髋关节置换术中不同假体对老年患者血流动力学的影响

目的探讨髋关节置换术中不同假体对老年股骨颈骨折患者血流动力学的影响。方法将自2012-01—2014-12行初次髋关节置换术的130例(130髋)老年股骨颈骨折分为骨水泥组(72例)和生物型组(58例)。术中监测患者血压、心率等生命体征的变化,分别于5个时间点(置入前,置入后0、5、10 min,手术完成时)记录患者的收缩压、舒张压、心率及血氧饱和度。分析2组术中血流动力学指标波动情况。结果骨水泥组63例(87.5%)在骨水泥置入后出现明显的血流动力学波动,11例血压下降20%基础值,1例发生心跳骤停。骨水泥置入后0~5 min患者发生血压下降和心率增快,10 min后稍有恢复,在手术完成时已恢复至术前水平(P0.05)。生物型组在假体置入前后均未发生明显血流动力学波动(P0.05)。2组术中血氧饱和度变化差异均无统计学意义(P0.05)。结论老年髋关节置换术中使用骨水泥容易并发短暂而明显的血流动力学波动,术中必须密切监测并积极调整患者生命体征。     

髋关节置换术中骨水泥植入后对老年患者血流动力学的影响

目的 探讨骨水泥型髋关节置换术中骨水泥植入后对老年患者血流动力学的影响.方法 2008年1月至2009年4月共对50例老年股骨颈骨折或股骨头坏死患者行骨水泥型髋关节置换术,男22例,女28例;年龄70～92岁,平均83.2岁.关节置换原因:股骨颈骨折46例,股骨头骨折术后股骨头坏死4例.比较患者骨水泥植入前和植入后1、2、3、4、5、6、7、8、9、10 min的收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)、心率、血氧饱和度(SPO2)等数据.结果 术后所有患者血压均有不同程度下降,骨水泥植入后1 min血压开始下降,2～6 min血压下降最为显著,与骨水泥植入前比较差异均有统计学意义(SBP,DBP:P<0.05),7 min开始回升,10 min基本恢复正常.SPO2下降明显,平均从99.65%±0.35%下降至92.80%±1.08%(P<0.05).心率无明显变化,差异无统计学意义(P>0.05).结论 髋关节置换术中骨水泥植入后对老年患者血流动力学影响显著.     

抗生素骨水泥预防人工关节感染研究进展

人工关节深部感染是关节置换术后严重并发症之一,它延长治疗进程,增加医疗开支,降低治疗效果.抗生素骨水泥目前已广泛应用于高人工关节感染风险的初次关节置换术和感染翻修术病例.该文就人工关节置换术后关节感染特性及抗生素骨水泥释放特性与力学性能,临床应用、潜在缺点和病例选择等作一综述.     

抗生素骨水泥和连续灌注治疗关节置换后感染

目的　为人工关节置换术后感染探索新的治疗方法。方法　回顾 68例人工关节置换手术 ,发生术后感染 10例 ,其中全膝关节置换术后感染 4例 ,全髋关节置换术后感染 6例 ,全部采用抗生素骨水泥同时采用抗生素连续灌注。结果　病程在 2周内的 4例用此方法全部保留假体成功 ,其余 6例病程都在 4周以上 ,保留假体失败。结论　关节置换术后感染是严重并发症 ,本方法是一种保留假体的补救措施。     

与骨水泥相关的肺栓塞

骨水泥(PMMA)应用在人工关节置换中已有50余年历史。多年的临床应用已证明骨水泥固定人工关节的疗效确切，在应用的过程中逐渐注意到一些公认的并发症，如低血压、低氧血症、心肺功能障碍、心脏骤停、猝死等，称之为骨水泥植入综合征。引起骨水泥植入综合征最可能的原因是由于插入股骨假体时进入肺循环的栓塞程度不同所造成．严重的肺栓塞可以造成患者的死亡。在人工髋关节置换过程中，通过检测右心室射血分数和经食道动态心动图，发现当插入股骨假体时．右心室的血液动力学都会发生改变，并且经食道动态心电图发现右心室内有异常物质通过，     

髋关节置换术中骨水泥反应综合征发生率分析

骨水泥反应是全髋置换术中出现的一种严重副反应.由于可导致血流动力学变化、心电图改变甚至心跳骤停以及猝死而成为髋关节置换术的一大难题.笔者自2006年9月～2009年8月,对263例行髋关节置换术中骨水泥对患者的影响进行回顾性总结.探讨其发生率.以指导术中如何预防和治疗骨水泥引起的血流动力学改变,提高手术的安全性.     

两种类型人工全髋关节置换术后体温变化的回顾性研究

[目的]研究骨水泥型人工全髋关节置换术后与非骨水泥型人工全髋关节置换术后患者体温变化规律,为临床观察及治疗提供参考.[方法]对84例骨水泥型人工全髋关节和非骨水泥型人工全髋关节置换术患者术前3d、手术当天至术后12 d每日6:00、10:00、14:00、18:00、21:00、1:006个时间点的体温进行观察.[结果]骨水泥型人工全髋关节置换术患者手术当天至术后7d的体温普遍高于非骨水泥型人工髋关节置换术患者.两种类型人工全髋关节置换术患者术后8～12d的平均体温、每日体温无明显差异.[结论]医务人员对骨水泥型人工全髋关节置换术后与非骨水泥型全髋关节置换术后患者体温变化要区别对待,做好观察及时处理,防止并发症的发生.     

全髋关节置换术中骨水泥对老年患者凝血功能的影响

目的探讨全髋关节置换术中骨水泥对老年患者凝血功能的影响。方法2004年7月至2005年3月，44例行骨水泥型全髋关节置换术患者，男21例，女23例；年龄55-78岁，平均64岁；股骨颈骨折21例，股骨头缺血性坏死15例，髋关节骨关节炎8例。对其凝血功能相关指标进行检测，包括血浆凝血酶原时间（胛）、活化的部分凝血酶原时间（APTT）、血浆纤维蛋白原（FIB）及鱼精蛋白副凝固试验（3P试验），分别于注入骨水泥前5min、注入骨水泥后30min及3h各检测一次。所有数据进行统计学处理。结果注入骨水泥后30minPT值较注入前5min显著缩短（R0．05）；而注入骨水泥后3h胛值与注入后30min比较，显著回升（P〈0．05）。FIB含量在注入骨水泥后30min较注入前5min明显增高（P〈0．05）；注入骨水泥后3h与注入后30min比较，差异有统计学意义（P〈0．05）。3P试验阳性率注入骨水泥后30min与注入骨水泥前5min比较，差异有统计学意义（R0．05）。骨水泥对AP丌影响不明显，注入3h后各项指标基本恢复。结论全髋关节置换术中注入骨水泥30min后PT缩短、FIB增高、3P试验的阳性率升高，但在3h后骨水泥对这些指标的影响基本消除，提示注入骨水泥后的3h内是严密监测病情的重要时段。在注入骨水泥后，老年患者凝血系统虽有高凝倾向，但各相关指标数值仍在正常值范围内。     

假体周围骨溶解与基因多态性

人工关节置换是治疗严重关节疾患最有效的治疗手段,可以明显改善关节功能和提高患者生活质量.尽管疗效确切,但人工关节置换术后远期发生骨溶解和假体无菌性松动等并发症的风险不容忽视[1-2].研究结果证实人工关节置换术后10年约有10％的患者发生了假体周围骨溶解及假体无菌性松动,其中大部分患者需要接受翻修手术[3].约20％的全关节置换患者在术后随访中存在不同程度的假体周围骨溶解的影像学证据[3-4].在人工关节假体失败的原因中无菌性松动占75％[5],因此,骨溶解导致的无菌性松动已成为人工关节翻修手术的最常见原因,是临床上亟需解决的难题[6].     

抗生素骨水泥在人工关节置换术后感染中应用研究的系统性综述

人工关节置换术后感染(prosthetic-joint infections,PJI)是人工关节置换术后最严重的并发症,抗生素复合骨水泥(antibiotic-impregnated bone cement,AIBC)是预防和治疗PJI的有效手段,目前AIBC的基础和临床研究积累了大量数据,但缺乏系统性分析。本文检索了PubMed、MEDLINE数据库中截至2014年1月的所有AIBC研究,对骨水泥的选择、抗生素的选择、AIBC的材料学性质、AIBC的抗菌活性、AIBC的临床疗效进行了系统性综述和分析。     

Preformed acrylic bone cement spacer loaded with antibiotics: use of two-stage procedure in 10 patients because of infected hips after total replacement

In 10 patients having deep infection after total hip replacement, we used a two-stage revision procedure involving implantation of a preformed spacer with a cylindrical rod coated with acrylic cement containing antibiotics (Spacer-G). This device, which remained in situ for an average of 5 months, permitted healing of the infection in 8 cases and reimplantation of a new prosthesis (mean follow-up 35 months). During treatment, 1 dislocation occurred. The spacer maintained the gap between both bone segments and allowed a certain degree of joint mobility. Use of Spacer-G improved the quality of life of the patients during treatment and accelerated recovery of function after reimplantation.     

Preformed acrylic bone cement spacer loaded with antibiotics: Use of two-stage procedure in 10 patients because of infected hips after total replacement

In 10 patients having deep infection after total hip replacement, we used a two-stage revision procedure involving implantation of a preformed spacer with a cylindrical rod coated with acrylic cement containing antibiotics (Spacer-G). This device, which remained in situ for an average of 5 months, permitted healing of the infection in 8 cases and reimplantation of a new prosthesis (mean follow-up 35 months). During treatment, 1 dislocation occurred. The spacer maintained the gap between both bone segments and allowed a certain degree of joint mobility. Use of Spacer-G improved the quality of life of the patients during treatment and accelerated recovery of function after reimplantation.     

Histamine release and cardiovascular reactions to implantation of bone cement during total hip replacement]

Cardiovascular reactions to acrylic bone cement in patients with total hip replacement are a common complication. Hypotension and arrhythmias are the most frequently observed symptoms. Elderly patients with fractures of the femoral neck constitute a special risk group. In some patients these reactions can be fatal. The mechanisms suggested to explain these reactions are embolism of air, polymer or fat, reaction to the heat, and toxic or vasodilating effects of the acrylic monomer. In a pilot study and in a case report a significant rise of the plasma histamine was described following cementation of the femur. We therefore performed an investigation to find whether application of bone cement to the femur caused histamine release in elective hip surgery, and, independently of this, also investigated whether premedication with H1- + H2-antagonists had any effect on the cardiovascular reactions due to bone cement implantation into the femoral shaft in elderly patients with hip fracture. METHODS. Part I. In all, 40 patients, scheduled for elective surgical hip replacement were anesthetized by general or epidural anesthesia. Patients were continuously monitored by ECG. Blood pressure was recorded noninvasively at 2-min intervals during the study. Blood samples for the determination of the plasma histamine were taken immediately before implantation of the bone cement into the femur, and 2, 5, and 10 min after. Part II. A further group of 20 patients aged greater than or equal to 70 years with fractures of the femoral neck and in whom total hip replacement was planned were included in the study. In this group, 10 patients were randomly assigned to receive 4 mg clemastine + 400 mg cimetidine i.v. about 15 min before implantation of the bone cement. All patients were operated on under general anesthesia. ECG was monitored continuously and blood pressure was monitored at 2-min intervals during the study. Changes of the blood pressure and heart rate and therapeutic interventions following the implantation of the bone cement were documented. RESULTS. Part I. In 11 of the 40 patients (27.5%) plasma histamine increased by greater than 0.5 ng/ml (9 patients greater than 1 ng/ml). In comparable groups (patients with a control systolic blood pressure less than or equal to 130 mmHg) the histamine responders showed a significantly greater reduction in systolic blood pressure (-5.7 +/- 14.7 vs -17.7 +/- 8.6 mmHg). Part II. In the control group we observed a significantly greater fall in systolic blood pressure than in premedicated patients (41.5 +/- 25.4 vs 11.0 +/- 13.4 mmHg). In the control group 7 of the 10 patients required therapeutic interventions, while in the premedicated group only one therapeutic intervention was necessary (P less than 0.05). DISCUSSION. We have demonstrated that the implantation of acrylic bone cement into the femur may increase plasma histamine by greater than 1 ng/ml. In elderly patients with preexisting cardiac diseases or/and hypovolemia even moderate histamine release can cause serious, sometimes potentially fatal, cardiovascular complications. In this special risk group with hip fractures we found a significant reduction in the frequency of cardiovascular reactions to bone cement implantation in patients premedicated with H1 + H2 antagonists. Because we also observed significant falls in systolic blood pressure in premedicated patients, we assume that the pathogenesis of cardiovascular reactions to bone cement implantation is multifactorial. It may be that potentially lethal complications only occur if two or more of the predisposing factors (hypovolemia, myocardial insufficiency, arrhythmia, embolism, histamine release) are present simultaneously. Pre- and intraoperative measures therefore have to be instituted to eliminate all possible risk factors.     

CHANGES IN CARDIAC OUTPUT AND SYSTEMIC ARTERIAL PRESSURE AFTER INSERTION OF ACRYLIC CEMENT DURING TRIMETAPHAN, SODIUM NITROPRUSSIDE AND GLYCEROL TRINITRATE-INDUCED HYPOTENSION: A comparison with changes during normotension

The effects of implantation of acrylic monomer on the cardiovascularresponse were studied in 37 patients undergoing hip arthroplastyand receiving high-dose f entanyl anaesthesia, under normotensiveconditions or during hypotension induced by trimetaphan (TMP),sodium nitroprusside or nitroglycerine. Heart rate, mean arterialpressure (MAP), the ventricular stroke volume (SV) and the cardiacoutput (CO) were monitored before, and at 1, 2, 4, 6, and 8-minintervals after the insertion of the acrylic cement into theacetabulum or the neck of femur. There was a moderate decreasein MAP after insertion into the acetabulum under normotensiveconditions and TMP-induced hypotension, while the reductionin pressure was significant after the cement's application inthe femur. Heart rate did not change on insertion of the monomerin any of the patients. Moderate decreases in SV and CO wereobserved during normotension or TMP-induced hypotension. Therewere no significant changes in the cardiovascular haemodynamicson the insertion of the acrylic material under hypotension inducedby nitroprusside or nitroglycerine.     

Hemodynamic and respiratory changes during hip and knee arthroplasty. An echocardiographic study

BACKGROUND: The "bone cement implantation syndrome" is a rare but severe complication observed especially during the insertion of cemented prostheses in hip and knee replacement surgery. Several mechanisms are involved: effects of methylmethacrilate, embolism of fat, air and bone marrow, and release of tissue thromboplastin during acetabular and femoral reaming. Aim of this study was to detect embolic events, right heart impairment, hemodynamic and respiratory changes during hip and knee replacement surgery. METHODS: Design: Prospective study, between February-May 2001. Environment: Orthopedic Operative room. PATIENTS: Twenty-one patients who underwent total hip or knee arthroplasty under general anesthesia. Patients were divided in methylmethacrylate cemented prostheses groups (CEM, n=10) and totally uncemented prostheses (NON CEM, n=11). Data collection: Standard anesthesia monitoring and omniplane TEE were performed. TEE probe was positioned in order to obtain "inflow-outflow" views of right heart. Measurements were obtained after anesthesia induction (T1), during femoral realing (T2) at prostheses insertion (T3), and at the end of surgery (T4). RESULTS: Hemodynamic and respiratory parameters measured in different phases of surgical procedures were not different within groups and between groups. Fourtheen patients had TEE evidence of emboli, and the phenomenon was more evident in CEM group (Z= -347; p<0.001). During prostheses insertion, a slight, not significant increase in right ventricular dimensions was observed in both groups, without any right ventricular wall kinetic abnormality. No difference was observed between groups. No adverse cardiac or cerebrovascular events in intra- and postoperatory period were observed. CONCLUSIONS: In normal patients total hip or knee arthroplasty is associated with embolic phenomena, without any significant change in systemic and right heart hemodynamics. Insertion of cemented prostheses does not modify hemodynamic profile. It remains to be elucidated if the occurrence of emboli has a critical role in patients with cardiorespiratory disease.     

股骨上端转移瘤并发骨折的手术治疗

目的:探讨股骨上端转移瘤并发骨折的手术方法选择和疗效。方法:1998年10月-2004年3月,收治股骨上端转移瘤并发骨折11例,男8例,女3例;年龄51~74岁,平均65岁。采用瘤段切除,人工假体置换术7例;瘤体刮除,骨水泥填充,带锁髓内钉固定4例。结果:获随访8例,随访时间10~82个月,平均46个月。术后肿瘤复发1例,无假体松动、感染等并发症。术后1年内死亡2例,2年内死亡3例,3年内死1例,余1例髋关节功能良好。结论:人工假体置换术可立刻恢复骨骼的连续性及关节功能,是股骨近端转移瘤并发骨折的治疗首选。肿瘤刮除和骨水泥填充后带锁髓内钉固定能维持肢体长度和连续性,保持肢体功能。     

Treatment of an infected total hip replacement with the PROSTALAC system: Part 1: Infection resolution

INTRODUCTION: Infection after total hip replacement (THR) is a serious medical complication with significant negative ramifications for both the patient and the health care system. The prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) was designed to treat the joint infection while maintaining functional movement in the hip. METHODS: We identified 28 patients treated for infected THR with the PROSTALAC system, by retrospective chart review. Preoperative and intraoperative cultures were taken to identify the causative organism. After PROSTALAC insertion, patients underwent at least 6 weeks of intravenous (IV) antibiotics. Prior to undergoing posttreatment cultures, patients were required to be antibiotic-free for a minimum of 6 weeks, with normal laboratory values. We defined resolution infection as retention of a joint prosthesis for a minimum of 2 years. RESULTS: Infection was identified in 28 patients in either the joint aspirate or intraoperative cultures. Of these patients, 2 failed to clear infection, requiring repeat PROSTALAC insertion. Two additional patients had positive 48-hour cultures post-second stage, treated with additional IV antibiotics. Retention of the post-PROSTALAC prosthesis is 100% at 2 years. CONCLUSION: PROSTALAC has acceptable infection resolution outcomes and appears effective for treating infected THR.     

Assessment of polyethylene wear in total hip replacement

The three-dimensional technique is a method for the measurement of polyethylene wear in patients with total hip joint replacement. Application of image processing technology allows automation of point selection from digital images of radiographs scanned into the computer. Validation of image processing modifications reveals a three-fold increase in accuracy and a 40-fold increase in reproducibility compared with manual input of points from a digitizer during bench testing. A review of three-dimensional technique application to clinical patients gives information on the factors that influence polyethylene wear. Increasing age, activity level, femoral head size, decreasing polyethylene thickness, and insertion of total hip prostheses without cement all increase polyethylene wear. Restoration of femoral offset during total hip replacement seems to decreases polyethylene wear. No apparent difference in polyethylene wear rate could be found between two groups of patients, one group had a stainless steel-polyethylene articulation and the other had a ceramic-polyethylene articulation. Measurement of the serial polyethylene wear of individual patients reveals a high rate of femoral head penetration during the first 2 years after total hip replacement using metal-backed acetabular components inserted without cement. Interpretation of this femoral head penetration as true polyethylene wear may be erroneous, however, because creep of the polyethylene and acetabular liner movement within its metal shell cannot be measured.     

Penetration of acrylic bone cements into cancellous bone

The depth of penetration of five commercial acrylic bone cements into cancellous bone was measured in vitro. Under standard, idealized conditions, cement penetration was found to vary significantly with different cements. Penetration was critically influenced by the coarseness of the cancellous bone and increased directly with the effective volume of the "cells" within the osseous matrix. An inverse correlation was determined between the mean cement viscosity during flow into the bone and final penetration depth. The dough time, set time and working time of each acrylic formulation was found to have no significant effect upon the depth of cement penetration. It is suggested that in addition to the techniques adopted for introduction of cement to the bone, the selection of the bone cement itself may critically influence the incidence of late loosening following total joint replacement.