沿长轴向中央发展。长段同种异体皮质骨移植在体内…     

全髋关节翻修术中股骨假体周围骨折的处理

目的研究全髋关节翻修术中股骨假体周围骨折的治疗方法。方法对2002年10月至2007年2月在全髋关节翻修术中出现股骨假体周围骨折的32例非感染翻修患者进行回顾性分析。采用Vancouver分型方法对骨折进行分类,其中A型11例,B型16例,C型2例,同时发生A、B型骨折的3例。24例采用加长广泛涂层柄翻修联合异体皮质骨板固定,6例采用加长广泛涂层柄加钢丝固定,1例采用骨水泥假体,1例仅采用异体皮质骨板固定。结果28例患者获得随访,平均随访时间23.5个月(3~56个月)。术后12~22周所有患者骨折均愈合(平均17.5周)。1例患者术后患肢疼痛,2例同侧膝关节僵直。术后平均Harris评分为92分。结论绝大多数翻修术中出现股骨假体周围骨折的患者能顺利恢复功能。非骨水泥广泛涂层柄可能是较好的选择。异体皮质骨板移植对骨量较差的患者来说是有用的技术。     

人工髋关节股骨假体周围Vancouver B型骨折治疗的临床分析

目的探讨人工髋关节置换术后股骨假体周围Vancouver B型骨折患者,进行假体翻修、内固定治疗的效果。方法 2005年1月至2009年12月间,广州医科大学大学附属第一医院关节外科收治人工髋关节置换术后股骨假体周围B型骨折患者16例,其中11例为全髋,5例为半髋;男4例,女12例;年龄平均69岁(59~81岁);Vancouver分类B1型3例,B2型5例,B3型8例。B1型骨折采用内固定、或加异体皮质骨板移植治疗;B2型骨折选择加长股骨柄翻修、捆扎带环扎;B3型骨折选择加长股骨柄翻修、加同种异体皮质骨板移植和捆扎带环扎固定。所有患者均进行随访,随访时间平均90个月(5~9年)。采用Harris髋关节功能评分、X线片对治疗结果进行评价。结果 12例患者获得随访,骨折全部愈合,患者能自由行走,末次随访髋关节功能评分(Harris评分)平均90分(76~93分)。结论针对人工髋关节置换术后股骨假体周围骨折的不同类型,分别采取切开复位内固定、加长股骨柄假体翻修、异体皮质骨板移植治疗,能取得较好疗效。     

全涂层远端固定长柄假体治疗髋关节置换术后股骨假体周围骨折的临床研究

目的分析全涂层远端固定长柄假体治疗髋关节置换术后假体周围骨折的临床效果。方法回顾性分析35例使用全涂层远端固定长柄假体治疗的髋关节置换术后股骨假体周围骨折病例,根据Vancouver分型,B2型12例,B3型20例,C型3例,通过Harris评分对患髋进行功能评价,X线片观察骨折愈合、股骨柄下沉情况。结果3例行单纯长柄假体翻修,10例行长柄假体翻修＋钢丝环扎固定,22例行长柄假体翻修＋同种异体颗粒骨压配植骨＋同种异体骨板捆绑固定治疗,平均随访4．5年,所有骨折均顺利愈合,平均愈合时间为15．3周,Harris评分平均86．5分,2例股骨柄分别下沉3mm和4mm,均在术后3个月达到稳定,32例假体获得骨长入固定,3例获得稳定的纤维固定,未发现骨溶解、感染以及再发骨折。结论髋关节置换术后假体周围骨折选择全涂层远端固定长柄假体翻修,根据骨缺损严重程度合理选择同种异体颗粒骨打压植骨＋同种异体骨板捆绑固定可以获得良好的临床效果。     

全髋关节置换术后温哥华B型假体周围骨折的治疗

背景:全髋关节置换手术是目前最为成功有效的外科手术之一,与之伴随的是多种术后并发症的出现,假体周围骨折是其中最显著的并发症之一,发病率有上升趋势。目的:回顾性研究全髋关节置换术后温哥华B型股骨假体周围骨折的治疗措施。方法:2006年1月至2011年1月收治全髋关节置换术后股骨假体周围骨折33例,男17例,女16例;年龄38～81岁,平均68.2 岁。33 例均为温哥华 B 型假体周围骨折:B1 型骨折组 11 例,采取切开复位钢丝捆扎固定或接骨板固定+异体皮质骨板植骨;B2型骨折组16例,采用记忆合金环抱器+大量植骨或长柄全涂层假体联合钢丝捆扎+局部异体松质骨植骨;B3型骨折6例,采用长柄生物性假体或组配型假体+同种异体骨板联合钢丝捆扎。结果:全部获得随访,随访时间为0.5～5.5年,平均3.6年。髋关节功能恢复良好,骨折愈合,对位对线良好。骨折愈合时间为3～22个月,平均6.5个月。B1型骨折组中1例术后因跌倒再次骨折,行二次翻修手术,末次随访时Harris评分为82～96 分,平均 91.2 分;B2 型骨折组中 1 例术后 3 年出现假体松动下沉,行二次翻修手术,末次随访时 Harris 评分为 76～92 分,平均 87.0 分;B3 型骨折组中 1 例术后 3 个月出现移植骨排异反应与感染,经治疗无效,再次手术取出同种异体骨板,抗生素药物治疗后症状缓解,末次随访时Harris评分为66～80分,平均71.5分。无一例发生深静脉血栓形成、神经损伤等并发症。结论:股骨柄假体周围骨折中温哥华B型较常见,根据骨折类型选择不同的治疗方法,均可获得满意疗效。     

全髋关节置换术后股骨假体周围骨折的治疗

目的：分析全髋关节置换术后股骨假体周围骨折的病因和治疗结果．探讨其治疗方法。方法：回顾性研究自1998年12月-2003年3月治疗并随访观察的11例全髋关节置换术后股骨假体周围骨折患者，男8例，女3例，平均年龄为56岁(43-75岁)，采用Vancouver分型，A型2例，B2型7例．B3型1例，C型1例。采用非手术治疗5例；手术治疗6例，其中1例为非手术治疗后骨折畸形愈合行翻修术。采用长柄假体翻修联合异体皮质骨板固定5例．其中使用非骨水泥型远端固定假体4例．使用骨水泥型假体1例。采用切开复位内固定治疗1例。结果：所有病例均获随访，平均随访25．6个月(7～50个月)。9例骨折愈合，平均愈合时间4个月(3-6个月)，2例骨折未愈合。均为非手术治疗病例，手术治疗6例骨折均愈合。至目前为止，7例假体稳定，1例翻修术后出现连续的影像学透亮线．3例假体松动，假体稳定的患者功能好于假体松动者．假体稳定患者的Harris评分平均91分。所有异体皮质骨板在1年内均与宿主骨整台．没有异体皮质骨板骨折发生。结论：假体稳定的A型骨折可以采用非手术治疗。对于B1型和C型骨折，如无手术禁忌证，应行切开复位内固定术。对于假体松动的骨折患者，使用长柄远端固定非骨水混型假体联合异体皮质骨板是最佳的治疗方法。     

人工髋关节置换术后股骨假体周围骨折的治疗

目的 探讨人工髋关节置换术后股骨假体周围骨折的治疗方法及临床效果.方法 采用温哥华术后骨折分型标准,共收治人工髋关节置换术后股骨假体周围骨折13例.结果 13例均获得随访,随访时髋关节功能按Harris评分:优4例,良5例,中3例,差1例.其中1例不愈合,其余12例获骨性愈合.结论 对此类骨折应根据近期影像资料进行周密的术前计划,结合骨折部位、假体稳定性及骨储备情况等因素,选择治疗方案.使用钢丝环扎、非骨水泥型长柄翻修联合应用异体皮质骨板及局部植骨是处理不同类型股骨假体周围骨折的有效治疗方法.     

全髋关节置换假体柄周围骨折的治疗

目的 :回顾性研究全髋关节置换假体柄周围骨折的治疗及预防。方法 :将本院近年收治的全髋置换假体柄周围骨折的 8例病例按Vancouver分类方法进行分类 ,其中A1型 3例 ,B1型 3例 ,B2型 1例 ,B3型 1例 ,分别用钢丝环扎固定 ,异体皮质骨板加钢丝环扎 ;骨水泥长柄假体翻修。结果 :术后随访 8～ 18个月 ,骨折愈合 ,假体固定可靠。结论 :全髋关节置换术后假体柄周围骨折用Vancouver分类方法分类 ,简单、适用。采用异体皮质骨板与钢丝环扎固定骨折 ,治疗假体柄周围骨折 ,不仅固定可靠而且能促进骨折愈合、恢复骨量。     

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。     

Cortical strut allografts in salvage revision arthroplasty: Surgical technique and clinical outcomes

BackgroundThe aim of this study was to present our clinical outcomes and surgical technique in strut allografts preparation using staggered holes to enhance osteointegration and demineralised bone matrix (DBM) as an adjunct to cortical strut allografts in salvage revision arthroplasty patients.MethodsRetrospective consecutive series of patients who required strut allograft femoral reconstructions with minimum 2 years follow up between 2012 and 2018. Frozen washed irradiated, cortical struts were used and prepared adding 2 mm staggered drill holes along the length of the strut and applying DBM paste on the graft-host interface. Outcome measures included radiographic strut union, graft resorption, infection and complications.Results15 patients included; 3 males and 12 females with median age 72 years (range 60–93). All had significant bony defects (Paprosky III/IV in 12 cases including 3 cases of periprosthetic hip fractures and further 3 cases of periprosthetic knee fractures around revision hinged implants). At final follow up, median 3.8 years (range 2.7–7.2), 14/15 (93.3%) struts had united at a median 6 months (range 5–8), complete incorporation with cortical round-off was seen at median 12 months (range 8–48) in 12/15 (80%) struts, 2/15 (13.3%) show radiographic evidence of proximal minimal graft resorptions although the remainder of the strut had integrated and were asymptomatic. There were no cases of infection.ConclusionsUse of strut allografts helps to reconstruct bone defects, restore bone stock, and provide stable fixation for complex patterns of periprosthetic fractures around hip/knee implants and salvage revision cases with 93.3% union rate at median 6 months.     

Locking compression plate fixation of Vancouver type-B1 periprosthetic femoral fractures

BACKGROUND: Fractures occurring at or near the distal tip of a hip prosthesis with a stable femoral stem (Vancouver type-B fractures) are associated with many complications because of the inherently unstable fracture pattern. Locking compression plates use screws that lock into the plate allowing multiple points of unicortical fixation. Such unicortical fixation may lower the risk of damage to the cement mantle or a stable femoral stem during the treatment of a periprosthetic femoral fracture. The purpose of this study was to analyze clinically and radiographically a group of patients with a Vancouver type-B1 periprosthetic femoral fracture treated with open reduction and internal fixation with use of a locking compression plate. METHODS: Fourteen consecutive patients (fourteen hips) with a Vancouver type-B1 periprosthetic femoral fracture were treated with a locking compression plate. There were five men and nine women with an average age of sixty-eight years at the time of fracture. All of the fractures occurred after a total hip arthroplasty performed with cement, and eleven of the arthroplasties were revisions. In addition to the plate, cortical strut allografts were used to stabilize five fractures. The patients were assessed clinically and radiographically. RESULTS: The average duration of follow-up was twenty months. Eight fractures healed uneventfully at an average of 5.4 months. Three treatment constructs failed with fracture of the plate within twelve months after surgery. An additional three constructs also failed because of plate pullout. All failures except one occurred in constructs in which a cortical strut allograft had not been utilized. CONCLUSIONS: On the basis of the high failure rate in this series of patients, locking compression plates do not appear to offer advantages over other types of plates in the treatment of type-B1 periprosthetic femoral fractures. Despite the potential to preserve the cement mantle, the locked screws did not appear to offer good pullout resistance in this fracture type. We believe that supplementation with strut allografts should be used routinely if this type of locking compression plate is selected to treat these fractures.     

Strut allografts for failed treatment of periprosthetic femoral fractures: Good outcome in 13 patients

Strut allografts are not recommended after a femoral shaft exposure, because they may endanger the femoral blood supply. Up till now, we have seen no clinical reports on this problem. We treated 13 consecutive patients with very large anteromedial and anterolateral femoral strut allografts to restabilize periprosthetic fractures which had become loose after a previous attempt at surgical fixation (Vancouver type B fractures with severe bone loss). In 8 cases, the stem was revised in conjunction with the use of strut allografts and in 5 cases, strut allografts alone were used. All refractures and nonunions healed without further treatment. At a mean follow-up of 3 (1.2-7) years, the mean Harris Hip Score was 78 (65-92). All strut grafts showed ingrowth with augmentation of periprosthetic bone on the radiographs. There were 3 complications, 1 nonprogressive subsidence of a revision stem (fibrous stable), 1 deep hematoma and 1 partial lesion of the sciatic nerve. In this series, strut grafts gave reliable healing with augmentation of the host bone stock despite previous femoral exposure, severe bone loss, adverse type of fracture, and persistent instability at the index operation.     

Strut allografts for failed treatment of periprosthetic femoral fractures: good outcome in 13 patients

Strut allografts are not recommended after a femoral shaft exposure, because they may endanger the femoral blood supply. Up till now, we have seen no clinical reports on this problem. We treated 13 consecutive patients with very large anteromedial and anterolateral femoral strut allografts to restabilize periprosthetic fractures which had become loose after a previous attempt at surgical fixation (Vancouver type B fractures with severe bone loss). In 8 cases, the stem was revised in conjunction with the use of strut allografts and in 5 cases, strut allografts alone were used. All refractures and nonunions healed without further treatment. At a mean follow-up of 3 (1.2-7) years, the mean Harris Hip Score was 78 (65-92). All strut grafts showed ingrowth with augmentation of periprosthetic bone on the radiographs. There were 3 complications, 1 nonprogressive subsidence of a revision stem (fibrous stable), 1 deep hematoma and 1 partial lesion of the sciatic nerve. In this series, strut grafts gave reliable healing with augmentation of the host bone stock despite previous femoral exposure, severe bone loss, adverse type of fracture, and persistent instability at the index operation.     

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.     

Use of Locking Plate and Strut Onlay Allografts for Periprosthetic Fracture Around Well-Fixed Femoral Components

Background

The purpose of this study was to determine: validated clinical and radiographic outcomes of periprosthetic femoral fractures around stable hip implants treated with plate fixation and additional cortical strut onlay allografts without revision of the stem; radiographic signs of fracture healing; allograft-to-host bone union; resorption of cortical strut allograft; and frequency of complications.

Vancouver B1型股骨假体周围骨折的手术治疗

目的探讨Vancouver B1型股骨假体周围骨折的理想手术治疗方式。方法2000年3月至2008年1月,12例VancouverB1型股骨假体周围骨折患者行切开复位、内固定治疗。男2例,女10例;年龄62—85岁,平均72岁。内固定方式包括LISS锁定接骨板系统、加压接骨板系统,部分病例结合使用多道钢丝或钢缆捆扎固定,及异体柱状皮质骨和（或）DBM人工骨植骨。对术后骨折延迟愈合患者行自体骨髓灌注等治疗。结果患者均获得随访,随访时间12—96个月,平均32个月。除1例术后发生骨折移位失败外,骨折均愈合,愈合时间3～12个月,平均4．3个月。Harris评分：65—92分,平均79分。结论VancouverB1型股骨假体周围骨折发生率高,处理棘手。目前,LISS系统是治疗此类骨折最有效的方式之一,应尽量使用微创技术以减少骨折处的血供破坏,如需切开整复骨折,应常规植骨,必要时术后可于骨折处定期灌注自体骨髓以促进骨愈合。