大转子延长截骨在股骨柄翻修术中的应用

目的 报道大转子延长截骨在股骨柄翻修术中的应用及其疗效。方法 从 1998年 1月～ 2000年 1月,采用大转子延长截骨术取出股骨柄、骨水泥,行翻修术 11例。男 7例,女 4例。年龄 53～ 69岁,平均 65.4岁。翻修原因 :股骨柄断裂 2例,人工股骨头置换术后髋臼骨关节炎 8例,假体位置异常 1例。结果 11例患者术后第 2 d均在助行器辅助下下床行走,术后 3个月大转子延长截骨处临床愈合后,改扶单拐行走, 6个月后弃拐行走。术后随访 6～ 30个月,大转子延长截骨处骨性愈合, Harris评分平均为 89.6分。结论 大转子延长截骨术多用于翻修术中取出固定牢固的骨水泥或非骨水泥假体柄。其适应证包括 :(1)股骨柄近端断裂,远端仍牢固固定者; (2)人工股骨头置换术后发生髋臼骨关节炎伴髋关节强直,股骨柄固定牢固,需行全髋翻修者; (3)股骨柄安放位置错误,但骨水泥固定良好者; (4)不伴有假体松动的早期严重感染需行翻修者。该方法显露充分,术后恢复快,是一种较好的股骨柄固定牢固的翻修方法。主要并发症有截骨处不愈合、移位及截骨片骨折。     

股骨大转子延长截骨在假体稳定股骨柄翻修中的应用

目的 评估大转子延长截骨在股骨假体固定稳定型全髋关节翻修术中应用的中期临床效果.方法 1998年1月至2005年6月对27例患者(27髋)采用大转子延长截骨对股骨柄和(或)骨水泥壳固定稳定的全髋关节翻修.临床随访评估包括Harris评分和WOMAC评分,术前Harris评分平均42.7分,WOMAC评分平均55.6分;影像学评估包括术后拍摄X线片,对比观察截骨块愈合时间、是否存在截骨延迟愈合或不愈合,截骨块是否发生移位以及假体是否下沉等.结果 共19例患者(19髋)获得随访,平均随访时间5.3年.无一例发生术中或术后骨折.术后Harris评分平均87.3分,WOMAC评分平均46.3分.所有患者大转子截骨块均于术后6个月内愈合.无股骨大转子截骨块向近端移位,3例发生股骨柄下沉,平均下沉3.4 mm,无钢丝断裂.结论 对于假体固定稳定型股骨柄翻修,采用股骨大转子延长截骨有利于手术操作和翻修假体的植入和固定,有利于截骨块的愈合,降低术中、术后并发症发生率,中期疗效显著.     

大转子延长截骨在全髋关节翻修术中应用的临床评价

目的 回顾性研究采用大转子延长截骨(extended troehanteric osteotomy,ETO)行全髋关节翻修术后股骨柄的位置变化,评价ETO在股骨假体稳定件髋关节翻修术中的作用.方法 1998年1月至2007年6月,采用ETO对股骨柄或骨水泥壳固定稳定性全髋关节33例33髋进行翻修.翻修术后采用Harris评分和MOMAC评分评估髋关节功能,摄动态X线片观察截骨块愈合、假体位置改变及股骨柄与股骨髓腔匹配等情况.结果 25例随访12～103个月,平均63个月.Harris评分由术前平均38.4分,提高到末次随访时88.7分;WOMAC评分由术前平均56.2分,降至末次随访时42.8分.大转子截骨块均在术后4～10个月骨性愈合.3例发生股骨柄下沉.平均3.4mm.股骨柄假体出现外翻、内翻各1例.无术中或术后骨折、钢丝断裂、感染、假体周围骨溶解以及异位骨化发生.术后关节脱位1例.结论 对假体固定稳定性股骨柄进行翻修,采用ETO有利于假体的安全取出,术后截骨块愈合率高,延长截骨不影响假体稳定性.股骨柄下沉、位置改变、截骨块骨折等并发症发生率低.     

人工髋关节翻修术的临床分析（附32例报告）

目的探讨人工髋关节翻修术的翻修原因、临床特点及手术方法。方法对32例人工髋关节翻修术的临床资料进行回顾性分析。取髋关节后侧入路,取出松动的股骨侧及髋臼侧假体,根据缺损情况植骨,然后按技术要求换置假体。结果2例术中出现股骨骨折,行内固定术,愈合良好。1例髋臼行植骨、骨水泥假体固定,术后1年出现髋臼假体松动。行二期翻修术。Harris评分术前平均41．3分,术后平均83．5分。结论①无菌性松动和医源性错误是人工髋关节翻修的最常见原因;②髋臼翻修首选非骨水泥假体生物型固定,对于包容性髋臼骨质缺损,应行颗粒打压植骨＋非骨水泥臼固定;（蓼翻修术中股骨柄取出困难可行股骨大粗隆延长截骨;④术后功能锻炼至关重要。     

髋关节置换术后骨水泥股骨假体断裂原因分析及处理

目的 探讨骨水泥股骨假体断裂的原因和处理方法.方法 自2003年3月至2009年3月,共收治8例国产骨水泥股骨假体断裂患者,男6例,女2例.断裂距初次关节置换手术时间为36～98个月,平均72个月;体重60～88 kg,平均75 kg.均无明确外伤史.分析断裂前、后X线片,观察原假体安放位置、断裂部位、骨水泥固定情况及有无假体周围骨折;对术中假体表面骨水泥覆盖情况及断裂假体取出要点进行同顾性分析.5例行股骨假体翻修手术,采用生物碰股骨假体同定.3例转诊.翻修术后3个月、6个月、1年定期复查,行X线及Harris评估.结果 4例初次置换假体内翻,1例外翻;5例假体偏小.断裂均位于假体中点至中、远1/3交界处,远端崮定牢固.4例断裂前X线片可见近端假体周围细透光线,1例假体周围骨折.近端假体取出容易,远端假体取出困难.4例行股骨开窗,1例行转子延展截骨.翻修病例随访12～80个月,平均48个月.开窗或截骨部化平均愈合时间3.5个月.无假体松动、下沉及感染.末次随访时Harris评分85～97分,平均92分.结论 骨水泥股骨假体断裂可能与骨水泥假体近、远端固定质量不一致有关.对假体断裂者应及早行翻修术,术中股骨开窗安全有效.     

混合型初次全髋关节置换术中骨水泥柄10年以上的随访研究

目的回顾性分析混合型初次全髋关节置换术（THA）中骨水泥柄的临床和影像学疗效及其相关影响因素。方法对1999年1月至2001年12月期间接受混合型初次THA治疗髋部疾病的患者126例（135髋）进行至少10年的随访。观察Harris评分、股骨假体位置、骨水泥壳及其周围骨质变化。假体生存率采用Kaplan-Meier方法进行分析,以无菌性松动导致翻修及单纯骨溶解病灶清除植骨术为随访终点。结果共有79例（85髋）获得10年以上随访。Harris评分由术前（44.5±18.8）分提高至末次随访时（92.1±5.6）分。截至随访终点,在Gruen 1区观察到2髋发生骨溶解,7区4髋发生骨溶解现象。共有4例（4髋）接受翻修手术,其中1例男性患者因骨溶解致髋臼假体松动,同侧股骨近端骨溶解,同期行右髋臼侧翻修及股骨侧骨溶解病灶清除植骨术。另3例因髋臼假体松动行髋臼侧翻修术,影像学及术中见股骨假体稳定。以无菌性松动为随访终点,股骨假体生存率为100%;以无菌性松动翻修、单纯骨溶解病灶清除植骨术为随访终点,股骨假体生存率为98.8%（95%可信区间,12.23~12.32）。结论混合型初次THA术中骨水泥假体的远期生存率令人满意;采用第3代骨水泥技术固定的股骨柄取得与现代非骨水泥假体柄相近的远期生存率。     

关节镜下经膝逆行击出股骨侧假体在髋关节翻修术中的应用

目的探讨关节镜下经膝逆行击出法在股骨侧假体翻修术中的应用及疗效。方法对16例患者采用关节镜下经膝逆行击出法取出股骨假体柄、骨水泥,行髋关节翻修手术。结果16例均获随访,时间6-24个月,髋关节功能均良好。Harris评分82-98（92±4.35）分。结论采用关节镜下经膝逆行击打法取出股骨侧假体和骨水泥,手术时间短,创伤小,患者可早期功能锻炼,无需加长柄假体,手术效果良好。     

延伸的转子截骨在一期复杂全髋置换术中的应用

延伸的转子截骨在全髋翻修术中广泛应用 ,而且非常有效。然而在一期复杂全髋置换术中的应用尚未得到广泛研究。这种方法在全髋翻修术中的优点包括 :广泛暴露以利于取出内植物和骨水泥 ;矫正畸形 ;直视下置入股骨干内假体 ;而且此较大的截骨面比标准的转子截骨更有利于骨愈合。因此我们认为 ,这种截骨术的指征为严重的股骨畸形及需取出股骨内植物。本组 6例复杂一期全髋置换术采用了这种截骨术。包括 2例因股骨畸形而导致假体柄插入困难 ,2例需取出股骨内植物 ,2例股骨畸形且需取出内植物及 1例髋关节发育不良。全部采用表面有孔股骨假体重建…     

股骨转子下叠加缩短截骨在CroweⅣ型成人髋脱位全髋置换术的应用

目的总结CroweⅣ型成人髋脱位采用股骨转子下叠加缩短截骨行全髋置换术的方法与疗效。方法2000年1月至2003年12月，收治8例（11髋）CroweⅣ型成人髋脱位患者，男3例，女5例；年龄40-57岁，平均48岁；单髋5例，双髋3例；先天性发育不良7例，陈旧性髋关节结核1例。假体臼杯为金属杯＋聚乙烯内衬设计，其中Duraloc（Depuy，Warsaw，USA）8髋，Pressfit SⅡ（LINK，Ger-many）3髋。股骨柄假体采用AML（Depuy，Warsaw，USA）4髋，Summit（Depuy，Warsaw，USA）4髋，Ribbed（LINK，Germany）3髋。假体均采用生物学固定。手术均采用股骨转子下叠加缩短截骨，并附加断端“V”形截骨，其中6髋因最小号股骨柄假体置 入困难，而附加股骨劈开成形术。结果无一例发生感染、脱位等并发症，无一例行臀大肌或臀中、小肌等短肌松解。转子下平均缩短截骨长度为4．5cm（4～6cm），无一例因截骨过短，导致股骨头假体复位困难或坐骨神经牵伸伤；也无一例因截骨过长，导致股骨头假体松弛性脱位。术后X线片示臼杯均位于真臼区，股骨柄假体的初始固定均优良，截骨断端在3～6个月后均骨性愈合。测量显示患肢平均延长3cm（2．5～3．5cm）。随访3～7年，髋关节Harris评分从术前的25～32分改善至1年后的90～98分。无一髋假体显示有X线松动和邻近骨溶解。结论股骨转子下叠加缩短截骨术可用于CroweⅣ型成人髋脱位的全髋置换术治疗。     

大粗隆延长截骨结合记忆合金内固定在股骨柄翻修术中的应用

目的探讨大粗隆延长截骨结合记忆合金卡环或环抱器在股骨假体固定稳定型髋关节翻修手术中的应用及疗效。方法 对2004年1月至2010年3月,35例（35髋）接受髋关节股骨假体翻修手术中进行大粗隆延长截骨结合记忆合金卡环及环抱器固定的患者,平均年龄（68.2±9.6）岁,进行了平均（36.8±13.2）个月的随访,对手术时间、出血量、截骨长度、内固定方式、截骨愈合时间及术后髋关节功能进行评价。结果 手术时间平均为（95.4±23.6）min,术中出血量平均（852.5±228.3）ml,截骨长度平均为（13.5±3.5）cm,术中内固定采用记忆合金卡环2～3枚或记忆合金环抱器1枚。术后截骨愈合时间平均（4.8±1.2）个月,患者Harris评分由术前平均（39.5±13.6）分提高到术后平均（82.2±17.8）分。结论 大粗隆延长截骨在股骨柄固定牢固的髋关节翻修术中可以充分显露术野,有利于取出固定良好的骨水泥和非骨水泥股骨柄;结合记忆合金卡环或环抱器固定操作简便、固定牢靠,有利于截骨块的愈合,术后功能恢复良好。     

Trochanteric slide osteotomy in revision total hip arthroplasty for loosening

We used a trochanteric slide osteotomy (TSO) in 94 consecutive revision total hip arthroplasties (90 with replacement of both the cup and stem). This technique proved to be adequate for removing the components, with few complications (two minor fractures), and for implanting acetabular allografts (18%) and reinforcement devices (23%). Trochanteric union was obtained in most patients (96%), even in those with septic loosening (18/19), major femoral osteolysis (32/32), or previous trochanteric osteotomy (17/18). TSO is versatile, since it can be extended by a femoral flap (four cases) or a distal femoral window (eight cases). Despite significant bone loss, in 24% of the femora and 57% of the acetabula, favourable midterm results were achieved and only six reoperations were required, Including two for trochanteric nonunion and two for loosening. It leaves the lateral femoral cortex intact so that a stem longer than 200 mm was needed in only 25% of patients. This is a considerable advantage compared with the extended trochanteric osteotomy in which the long lateral flap (12 to 14 cm) requires an average length of stem of 220 mm beyond the calcar. TSO provides an approach similar in size to the standard trochanteric osteotomy but with a rate of nonunion of 4% versus 15%. It reduces the risk of difficulties with removal of the stem, and removes the need for routine distal anchoring of long revision stems. The limited distal femoral compromise is very important in patients with a long life expectancy.     

Trochanteric osteotomy and fixation during total hip arthroplasty

Once used routinely, trochanteric osteotomy in total hip arthroplasty now is usually limited to difficult primary and revision cases. There are three types: the standard trochanteric osteotomy and its variations, the trochanteric slide, and the extended trochanteric osteotomy. Each has unique indications, fixation techniques, and complications. Primary total hip arthroplasty procedures requiring the enhanced exposure provided by trochanteric osteotomy may be needed in patients with hip ankylosis or fusion, protrusio acetabuli, proximal femoral deformities, developmental dysplasia, or abductor muscle laxity. Trochanteric osteotomies in revision arthroplasties, primarily the extended trochanteric osteotomy, facilitate the removal of well-fixed femoral components, provide direct access to the diaphysis for distal fixation, and enhance acetabular exposure.     

Vastus-psoas release for acetabular exposure in revision hip surgery

A technique is presented for wide exposure of the acetabulum for revision total hip arthroplasty surgery in the presence of a solidly fixed, modular, or monoblock femoral component without the need for trochanteric osteotomy. The technique involves release of the proximal portion of the vastus lateralis, vastus intermedius, and vastus medialis muscles and the iliopsoas tendon from the femur and placement of the femoral head/neck posterior to the acetabulum. The exposure afforded by this release usually precludes the need for trochanteric osteotomy and/or removal of a well-fixed femoral component in revision surgery that is being done for isolated loosening of acetabular components, thereby decreasing operative time, morbidity, and the risks of complication of trochanteric osteotomy.     

Fractures of distally-fixed femoral stems after revision arthroplasty

We identified five (2.3%) fractures of the stem in a series of 219 revision procedures using a cementless, cylindrical, extensively porous-coated, distally-fixed femoral stem. Factors relating to the patients, the implant and the operations were compared with those with intact stems. Finite-element analysis was performed on two of the fractured implants. Factors associated with fracture of the stem were poor proximal bone support (type III-type IV; p = 0.001), a body mass index > 30; (p = 0.014), a smaller diameter of stem (< 13.5 mm; p = 0.007) and the use of an extended trochanteric osteotomy (ETO 4/5: p = 0.028). Finite-element analysis showed that the highest stresses on the stem occurred adjacent to the site of the fracture. The use of a strut graft wired over an extended trochanteric osteotomy in patients lacking proximal femoral cortical support decreased the stresses on the stem by 48%.We recommend the use of a strut allograft in conjunction with an extended trochanteric osteotomy in patients with poor proximal femoral bone stock.     

Combined vertical and horizontal cable fixation of an extended trochanteric osteotomy site

BACKGROUND: The use of an extended trochanteric osteotomy facilitates exposure and aids in the removal of a well-fixed femoral implant and cement during revision total hip arthroplasty. Occasionally, nonunion, fracture, and trochanteric migration have been reported following osteotomy. We evaluated the rate of healing of the osteotomy site and of implant stability when fixation was accomplished with use of vertical trochanteric and horizontal metaphyseal cable fixation (combined cable fixation). METHODS: The clinical and radiographic results of revision total hip arthroplasty with use of an extended trochanteric osteotomy followed by implantation of a distally porous-coated component and combined cable fixation of the osteotomy site in forty-two consecutive patients (forty-three hips) were reviewed. Intraoperative fracture at the osteotomy site occurred in five hips (12%). RESULTS: All osteotomy sites healed by six months, with an average time to union of fifteen weeks. One implant subsided 5 mm in a patient in whom a fracture had occurred at the time of the osteotomy. No trochanteric migration occurred. Two patients required a reoperation: one because of instability, and another because of recurrent infection. CONCLUSIONS: The extended trochanteric osteotomy facilitates revision of a well-fixed femoral component. Despite occasional intraoperative fracture at the osteotomy site, combined vertical trochanteric and horizontal metaphyseal cable fixation resulted in an excellent rate of healing and implant stability.     

Nonunion of extended trochanteric osteotomies in impaction grafting femoral revisions

Extended trochanteric osteotomies have been recommended to facilitate femoral component removal, femoral cement removal, and acetabular exposure in cases of difficult revision hip arthroplasty. Complications due to the osteotomy have been rare and no nonunions have been reported when this osteotomy has been used in conjunction with extensively porous-coated implants. It has been suggested that the osteotomy should also work well with impaction grafting revisions. This is a report of two cases of nonunion of extended trochanteric osteotomies in which the impaction grafting technique was used.     

Extended Trochanteric Osteotomy Followed by Cemented Impaction Allografting in Revision Hip Arthroplasty

The aim of this study is to present the medium- to long-term results of all cases of femoral impaction allografting revision at our institution that required an extended trochanteric osteotomy (ETO) at the time of surgery. Eighteen patients with a mean age of 60 years were evaluated. Indication for revision was aseptic loosening in all cases. The mean follow-up was 123 months (51-170). Charnley-D'Aubigné-Postel scores, stem length, ETO length, ETO healing, and complications were recorded. No patient was lost to follow-up. Signs of clinical healing were noted within the first 6 postoperative months. The difference between the preoperative and postoperative clinical scores was statistically significant. No nonunion of the ETO was observed in any case. These results give support to the combined use of these techniques.     

Fractured Femoral Stems in Primary and Revision Hip Arthroplasties Revisited: Wrightington Experience

BackgroundThe aim of this study is to present our experience in managing fractured femoral stems over the last 10 years for both primary and revision stems at our tertiary unit focusing on modes of failure and operative techniques.MethodsThis is a retrospective consecutive study of all patients with fractured femoral stems that were operatively managed in our unit between 2008 and 2018. Detailed radiographic evaluation (Paprosky classification) was undertaken and data collected on operative techniques used to extract distal fractured stem fragments.ResultsThirty-five patients (35 hips) were included (25 men/10 women) with average age at time of presentation of 68 years (range, 29-93). Average body mass index was 30 (standard deviation, 3.8; range, 22.5-39). There were variety of stems both contemporary and historical, primary and revision cases (15 hips polished tapered cemented stems, 10 hips composite beam and miscellaneous stems, and 10 revision hip stems). The predominant mechanism of failure was fatigue due to cantilever bending in distally fixed stems. Surgical techniques used to extract distal fragment were drilling technique in 2 hips, cortical window in 13 hips, extended trochanteric osteotomy (ETO) in 5 hips, and proximal extraction in 15 hips.ConclusionWhen faced with a contemporary fractured stem, drilling techniques into the distal fragment are unlikely to succeed. If a trochanteric osteotomy had been used at time of index surgery, this could be used again to aid proximal extraction with conventional revision instrumentations. The cortical window technique is useful but surgically demanding technique that is most successful in extracting polished tapered fractured stems particularly when an ETO is not planned for femoral reconstruction. Use of trephines can be useful for removal of longer, uncemented stems. Finally, an ETO might be necessary when other techniques have failed.