髋臼加强环联合同种异体骨植骨髋关节翻修的中期临床疗效观察

[目的]观察分析髋臼加强环联合同种异体骨植骨在严重髋臼骨缺损人工髋关节翻修术中的应用及临床疗效,探讨其在髋臼骨缺损重建中的作用。[方法]2010年3月~2015年2月,采用髋臼加强环联合同种异体骨植骨行髋关节翻修75例(87髋),67例患者79髋获得随访(失随访8例)。男39例,女28例;年龄45~72岁,平均59.2岁。初次置换至此次翻修时间为2~15年,平均10.3年。翻修原因:假体松动和骨溶解。术前髋关节功能Harris评分为(32.5±3.3)分。髋臼骨缺损按照美国骨科医师协会(AAOS)分型标准:Ⅲ型51髋,Ⅳ型28髋。[结果]67例患者79髋获得随访(失随访8例),随访时间3~60个月,平均32个月。术后切口Ⅰ期愈合,无股神经和坐骨神经损伤、下肢深静脉血栓形成等并发症发生。3例患者术后1个月发生髋关节脱位,2例腰麻下切开复位,1例手法复位后无再脱位。患者术后疼痛症状均明显缓解或消失,末次随访时髋关节Harris评分为(82.5±8.2)分,与术前比较差异有统计学意义(P=0.002)。X线片提示髋臼假体均无骨溶解、松动,所植异体骨与宿主骨融合,未见明显骨吸收区。[结论]采用髋臼加强环联合同种异体骨植骨技术,髋臼假体可获得满意的初始稳定,近期疗效满意,远期疗效尚需进一步观察。髋臼加强环联合同种异体骨植骨可成为严重髋臼骨缺损人工髋关节翻修时重建髋臼的方法之一。     

Curettage of benign bone tumors without grafts gives sufficient bone strength: A case-series of 78 patients

Background and purpose The defect that results after curettage of a bone tumor is usually filled in the same way. We report the outcome in patients with benign bone tumors that were treated with curettage but no filling.Patients and methods We retrospectively studied 78 patients (mean age at the time of operation was 27 (6–73) years, 44 men) who had had a benign bone tumor curetted with no filling of the defect. The commonest tumor types were giant cell tumor of bone (27), fibrous dysplasia (13), enchondroma (9), and simple bone cyst (7). The mean size of the lesions was 35 (2–196) cm³. Normal activities, including full weight bearing for lower extremity lesions, were allowed after 3 months or less. The patients were followed for an average of 10 (1.2–21) years.Results A postoperative fracture with a minor displacement occurred in 3 patients, in 2 of them because of local recurrence. All fractures healed. Local recurrence occurred in 9 patients; 7 of them had a giant cell tumor. Repeated local recurrences necessitated above-knee amputation in 1 patient. All other patients had unrestricted activities of daily living.Interpretation Routine filling of curetted bone lesions does not appear to be necessary from a mechanical point of view.     

Tibial tubercle elevation with bone grafts

We retrospectively investigated the fate of bone auto- and allografts in 64 patients who underwent a tibial tubercle elevation with bone graft. Half of them received an autograft and the other half, an allograft that had been processed and freeze-dried. The two groups had similar preoperative characteristics concerning age, sex and pathology. Roentgenograms were reviewed by three independent observers and scored for fusion, resorption and collapse. Clinical charts were analysed for different variables. The overall radiological score for both groups did not differ statistically. Comparison of graft fixation with one or two screws demonstrated more bone resorption in the case of a single-screw fixation. In such a case, the occurrence of a preoperative tubercle fracture had a significant adverse influence, due to a less stable fixation. From the clinical charts review, only the mean stay at hospital was significantly shorter when an allograft was performed. A bone allograft appears to be suitable to maintain an osteotomy but requires a more careful surgical technique fixation to obtain a similar result to an autograft.     

Preliminary experience with a novel model assessing In vivo mechanical strength of bone grafts and substitute materials

A novel canine tibia model was used to evaluate four bone graft materials: autologous cortical bone, allograft cortical bone, hydroxyapatite/tricalcium phosphate (HA/TCP) ceramic granules, and a HA/TCP and collagen composite. Mechanical material properties were assessed using custom-designed stainless steel plugs for control of graft volume and interface surface area. These plugs held the bone graft materials in the cortex of the tibia shaft and allowed in vivo mechanical testing. After 6 months of ad lib weight bearing, the grafts were harvested and tested in torsion. The samples in each animal were compared with the test plugs into which new bone had grown without the addition of graft. Control bone peak shear strength averaged 47 (±8.3) MPa (6.78±1.2 kpsi). Compared on the basis of peak torque, stiffness, and energy to peak torque, no significant differences were found among any of the graft materials or control bone. Histologic examination revealed the materials to be osteoconductive with the extensive formation of dense, compact cancellous bone. The new bone in the autograft and allograft samples completely filled the available space, whereas gaps persisted in the synthetic ceramics.     

Compressive strength of autologous and allogenous bone grafts for thoracolumbar and cervical spine fusion

The selection of the bone graft type for stabilization of spinal fusion depends on availability, the clinical situation, and the desired mechanical stability. The authors determined the potential immediate postoperative compressive strength of various types of bone grafts under axial compression on a material testing machine. The fibular strut graft (5,070 +/- 3,250 N, mean +/- standard deviation [SD]) was significantly stronger (P less than 0.05) than the anterior (1,150 +/- 487 N) and posterior (667 +/- 311 N) iliac crest grafts, and the rib grafts (452 +/- 192 N). Hydroxyapatite grafts with a pore size of 200 mu were significantly stronger (P less than 0.05) than those with a pore size of 500 mu (1,420 +/- 480 N versus 338 +/- 78 N). Ethylenoxide sterilization had no significant effect on the immediate compressive strength. Bicortical and tricortical Bailey-Badgley and Cloward bone grafts also were compared. Results showed that all cervical graft types may be sufficiently strong to support sizable loads.     

预成纯钛修复体修复下颌骨缺损

目的：探讨应用反求工程和快速原型技术进行下颌骨缺损修复的设计并预制修复体的可行性。方法：应用反求工程和快速成型技术为4名患者完成了下颌骨缺损的修复体设计和制作，并进行了修复体植入手术。结果：修复体就位顺利，各部件达到设计位置，术后患者面部外形满意，咬合关系良好，下颌偏斜纠正。结论：反求结合快速成型能够完成下颌骨缺损的修复体的设计和预制，提高了手术精度，节省了手术时间，在颌骨缺损的个体化和定制化修复中有独特的优势。     

Cranial nasal bone grafts

Reconstitution of the nasal scaffolding with maintainence of soft tissue proportions either following severe facial trauma or as a sequela to aesthetic rhinoplasty misadventures frequently is best achieved using the stability afforded by bone grafts. Split cranial bone grafts offer many advantages and may be the donor site of choice, and may even allow such surgery to be performed on an outpatient basis in some cases. The use of miniplate or screw osteosynthesis, now commonly accepted as a superior technique in craniomaxillofacial procedures, may simplify fixation of these calvarial nasal bone grafts with an apparent decrease in the risk of resorption.     

Massive autogenous bone grafts

Autogenous bone graft is the best biologic material available to repair a skeletal defect. These necrotic grafts are revascularized and repaired through creeping substitution to provide an almost identical structure for the one it replaced. There is a limited supply of autogenous bone, but it is the standard against which other methods should be measured.     

Vascularised pedicular bone grafts

Summary When a massive free bone graft has to be incorporated into a large bone defect in the presence of a poor vascular recipient bed, the risks of absorption and failure of the graft to revascularise are high. Experimental studies have confirmed that a bone graft transferred to its recipient site with an intact pedicle of blood supply remains viable, and unites directly with the recipient bone without having to be revascularised and replaced by creeping substitution. It also provides a live bone bridge for reconstruction of a massive bone defect, and is a ready source of vascular osteogenic tissue which sprouts new outgrowths to revascularise avascular recipient bone. A vascularised bone graft can be raised on a pedicle of muscle attachment or a main axial vessel, but the mobility of the vascularised pediculated graft is limited by the length of its pedicle.The vascularised muscle-pedicle graft of the ipsilateral fibular shaft described by Chacha et al has been proved viable both in monkeys and in humans. The shaft is raised on a pedicle of the peroneal vessels and the peroneal and the anterior tibial muscles, and provides an excellent viable bone strut to bridge a large defect in the tibial shaft.Judet's quadratus femoris muscle-pedicle graft from the greater trochanter has proved superior to Phemister's tibial cortical or fibular strut graft for the treatment of non-union of the femoral neck and the silent-phase of avascular necrosis of the femoral head. The tensor fascia lata muscle-pedicle graft of the anterior iliac crest, described by Davies and Taylor, provides a good viable bone strut for anterior hip fusion and for filling defects in the acetabulum and the upper femur. The whole of the greater trochanter attached to a thick pedicle of the gluteal muscles can be used as a live extra-articular graft for hip fusion. A pedicular rib graft raised on its intercostal vessels, as described by Rose et al. and Bradford, is a very useful live bone strut for correction of kyphosis and grafting of infective lesions of the vertebral bodies.The cortical graft of the radius within the radial forearm skin flap for reconstruction of the thumb, the pronator quadratus muscle-pedicle graft of the lower radius for non-union of the scaphoid and avascular necrosis of the lunate, and the erector spinae muscle-pedicle graft of the posterior ilium for intertransverse fusion are new concepts which need to be evaluated for wider clinical application.

---

Résumé Lorsqu'une greffe osseuse libre, de volume important, doit combler une vaste perte de substance dans une région mal vascularisée, il existe un risque majeur de résorbtion du greffon par échec de la revascularisation. Les études expérimentales ont confirmé qu'un greffon osseux transféré avec son pédicule vasculaire intact reste vivant et fusionne directement avec l'os receveur sans qu'il ait besoin d'être revascularisé et réhabité par le mécanisme de la «creeping substitution». Il constitue également un pont osseux vivant lors de la reconstruction d'une perte de substance osseuse étendue ainsi qu'une source de tissu ostéogénique qui enverra des bourgeons vasculaires capables de réhabiter l'os receveur dévascularisé. Un greffon osseux vascularisé peut être alimenté par un pédicule relié aux insertions musculaires ou par une artère nourricière principale, mais sa mobilité sera limitée par la longueur du pédicule.On a démontré, aussi bien chez le singe que chez l'homme, que la greffe de péroné homolatéral vascularisée par un pédicule musculaire, décrite par Chacha et coll. restait vivante. Le greffon est irrigué par une branche des vaisseaux péroniers, par l'intermédiaire des muscles péroniers et jambier antérieur. Il constitue un excellent étai osseux vivant, capable de ponter une perte de substance tibiale étendue.La greffe pédiculée de Judet provenant du grand trochanter s'est montrée supérieure au greffon cortical tibial ou péronier de Phemister dans le traitement de la pseudarthrose du col du fémur et la prévention de la nécrose de la tête fémorale. La greffe pédiculée par le tenseur du fascia lata de la crête iliaque antérieure, décrite par Davies et Taylor, fournit un bon greffon vivant pour placer sur la face antérieure d'une arthrodèse de hanche ou pour combler une perte de substance du cotyle ou de l'extrémité supérieure du fémur. La totalité du grand trochanter relié à un épais pédicule provenant des muscles fessiers peut être utilisée comme greffon vascularisé extra-articulaire lors d'une arthrodièse de hanche, Un greffon costal irrigué par les vaisseaux intercostaux, tel que l'ont décrit Rose et coll. et Bradford, peut être très utile lors de la correction des cyphoses ou pour le comblement de lésions d'ostéite des corps vertébraux.Le greffon radial prélevé avec un lambeau cutané d'avant-bras pour reconstruction du pouce, la greffe pédiculée par le carré pronateur de l'extrémité inférieure du radius pour pseudarthrose du scaphoïde ou nécrose du semi-lunaire et la greffe pédiculée par les muscles lombaires de la crête iliaque postérieure pour arthrodèse inter-transversaire, sont de nouvelles possibilités qui nécessitent, pour être évaluées, une plus large application clinique.

     

Delivering bone grafts percutaneously

Many fractures that require external fixation occur in patients with deficient bone. To prevent later collapse after the fixation is removed, bone graft material can be placed into the fracture defect. Mineral can be placed accurately through a minimal incision by using equipment in the external fixation set.