全髋关节置换失败后的髋臼翻修

由于在缓解疼痛、改善关节功能方面具有良好疗效,全髋关节置换手术（total hip arthroplasty,THA）在临床治疗髋部疾患中应用极为广泛。但是初次THA有一定的使用年限,随着THA手术越来越多在年龄较轻患者中使用以及人们的预期寿命越来越长,因此,人工髋关节翻修数量可能会不断增加。在长期的研究中发现,髋臼侧失败是THA翻修的首要原因,其中包括髋臼假体位置不良、松动、严重的聚乙烯内衬磨损、骨盆骨溶解等。     

Comparison of function two years after revision of failed total hip arthroplasty and primary hip arthroplasty

Because of the known high complication rate, it is important for both the patient and physician to know as much as possible about the outcome of revision operations for loosened total hip arthroplasties. This study evaluates the changes in subjective ratings and objective kinesiologic measurements from before revision operations through two years after revision operations. The object is to compare these measurements with the measurements of a group of patients with primary replacements. Both groups of patients showed significant improvement in most parameters from before to after surgery. These parameters included walking performance, hip muscle strength, range of motion, forces applied to canes, and the amount of weight borne on the operated limb during quiet standing. Compared to the control group with primary replacements, the group with revision used more assistive devices, had less pain relief, walked slower, had less hip motion, and had more lateral lurch. While results after revision surgery were not as gratifying as those after primary hip replacement, patients requiring revision can still anticipate substantial improvement.     

Function after revision of failed total hip arthroplasty

Measurements of functional performance were made before and 6 months after 31 primary total hip replacements and 31 total hip revisions for prosthetic loosening. After revision, functional performance returned to levels substantially the same as after primary hip replacement except for greater reliance on canes for patients in the revised group. Ratings of hip status and hip pain were slightly less satisfactory after revision as compared to after the primary operation.     

Acetabular reconstruction in revision total hip arthroplasty

The number of total hip arthroplasty (THA) procedures performed annually continues to rise. Specific challenges, including acetabular bone loss, are commonly encountered at the time of revision surgery, and orthopaedic surgeons must be prepared to address them. This review focuses on topics related to acetabular reconstruction, including pre-operative patient evaluation (clinical and radiographic), pre-operative planning, common causes of acetabular failure, classification of acetabular bone loss, methods of acetabular reconstruction, and clinical results based on reconstruction method. Pre-operative patient evaluation for revision THA begins with a thorough history and physical examination as well as laboratory workup to rule out infection. Detailed radiographic evaluation and pre-operative planning are also essential and will facilitate communication amongst all members of the operative team. Although there are several ways to describe acetabular bone loss, the Paprosky classification system – defined by anterosuperior and posteroinferior acetabular column integrity – is the system most commonly used today and will guide treatment strategy. Several treatment strategies have been developed and may be termed either “cemented” (e.g. impaction grafting, ring and cage construction, structural allograft) or “uncemented” (e.g. hemispheric shell ± porous metal augment, cup-cage, custom triflange acetabular component). Although each strategy has its advantages and disadvantages, the general principles remain the same. Successful treatment depends upon detailed pre-operative assessment, planning, and team-based plan execution. Uncemented techniques that allow for biologic fixation are preferred. In the special case of pelvic discontinuity, acetabular distraction is the authors’ preferred technique. Longer term studies are still needed to evaluate the longevity of each of the various reconstruction methods presented.     

Acetabular reconstruction in revision total hip arthroplasty

Acetabular revision surgery is always associated with some degree of bone loss. Where an intact peripheral rim is present it can be used to achieve ingrowth and cementless prosthetic fixation. Where major segmental defects are present and prosthetic stability is not possible in host bone, structural allografts may be necessary to satisfy the principles of acetabular reconstruction. Using quality bone, proper fixation, and buttressing of structural allografts against host bone, a high degree of success can be expected. The majority of acetabular revisions can be reconstructed with large hemispherical sockets and adjuvant screw fixation and the use of bulk allografts should be reserved for those reconstructions where no good alternative exists.     

Results of cementless revision for failed cemented total hip arthroplasty

The goals of revision total hip arthroplasty (THA) are to reestablish and maintain stable implant fixation. Based upon promising early results in primary THA, porous-surfaced implants designed for bone ingrowth fixation are being increasingly used in hopes of more successfully achieving these goals than has been the case using cement. One hundred and sixty such revisions were followed for a mean of 4.4 years, with specific reference to implant fixation. Roentgenographic evaluation of implant fixation suggested four categories of femoral and acetabular components: (1) bone ingrown, (2) stable fibrous encapsulation, (3) questionable, with signs of impending instability, or (4) definitely unstable implant migration, indicative of the need for rerevision. Not surprisingly, success in achieving and maintaining stable implant fixation following revision THA is dependent upon component design, surgical technique, and preexistent bone stock damage. This classification according to bone stock damage should be borne in mind when critically evaluating the results from various revision series.     

Acetabular reconstruction with a threaded prosthesis for failed total hip arthroplasty.

The MEC-Ring threaded acetabular component was used in 35 patients for revision of failed cemented hip arthroplasties, and 32 have been observed for two to four years (mean, 2.5 years). With only a short-term follow-up period, 44% of patients have already required revision for failure of the MEC-Ring acetabular component. Patients with especially poor acetabular bone stock that had had structural bone graft had a significantly higher rate of failure. The authors developed a technique of supine oblique roentgenograms that allowed better visualization of the component-bone interface. Eighty-six percent of patients had radiolucencies, and 67% of these were progressive. The presence of progressive radiolucencies, component migration, or both was associated with a higher failure rate. Progressive radiolucencies were also associated with a worse pain score in patients whose arthroplasties have not failed. The MEC-Ring threaded component is not recommended for revision hip arthroplasty, especially in cases with poor acetabular bone stock.     

Acetabular preparation in cementless revision total hip arthroplasty

The rationale for and experience with the use of a hemispherical, cementless, microporous socket (Harris-Galante prosthesis) are presented as an approach to acetabular revision arthroplasty. Advantages are noted in preservation of existing bone, ease of rigid fixation, and bone grafting with either lyophylized particle allograft or autograft. The early results of a series of 75 sockets show no loss of fixation, mild to major resorption of non-contained bone graft, and favorable roentgenographic appearance of contained bone graft. In bone-grafted regions, a high percentage of lucencies at the graft-porous interface implies a lack of bone ingrowth. The authors were unable to characterize any roentgenographic behavioral differences between allograft or autograft. The approach is successful in severely deficient acetabulae, especially of the Type III combined cavitary and segmental medial wall deficiency.     

Cementless total hip arthroplasty in patients with high congenital hip dislocation

BACKGROUND: The optimal surgical treatment for patients with high congenital dislocation of the hip remains controversial. The purpose of our study was to evaluate the mid-term to long-term results of cementless total hip arthroplasty in such patients. METHODS: The study included sixty-eight total hip replacements performed between 1989 and 1994 in fifty-six consecutive patients with high congenital hip dislocation at our hospital. The cup was placed at the level of the true acetabulum, and a shortening osteotomy of the proximal part of the femur and distal advancement of the greater trochanter were performed in 90% of the hips. At the time of final follow-up, at a mean of 12.3 years postoperatively, fifty-two patients (sixty-four hips) were evaluated by us with a physical examination, determination of Harris hip scores, and radiographs. RESULTS: The mean Harris hip score increased from 54 points preoperatively to 84 points at the time of final follow-up (p < 0.001). There was a negative Trendelenburg sign in fifty-nine (92%) of the sixty-four hips. There were thirteen perioperative complications (19%): three peroneal nerve palsies, one femoral nerve palsy, one superior gluteal nerve palsy, four nondisplaced fractures of the proximal part of the femur, one malpositioned stem perforating the posteromedial cortex of the femur, one superficial wound infection, and two early dislocations. With revision because of aseptic loosening as the end point, the ten-year survival rate for press-fit, porous-coated acetabular components was 94.9% (95% confidence interval, 89.3% to 100%). Eight of nine threaded acetabular components were revised, and the ninth was radiographically loose at the time of the last follow-up examination. The rate of survival for the CDH femoral components, with revision because of aseptic loosening as the end point, was 98.4% (95% confidence interval, 96.8% to 100%) at ten years. CONCLUSIONS: Total hip arthroplasty, with placement of the cup at the level of the true acetabulum, distal advancement of the greater trochanter, and femoral shortening osteotomy, can be recommended for patients with high congenital hip dislocation. Complications such as wear, osteolysis, and cup revision were secondary to the suboptimal design of the acetabular components used in this series.     

High placement of an acetabular component inserted without cement in a revision total hip arthroplasty. Results after a mean of ten years

BACKGROUND: Revision of an acetabular component in a patient who has severe periacetabular bone loss is a complex problem, particularly when there is not enough bone stock to allow placement of an acetabular component near the normal anatomical hip center. A valuable option for revision in such a situation is placement of a hemispherical shell, fixed with screws and without cement, against the superior margin of the acetabular defect. The resulting hip center is more proximal than that seen following a typical primary total hip replacement. METHODS: Forty-six hips in forty-four patients were treated consecutively, between July 1984 and February 1988, with a revision in which a hemispherical acetabular component was fixed with screws and without cement. All shells but one were placed with a so-called line-to-line fit. The procedures resulted in a so-called high hip center--that is, the center of rotation of the revised hip was located at least thirty-five millimeters proximal to the interteardrop line. The mean age of the patients at the time of the index procedure was fifty-two years (range, twenty-five to eighty-one years). The most common diagnosis for which the original arthroplasty was performed was osteoarthritis secondary to congenital hip dysplasia or dislocation (twenty-two hips). Thirty-four hips had had a high hip center before the index revision, and most patients had had a substantial limb-length discrepancy, with a mean of 1.6 centimeters of shortening on the side of the operation. In thirty-three hips, the femoral component was replaced as well, with a long-neck or calcar-replacement stem used when necessary to maintain or increase the length of the limb. RESULTS: Six patients (six hips) died before the minimum eight-year follow-up interval; none had had another revision or loosening of the revised acetabular component. Of the remaining patients, four (four hips) had the implant removed. One of them had a resection arthroplasty and one of them had a hip disarticulation because of infection after a subsequent femoral reoperation. Another had a hip disarticulation because of late infection. The fourth implant was removed because it had displaced into the pelvis at approximately six years; this was the only reoperation for aseptic loosening in the series. The remaining thirty-six hips (thirty-four patients) were followed for a mean of 10.4 years (range, 8.5 to 12.7 years). One acetabular component migrated medially and was scheduled for revision. No other acetabular component was loose or had been revised. The mean Harris hip score was 81 points (range, 56 to 100 points) at the time of the most recent follow-up. Despite the use of a high hip center, the prevalence of a positive Trendelenburg sign was reduced from 98 percent (forty-five of forty-six hips) preoperatively to 44 percent (sixteen of thirty-six hips) at the time of the most recent follow-up. The short limbs were lengthened a mean of seven millimeters (range, five millimeters of shortening to forty millimeters of lengthening). CONCLUSIONS: In this study of acetabular revisions with use of a high hip center in patients who had major periacetabular bone loss, mechanical failure occurred in 4 percent (two) of the forty-six hips in the entire series and in 6 percent (two) of the thirty-six hips in patients who were alive and still had the implant in place after a mean of 10.4 years of follow-up. The use of a high hip center did not adversely affect function of the abductor muscles, and the mean limb-length discrepancy was reduced by the femoral reconstruction.     

全髋关节置换术治疗成人髋关节发育不良的髋臼重建

目的探讨全髋关节置换术治疗成人髋关节发育不良（DDH）时不同方式髋臼重建对疗效的影响。方法 2000年1月至2007年10月,36例（44髋）先天性髋臼发育不良患者进行了全髋关节置换。年龄42～65岁,平均48岁。术前Harris评分平均为49.9分,双下肢长度差异平均为1.8 cm,髋关节平均活动度：屈曲59.6°,外展21.6°,内收13.9°,外旋10°,内旋8.2°。术中臼杯均安装于真臼处,髋臼内移14髋,髋臼内陷成形术18髋,自体股骨头结构性植骨12髋。髋臼侧均选用非骨水泥型假体。疗效评价：根据Harris评分分为优、良、可、差四级。结果所有患者均获得随访,随访时间1.8～9.2年,平均5.1年。平均Harris评分由术前的49.9分恢复到术后的90.1分,两者比较有统计学差异（P〈0.01,t=28.807）,其中评定为优23髋、良17髋、可4髋,术后优良率达90.9%。术后髋关节平均活动度：屈曲105°,外展35°,内收15.8°,外旋45°,内旋15°。本组病例无肺栓塞、深静脉血栓形成、感染等并发症发生。X线检查示假体无松动移位,无翻修病例。结论全髋关节置换术治疗成人髋臼发育不良采用恰当的髋臼重建结合非骨水泥型髋臼假体可获得满意中远期疗效。     

Treatment of recurrent dislocation associated with impingement after revision total hip arthroplasty

The authors report a case of total hip replacement in which, following several revision operations ending up in a Girdlestone arthroplasty, a patient presented recurrent episodes of posterior dislocation of his total hip prosthesis after revision using an antiprotrusio cage. The main causes for dislocation were anterior impingement of the neck against the anterior wall of the antiprotrusio cage and slackness of the periarticular musculature, due to shortening and reduced femoral offset. In order to avoid further major reconstruction and minimise the risk of infection recurrence, a limited revision operation was performed to address the factors responsible for the instability: the anterior wall of the antiprotrusio cage was removed and an extension module was added to the femoral component. Good stability of the arthroplasty was achieved with this limited procedure.     

Acetabular anti-protrusio rings and cages in revision total hip arthroplasty

Uncemented hemispherical porous-coated acetabular components work well for the great majority of acetabular component revisions. Unfortunately, when bone loss is so severe that little contact between a porous-coated socket and native bone can be achieved, high rates of failure of uncemented porous-coated sockets have been reported. When circumstances are encountered in which porous-coated hemispherical sockets are unlikely to succeed, acetabular reinforcement devices have advantages over cemented polyethylene sockets alone. The ability of antiprotrusio rings and cages, now used to augment socket fixation to the pelvis, facilitate extensive pelvic bone grafting, and prevent early socket migration, have led to renewed interest in these devices as useful tools in the orthopedic surgeon's armamentarium to manage some of the most challenging acetabular reconstruction problems. This article discusses the rationale for selected use of acetabular reinforcement devices, the reported results of using acetabular reinforcement rings and cages in revision total hip arthroplasty, and the circumstances in which these devices may be considered for acetabular reconstruction at the present time.     

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。     

The angle-bore acetabular component and dislocation after revision of a failed total hip replacement

We reviewed 1039 revision total hip replacements where an angle-bore acetabular component was used. After a mean follow-up of nine years (0 to 20.6), the incidence of revision for dislocation was 2.1% (22 revisions), a success rate of 97.9%. In 974 revisions, where the indication was other than dislocation, the success rate was 98.5%. Of the 65 revisions for dislocation, 58 (89.2%) were successful after the first revision and a further five after the second revision, an overall success of 96.9%. Two patients elected to have their implants removed. Dislocation after revision of failed total hip replacement is a complex issue. There is often no single cause and no simple solution. The angle-bore acetabular component, in combination with a 22.225-mm diameter femoral head, offers a high level of success.     

Acetabular augmentation in primary and revision total hip arthroplasty with cementless prostheses

Twenty-four consecutive cementless hip arthroplasties (13 autografts and 11 allografts) have been done in which large bone grafts were used to augment major acetabular deficiencies and have been followed for a minimum of 24 months with a mean of 34 and a maximum follow-up period of 55 months. The autograft augmentations were uniformly successful. Two fixation failures occurred in the allograft group. Considering the extreme deficiency in the acetabulae encountered and the absence of sufficient autograft material in this group of patients, the use of frozen allografts (although less successful in this series) seems justified. Graft resorption as determined by direct roentgenographic measurements was less than might be expected but may be a manifestation of the short-term follow-up period. Resorption, however, was greater in the allograft group and, when marked, was associated with fixation failure.     

全髋翻修术后假体脱位的预防

目的：探讨采用后方关节囊重建方法对行后外侧入路全髋翻修术后假体脱位的防治作用。方法：本组45例（47髋）经后外侧入路行全髋翻修术的患者，男20例，女25例；平均年龄65岁（55-78岁）。术中将后方关节囊与外旋肌群分别重建固定于前上方原先切开的关节囊断端和大转子顶端的软组织处，回顾性分析术后假体脱位率及脱位的风险因素。股骨假体和髋臼假体均翻修29例（31髋），更换内衬5例（5髋），髋臼、股骨翻修的分别是10例（10髋）和1例（1髋）。第1次翻修的有29例（30髋），第2次翻修的有15例（16髋），第3次翻修的有1例（1髋）。X线评估包括翻修前后下肢长度，髋臼位相，股骨偏心距、前倾角和假体松动。临床功能评价采用Harris评分。结果：45例均获随访，平均随访时间2．7年，除1例感觉前方不稳外，无髋关节感染及脱位发生，该例X线片示髋臼假体过度前倾但无脱位发生。术后所有患者双下肢基本等长，髋臼外展角及前倾角、股骨偏心距和前倾角基本恢复至初次手术前水平。髋臼、股骨假体发生松动各1例。髋关节功能Harris评分由术前平均（49.13±15．53）分升至末次随访的平均（83．59±6.93）分（P〈0．05）。按Harris功能评分标准：优36髋，良5髋，可5髋，差1髋。结论：在假体安放正确、软组织张力恢复满意基础上，后方关节囊及外旋肌群重建有助于降低后外侧入路全髋翻修术后假体脱位的发生率。     

Long-term results of total hip arthroplasty in congenital dislocation and dysplasia of the hip. A follow-up note

Twenty-three of twenty-nine hips that were previously reported on were studied at an average of fourteen years (range, eight to 16.5 years) after total hip arthroplasty with cement. The original arthroplasties had been performed between November 1971 and January 1976. In all hips, there was dislocation or severe dysplasia. In six hips, superolateral bone grafts were used to increase acetabular coverage. At the latest follow-up examination, seven hips were rated excellent; nine, good; and one, fair. There were six failures (26 per cent) that were revised: four hips (17 per cent) had a fractured Trapezoidal-28 stem, one had loose femoral and acetabular components, and one had loosening of only the acetabular component. Radiographic analysis of the remaining hips revealed that one had progressive acetabular radiolucencies. This patient had an excellent clinical result. Two-thirds of the failures were due to a fractured stem.     

髋关节发育不良患者全髋关节置换术的髋臼中心化

目的 探讨采用全髋关节置换术(THA)治疗髋关节发育不良继发骨关节炎术中髋臼杯假体放置的方法及其对手术疗效的影响。方法 对38例(44髋)于1989年9月至2003年4月接受全髋人工关节置换术的髋关节发育不良继发骨关节炎患者进行了随访。其中男14例,女24例,平均年龄51．2岁(29～80岁),平均随访36．4个月(8～168个月)。按Crowe方法进行分类：Ⅰ型12髋,Ⅱ型24髋,Ⅲ型7髋,Ⅳ型1髋。测量泪滴与髋旋转中心的水平距离并与术后测量结果比较。结果 髋臼杯假体中心化放置者24髋,未加深髋臼者20髋。术后两组Harris评分分别为90．2分、86．3分。结论 对于多数髋关节发育不良患者在行THA时,术中加深髋臼而将髋旋转中心内移和下移,可使髋臼杯假体置于中心化位置得到牢固固定及满意的骨覆盖,术后获得良好的临床疗效。