髋关节置换术后翻修原因分析

１９７４年～１９９１年对２６４例老年股骨颈骨折、股骨头缺血坏死、髋关节骨性关节炎患者行髋人工关节置换，其中人工股骨头置换１５０例，全髋关节置换１１４例。术后因假体松动、下沉、脱位，髋臼磨损等原因，引起患者疼痛，功能障碍而行翻修术１５例，翻修率为５．７％，翻修时间为术后５年～１６年，平均７．４年。翻修手术为人工股骨头再置换术３例，全髋关节置换术１２例。翻修术后随访２年～６年，平均４．７年。按Ｊａｃｏｂｓ法评价，优１１例，占７３％；良３例，占２０％；可１例，占７％。翻修原因主要与假体松动、下沉，髋臼磨损，髋臼软骨切取不彻底，臼窝太浅，植入假体时存有血迹等有关。     

人工髋关节假体周围股骨骨折的内固定治疗

人工髋关节置换术中或术后骨折是一种少见的特殊骨折。由于髓腔内金属假体的存在，使这类骨折处理较为困难。而人工关节置换的广泛开展及翻修手术的不断增加，又使此类骨折的发生明显增多。1999年8月～2004年8月间对8例人工髋关节假体周围股骨骨折患者采用切开复位、不锈钢钢丝环扎、金属带绑扎及记忆合金环抱器内固定治疗取得不同疗效。现报告如下。     

全髋与半髋关节置换术治疗老年人股骨颈骨折结果比较

目的 比较全髋关节置换术与半髋关节置换术治疗老年人完全移位股骨颈骨折的疗效。方法 将1995～2001年在我院治疗的262例60岁以上有移位的股骨颈骨折患者分为两组，A组为全髋关节置换术，B组为人工股骨头置换术。随访12～78个月，平均37个月。结果 按Harris评分标准，A组术后优良率达到93.8％；B组术后优良率达78.4％，单极与双极股骨头置换组之间结果没有明显的差别；人工股骨头置换后有5例需行全髋翻修手术；双极人工股骨头置换中有2例发生双极之间脱位，7例出现假体周围骨溶解。结论 人工股骨头或全髋关节置换术是治疗老年股骨颈骨折的有效方法，可提高老年人的生活质量，减少并发症。全髋关节置换结果优于人工股骨头置换。     

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。     

人工股骨头置换治疗陈旧性股骨颈骨折79例

目的：探讨人工股骨头置换治疗陈旧性股骨颈骨折的技术措施对疗效的影响。方法：根据７９例陈旧性股骨颈骨折的病理特点，恰当选用骨水泥型／非骨水泥型人工股骨头置换，并彻底松解髋关节周围软组织，切断关节囊，重建矩部，恢复肢体长度。结果；平均随访５年２个月，疗效优良率为８８．６％。结论：恰当选用假体类型，彻底松解髋关节周围软组织，重建矩部，恢复肢体长度，是提高疗效，减少并发症的重要措施。     

高龄陈旧性股骨颈骨折合并头颈吸收短缩的人工髋关节置换术

目的探讨对高龄陈旧性股骨颈骨折合并头颈吸收短缩行人工髋关节置换术的临床疗效及手术技巧。方法自2009-10—2012-10对高龄陈旧性股骨颈骨折合并头颈吸收短缩23例行人工髋关节置换术,手术均采用后外侧入路,在预定平面截断股骨颈,松解关节囊后进行假体置入。本组8例行全髋关节置换术,15例行半髋关节置换术。均选择生物型假体,其中初次置换生物柄17例,圆锥形生物翻修柄6例。采用髋关节功能Harris评分评估术后髋关节功能改善情况。结果 23例术后均获得平均29.5(14~50)个月随访。髋关节功能Harris评分从术前(36.35±2.11)分提高至末次随访时(89.58±4.21)分,差异有统计学意义(t=-59.08,P0.05)。术后X线片均显示股骨柄生物填充固定良好,术后3个月X线片显示均获骨性固定。结论髋关节置换术是治疗高龄陈旧性股骨颈骨折的有效手术方法,应根据髓腔形态、股骨距完整性及骨质疏松情况选择适配的股骨假体柄类型。采用髋关节复位后梯次松解法可安全、有效地对髋关节囊及周围软组织挛缩进行分层松解。     

人工髋关节置换术后翻修原因分析及预防

目的对人工髋关节翻修病例进行回顾性分析,总结经验,以便规范手术操作,提高远期疗效。方法总结自1999~2010年,对78例80髋行全髋关节翻修术,分析翻修原因。初次关节置换类型:全髋关节置换40例,单极股骨头置换12例,双极股骨头置换26例。翻修距初次手术时间:1年内11髋,1～2年6髋,5～10年42髋,10～17年21髋。结果根据本组统计,翻修常见原因依次为假体无菌性松动、髋臼磨损、假体位置不良、术后感染、假肢周围骨折、人工关节脱位及假体断裂,而且其中某些病例失败原因往往存在合并症。结论人工髋关节置换术作为髋关节重建的一种有效方法,其远期疗效有赖于适当的假体及手术方式的选择、正确的手术操作以及出现并发症后的合理治疗。     

髋关节置换术中假体周围骨折12例报告

目的 分析髋关节置换术中并发假体周围骨折的原因及防治措施.方法 自1999年5月～2010年9月,笔者施行人工髋关节置换术385例,共12例发生术中假体周围骨折,其中全髋关节置换术7例,髋关节翻修术4例,股骨头置换1例.全部病例术中均同期内固定.结果 11例获得随访,平均随访时间17.3个月(9～28个月),骨折均骨性...     

髋关节置换术中股骨假体周围骨折危险因素的分析

目的分析髋关节置换术中股骨假体周围骨折的发生情况和危险因素。方法选择本组自2002年1月至2008年12月所有行初次和翻修髋关节置换术患者共3021髋(初次置换术2718髋,翻修术294髋),分析术中股骨假体周围骨折的发生情况,并用Logistic回归分析骨折发生的相关因素,包括性别、年龄、术前诊断、假体类型、固定方式。用2检验进行初次置换和翻修术中发生骨折的差异性检验。结果总的术中股骨假体周围骨折发生率为5.7%(173/3021),其中初次置换发生率为4.0%(110/2718),翻修术发生率为21.4%(63/294)。初次置换应用骨水泥股骨假体术中骨折发生率为1.9%(8/429),非骨水泥股骨假体术中骨折发生率为4.5%(102/2289),初次置换术中骨折82.7%(91/110)发生于干骺端;翻修术应用骨水泥股骨假体术中骨折发生率为18.8%(21/112),非骨水泥股骨假体术中骨折发生率为23.1%(42/182),翻修术术中骨折62%(39/63)发生于骨干部。Logistic回归分析显示:初次髋关节置换术中骨折的危险因素包括性别、术前诊断、固定方式、假体类型;翻修术性别、年龄、假体固定方式不是引起术中骨折的危险因素。应用2检验,翻修术中股骨假体骨折的风险与初次置换相比差异有统计学意义(P0.000),OR值为6.5,95%CI(4.6,9.1)。结论初次髋关节置换术中股骨假体周围骨折的发生率为4.0%,主要发生于干骺端(83.6%),女性、髋关节发育不良、髋部骨折、高位脱位、非骨水泥固定是术中骨折的危险因素;髋关节翻修术中股骨假体周围骨折的发生率(21.4%),远高于初次髋关节置换术,主要发生于骨干部(61.9%),骨折的发生与否可能主要取决于翻修时的骨质情况,性别、年龄、假体固定方式并不是主要的影响因素。     

珊瑚型人工髋关节置换术的临床随访及松动原因的分析

自１９８３年至今应用珊瑚型人工髋关节置换术共５４例６０髋。其中人工全髋关节置换术３４例４０髋，人工股骨头置换术２０例２０髋。在５４例６０髋珊瑚型人工髋关节置换术中，有３７髋随访６个月～１３年，平均随访时间约７年，疗效满意率为８５．１％，其中假体松动４例占１４．８％，髋臼松动２例７．４％。假体松动原因是假体与股骨负重界面之间没有达到稳定接触，假体与髓腔形状不相匹配，修整髓腔松质骨时，髓腔扩大器应比假体小一号，避免假体与界面存留缝隙。对于髋臼发育不良的患者应避免髋关节旋转中心向外侧移位，应向内上方加深髋臼以减少水平移位距离，其次髋臼植骨加盖勿在负重区。     

The uncemented total hip arthroplasty. Intraoperative femoral fractures

Intraoperative fractures of the proximal femur occurred in 40 (38 patients) of 630 (6.3%) biological ingrowth total hip arthroplasties performed between January 1984 and July 1986. Twenty-three of these fractures occurred during 131 revision arthroplasties (17.6%) and 17 during 499 primary arthroplasties (3.5%). All but two of the fractures were recognized during surgery. Thirty-seven were treated with either Parham bands or cerclage wires. Bone graft was added to the fracture site in 31 fractures. All of the fractures healed. Three of the patients failed to achieve stable fixation and have required revision surgery. An additional patient has thigh pain with 2 mm of subsidence noted with serial roentgenographs. Femoral fractures can be prevented by preoperative templating of roentgenograms containing markers to measure magnification, routine overreaming of the femoral canal when implanting long-stemmed prostheses, and prophylactically applying wires or bands to femurs requiring the removal of screws.     

Controlled perforation. A safe method of cement removal from the femoral canal

Removal of cement from the femoral canal during total hip revision arthroplasty continues to be very challenging. The technique is described using multiple 9-mm perforations placed at least 5 cm apart on the anterior surface of the femoral shaft. The tip of the revision stem should be at least 5 cm distal to the most distal perforation. From January 1984 to December 1986, 219 cases of revision total hip arthroplasties were performed using this technique; the incidence of ipsilateral postoperative femoral fractures was nine out of 219. Eight of these fractures were at the tip or distal to the femoral prosthesis and were associated with trauma. One fracture occurred through a perforation site and had an associated fracture of the femoral component. This method appears to be a reliable and safe method of cement removal from the femoral canal.     

One Surgeon's Experience With the 2-Incision Technique for Total Hip Arthroplasty

This study's purpose was to analyze the complications that occurred during and after one surgeon's first 200 two-incision total hip arthroplasties. Complications included 4 intraoperative femur fractures, 4 postoperative femur fractures, 2 nondisplaced greater trochanter fractures greater than 2 cm, 14 asymptomatic greater trochanter fractures 2 cm or less, 1 malpositioned cup requiring revision, 1 loose stem, 7 cases of heterotopic ossification of grade 2 or higher, 4 dislocations, 1 superficial infection, 80 lateral femoral cutaneous nerve neuropraxias (78 resolved within 6 weeks), and 4 femoral nerve neuropraxias (3 resolved within 12 weeks). This study shows that the 2-incision technique can be performed with a low risk of major complications, and patients can expect reduced tissue trauma and faster rehabilitation. When carefully sought out, minor complications were not uncommon after 2-incision total hip arthroplasty.     

The use of interlocking prostheses for both temporary and definitive management of infected periprosthetic femoral fractures

Infected periprosthetic fractures around total hip arthroplasties are an extremely challenging problem. We describe our experience of managing infected periprosthetic femoral fractures using interlocking long-stem femoral prostheses either as temporary functional spacers or as definitive implants. The Cannulock (Orthodesign, Christchurch, United Kingdom) uncoated stem was used in 12 cases, and the Kent hip prosthesis (Biomet Merck, Bridgend, United Kingdom), in 5 cases. Satisfactory outcome was noted in all cases, and in 11 cases, revision to a definitive stem has been undertaken after successful control of infection and fracture union. The use of interlocking stems offers a relatively appealing solution for a complex problem and avoids the complications that would be associated with resection of the entire femur or the use of large quantities of bone cement.     

Three- to 7-year results with the uncemented SL femoral revision prosthesis

Between 1988 and 1991, 40 Wagner SL femoral revision stems were irnplanted at the Orthopaedic Departments of the University of Basel and of the Kantonsspital Liestal, Switzerland. The indications were: 27 cases of extensive bone resorption and destruction of the proximal prosthetic bed, seven periprosthetic fractures, two Girdlestone situations after removal of infected total hip arthroplastiy (THA), 1 case each of primary arthroplasty for congenital dysplasia of the hip, failed osteosynthesis of a pertrochanteric fracture, subtrochanteric femoral fracture and femoral fracture with subsequent osteomyelitis. The average follow-up time was 47 months. The average age of the patients was 70 years (range 37–85 years). The average preoperative hip score was 32 points, postoperative 78 points. We noted to severe complications such as thrombosis, pulmonary embolism or nerve injury. No case of early infection has occurred to date. Four hips required further revision, one after a haematogenous infection of the prosthesis 2 years after implantation, one 4 weeks after surgery because of a stem which was significantly undersized compared with the medullary canal of the femur. Two hips were revised after 3 and 4 years, respectively, for continuous subsidence and loosening in the medullary canal. Both revisions were successfully achieved using a femoral component of larger diameter. We recommend the Wagner SL femoral revision stem, not as a routine procedure to treat loosening, but for patients with severe femoral bone resorption after THA or periprosthetic fractures, those in the Girdlestone situation and geriatric patients with pertrochanteric or subtrochanteric fractures.     

Fracture of the femur in revision hip arthroplasty with a fully porous-coated component

Fifty-four consecutive femoral component revisions with uncemented fully porous-coated stems were retrospectively reviewed for the prevalence of intraoperative fracture. Fracture of the femoral diaphysis occurred during insertion of a curved stem in 8 (15%) hips. One additional distal fracture of the femur occurred during exposure of the hip. All fractures occurred with a curved femoral stem. Treatment for intraoperative fractures included open reduction and internal fixation with cortical strut grafts and cables followed by protected weight bearing. This was successful in 6 hips. Even with the use of a curved stem, we report a high prevalence of intraoperative fracture of the femur in revision hip arthroplasty.     

Fractures at the tip of long-stem prostheses used for revision hip arthroplasty

We report a retrospective analysis of the incidence of intraoperative femur fractures at the tip of the prosthesis in 45 consecutive, uncemented, long (205-mm), straight hydroxyapatite, fully coated stems used for revision arthroplasty of the hip. Five patients were lost to follow-up. Intraoperative fractures of the distal femur occurred in 7 cases (17.5%). In the remaining 33 cases in which no fracture occurred, the tip of the implanted stem was found to be potentially at risk for causing a fracture in 18 (55%) cases. We concluded that uncemented, 205-mm, straight femoral stems should be used with caution in the setting of revision hip surgery. A bowed stem of that length may be a safer alternative. Otherwise, a shorter, straight stem may reduce the risk of complications at the stem tip.     

Femoral component revision using extensively porous-coated cementless stem

The number of revision hip arthroplasty increasesannually. Because of the loss of proximal femoralbone stock, femoral component revision is still achallenging problem for orthopedic surgeons. In mostcases, the femoral stem should be supported byremaining host bone for avoiding the need for structuralallografts. Previous results of cemented or proximalcoated implant for arthroplasty revision are notencouraging because the remaining bone is frequentlysclerotic and smooth.1-6The extensively porou…     

Collarless polished tapered impaction grafting of the femur during revision total hip arthroplasty: pitfalls of the surgical technique and follow-up in 31 cases

Impacting morcellized allograft bone into the femur during revision total hip arthroplasty is a simple concept with the goal of rebuilding femoral bone stock and providing secure fixation to the femoral stem. Using the collarless polished tapered (CPT, Zimmer, Warsaw, IN) stem impaction grafting system, we became concerned about the discrepancy between the straightforward concept and precise execution of the technique. In this study, we examined 31 consecutive procedures to determine intraoperative difficulties and report on the clinical outcome of 30 cases at an average follow-up of 31 months. Modified Harris Hip Scores averaged 41 points preoperatively and improved to 86 points at follow-up. Nineteen cases were performed on intact femora, whereas 12 cases had disrupted femoral integrity, either extended trochanteric osteotomy or periprosthetic fracture. Successful outcome was seen in all cases with an intact femur, and restoration of femoral integrity was key to successful outcome in cases with compromised femoral integrity. Among cases with disrupted femoral integrity, 3 distal fractures occurred as a result of the rigid CPT cement plug, and 2 complete femoral fractures occurred as a result of bone impaction, for a technique-related fracture rate of 16%. Difficulty packing bone distally occurred in 94% of cases and was associated with varus and valgus stem alignment and medial and lateral stem displacement. Complete cement mantles were seen in 77% of cases. No stem subsidence was seen in 15 of 30 cases (50%). Stem subsidence of <5 mm was seen in 10 of 30, stem subsidence of 6 to 8 mm was seen in 4 of 30, and stem subsidence of >10 mm was seen in 1 patient (4%). Of the patients, 87% thought the procedure improved their function, and 97% would recommend it to a friend with a failed femoral component. Although we hope that the instruments for this procedure can improve, we endorse the concept of impaction grafting with the CPT stem as a successful way of dealing with revision femoral surgery.