The value of contrast arthrography in assessing loosening of symptomatic uncemented total hip components

Twenty-five patients with symptomatic uncemented total hip components were studied with contrast arthrography prior to surgical exploration. All but one had uncemented femoral stems and 16 had an uncemented acetabular component. As judged by the findings at surgery, on the femoral side the sensitivity, specificity, and accuracy of arthrography were 57%, 60%, and 58% respectively. There was a relatively high incidence of both false positives (17%) and false negatives (25%). On the acetabular side sensitivity, specificity, and accuracy were 29%, 89%, and 62.5%. False negatives were common (31%), while there was only one false positive. The results in this small series show that arthrography has distinct limitations in identifying the fixation status of uncemented total hip components.     

Weight-bearing radiography in total hip replacement

Serial anteroposterior (AP) radiographs of the weight-bearing pelvis and hips were taken of 29 patients with total hip replacement (THR). For constant positioning the patient stands with straight knees on a board with a block between the heels. A U-shaped mercury level strapped to the patient provides a horizontal reference line on the radiograph. On the average, individual variation of pelvic tilt in serial films was 1° and pelvic rotation 3.5° confirming satisfactory reproducibility. The horizontal reference enables estimation of pre- and postoperative leg length inequality (LLI) and of the angle of the acetabular cup (AA). Reproducibility allows assessment of the exact position of the femoral component and quantitative evaluation of radiolucency and bone resorption around the prosthetic implant in the follow-up of THR.     

人工全髋关节置换术后感染翻修30例

目的探讨人工全髋关节置换术术后感染的细菌学特点、翻修策略、翻修术中常见的困难及对策。方法30例人工全髋关节置换术后感染患者，其中男12例，女18例；年龄31～86岁，平均62．5岁。感染发生时间为术后1个月～4年，平均为术后7个月。其中股骨颈骨折12例，股骨头坏死11例，骨关节炎5例，类风湿性关节炎2例。行Ⅰ期翻修术12例，Ⅱ期翻修术18例。结果翻修术前24例明确诊断为感染，其中细菌学明确诊断18例，其中表皮葡萄球菌5例，金黄色葡萄球菌4例，其他细菌9例。术中标本细菌培养23例阳性，7例阴性。Ⅰ期翻修12例中10例患者得到随访，时间平均16个月，2例感染复发；Ⅱ期翻修中13例得到随访，时间平均20个月，1例感染复发。Harris评分术前平均为44分，随访截止时评分平均为84分。结论（1）耐药葡萄球菌是人工髋关节置换术后感染的主要病原菌；（2）术后感染翻修手术难度大，术前要做好周密的准备，没有手术经验的医师尽量不要尝试；（3）术后感染采用Ⅰ期或Ⅱ期翻修应根据患者具体情况决定，Ⅱ期翻修术后感染复发率较低；（4）抗生素骨水泥在人工关节感染翻修术中的应用可以提高疗效，有利于关节功能恢复；（5）术后科学的康复对功能恢复十分重要。     

Focal osteolysis in total hip replacement: CT findings

Objective To describe the CT findings of focal osteolysis following total hip replacement (THR).Design and patients CT imaging features of 30 THRs with focal osteolysis visualized on follow-up radiographs and undertaken revision surgery were reviewed. On CT scans, the shape and anatomic location of osteolytic lesions was recorded, as well as their size and number. The presence of cortical disruption or expansion, liner wear, metallosis, and heterotopic ossification was also noted. In each case, surgical and histologic findings were correlated with imaging features.Results Focal osteolysis was common in the superior part of acetabular and femoral components. CT features of focal osteolysis were multiple, expansile, oval, or round radiolucencies, which were conglomerated into multilobular shape. The cortex adjacent to the osteolytic lesions revealed irregular thinning and discontinuity (29/30, 97%) accompanied by a few tiny fragments. Liner wear was common (27/30, 90%), and metallosis was frequent (8/30, 26.7%). Pathologic results were foreign body reaction in 20 patients, chronic inflammation in eight, and fibrosis in two.Conclusion CT appearances of focal osteolysis following THR are multilobulated lucent areas with expansile periosteal reaction and cortical abnormalities, mimicking infection or tumor. We consider that CT is useful for the prediction and assessment of the nature and extent of focal osteolysis.     

Arthroscopic assessment of total hip replacement and polyethylene wear: a case report

We report the case of a patient who showed clinical and radiological signs of massive polyethylene wear 3 years after total hip replacement. Arthroscopy was performed to assess the loosening of the acetabular cup. The procedure showed the polyethylene element to be broken into three pieces in the area corresponding to the upper border. Received: 18 December 1998 Accepted: 25 November 1999     

Ultrasound diagnosis of anterior iliopsoas impingement in total hip replacement

Iliopsoas impingement syndrome, an infrequent complication of total hip replacement, has been rarely reported in the radiological literature. It follows chronic friction of the posterior aspect of the iliopsoas muscle and tendon against the acetabular cup, a piece of cement, or cup fixation screws. Clinical findings are non-specific and an imaging modality is required to diagnose the condition. Computed tomography (CT) is considered the gold standard imaging modality in evaluating iliopsoas impingement. We report a case of a patient in which the diagnosis was made by ultrasound and later confirmed by CT.     

SuperPath全髋置换与全髋关节置换术的近期疗效对比分析

目的对比分析SuperPath全髋置换与全髋关节置换术的近期疗效。方法回顾性分析2015年12月—2016年12月新沂市中医医院骨伤科行全髋关节置换的60例患者临床资料,其中男性39例,女性21例;年龄40～75岁,平均58.6岁。按照手术方式分组,常规全髋关节置换术30例(常规切口组),SuperPath全髋置换30例(SuperPath组)。观察统计两组的术中出血量、术后3、7d VAS评分、临床疗效、早期恢复时间及Harris评分并进行比较。结果 SuperPath组术中出血量显著少于常规切口组[(350.12±41.12)mL vs.(470.15±60.24)mL],术后3、7d分别SuperPath组VAS评分均低于常规切口组[(5.35±1.01)分vs.(5.25±1.02)分、(3.25±2.12)分vs.(1.02±0.11)分];SuperPath组术后首次下床行走时间、脱拐行走时间、住院时间显著低于常规切口组;与术前比较,两组患者术后不同时间的Harris评分、均显著提高,且术后不同时间组间比较SuperPath组Harris评分均显著高于常规切口组(P<0.05)。结论与常规全髋关节置换术进行比较,对患者行SuperPath全髋置换治疗效果更好,可以显著减轻患者的疼痛程度,改善其髋关节功能,提高近期疗效。     

Aberrant pelvis and hip kinematics impair hip loading before and after total hip replacement

Musculoskeletal loading is an important factor affecting the development of osteoarthritis, bone remodelling and primary fixation of total hip replacement (THR). In this study, we analyzed the relation between muscular force, gait kinematics and kinetics and hip loading in 20 patients before and six weeks after THR. Hip contact forces were calculated from gait analysis data using musculoskeletal modelling, inverse dynamics and static optimization. We found aberrant pelvis and hip kinematics and kinetics before and six weeks after surgery, confirming previous findings in literature. Furthermore, we found a decrease in the total contact force and its vertical component. These changes result in a decrease of the associated inclination angles of the total hip contact force in the sagittal and transverse planes, changing the orientation towards more vertical implant loading after THR. These changes in hip loading were related to observed gait kinematics and kinetics. Most importantly, excessive pelvic obliquity and associated hip adduction related to impaired implant loading. We concluded, therefore, that physical therapy in the early post-operative phase should primarily focus on stretching of anterior and medial structures and strengthening of hip flexors and abductors to achieve normalization of the hip and pelvis kinematics and consequently normalize hip loading.     

The migration of femoral components after total hip replacement surgery: accuracy and precision of software-aided measurements

Objective To assess the accuracy and precision of a software-aided system to measure migration of femoral components after total hip replacement (THR) on digitised radiographs.Design and patients Subsidence and varus-valgus tilt of THR stems within the femur were measured on digitised anteroposterior pelvic radiographs. The measuring software (UMA, GEMED, Germany) relies on bony landmarks and comparability parameters of two consecutive radiographs. Its accuracy and precision were calculated by comparing it with the gold standard in migration measurements, radiostereometric analysis (RSA). Radiographs and corresponding RSA measurements were performed in 60 patients (38–69 years) following cementless THR surgery.Results and conclusions The UMA software measured the subsidence of the stems with an accuracy of ±2.5 mm and varus-valgus tilt with an accuracy of ±1.8° (95% confidence interval). A good interobserver and intraobserver reliability was calculated with Cronbach's alpha ranging from 0.86 to 0.97. Measuring the subsidence of THR stems within the femur is an important parameter in the diagnosis of implant loosening. Software systems such as UMA improve the accuracy of migration measurements and are easy to use on routinely performed radiographs of operated hip joints.     

Bupivicaine arthrography of the post-arthroplasty hip

Addition of bupivicaine, a medium-length-acting local anesthetic, to the contrast material in arthrography of total hip prostheses provides reliable information as to whether the source of pain is intracapsular or extracapsular. In 12 surgically proven cases, complete relief of pain after bupivicaine injection correctly identified an intracapsular source of pain in 10, with only 1 false-positive and 1 false-negative. These results compare favorably with the results of the contrast arthrograms in these patients in localizing the pain even if a specific diagnosis could not be reached. Bupivicaine as an adjunct to contrast material during arthrography provides additional information useful in management decisions regarding the necessity of revision arthroplasty.     

髋臼骨折后全髋关节置换效果分析

目的 总结分析髋臼骨折后全髋关节置换的特点及效果,为治疗提供依据.方法 选取全髋关节置换方法治疗的髋臼骨折58例患者的临床资料进行回顾性分析.结果 58例（59髋）中,行切开复位内固定（open reduction and intemal fixation,ORIF）治疗46例（79%）,非ORIF固定7例（12%）,非手术治疗5例（9%）;关节置换术前术中检查确定存在感染者共13例,均为ORIF病例,占28%,均行清创骨水泥占位器置入,二期翻修.其余病例行一期关节置换.平均随访45个月（20～58个月）,Harris评分由平均术前的48.2分提高到87.3分,并发症6例,髋关节脱位3例（5.2%）,经手法复位石膏固定治愈;深部感染2例（3.4%）,经二期翻修治愈.结论 关节置换可获得良好效果,但应注意排除术前存在感染,并注意预防术后并发症.     

人工髋关节置换术后常见并发症的X线表现

目的 探讨人工髋关节置换术后常见并发症的X线表现，以期提高对人工髋关节置换术后并发症的早期诊断及病因鉴别诊断能力。方法 回顾性分析46例人工髋关节置换术后由于出现并发症而行翻修术的病例，观察其X线表现，并通过与手术对照以评价X线对并发症的诊断价值。结果 术后诊断股骨柄无菌松动34例，髋臼假体无菌松动13例，X线表现为假体周围≥2mm的轮廓与假体形态一致的透亮带伴或不伴假体移位；感染伴股骨柄和(或)髋臼假体松动4例，X线表现为假体周围≥3mm的轮廓与假体形态不一致的透亮带和(或)假体移位，同时伴有骨质破坏、窦道形成等；股骨头脱位6例，X线2例表现为股骨头位于髋臼外，2例表现为股骨头中心型移位，2例表现为股骨头在髋臼假体内不对称。结论 透亮带和假体移位是松动最重要的X线表现，透亮带的形态和窦道的形成有助于鉴别感染性和无菌性松动。髋臼内股骨头位置的不对称或股骨头完全位于髋臼外为股骨头半脱位或脱位的表现。     

全髋关节置换术后早期常见并发症防治

目的探讨全髋关节置换术早期常见并发症的发生原因及防治对策。方法随访2007—2011年在我科施行全髋关节置换术的258例患者,分析发生早期并发症的原因并提出防治措施。结果发生早期并发症者共18例,其中感染1例,髋关节脱位6例,股骨假体周围骨折7例,有症状下肢深静脉血栓形成2例,神经损伤2例。结论人工髋关节置换术后发生并发症,部分与手术技术有关,对此应提高认识,严格围术期风险评估,做好充分的术前准备、实施正确的手术操作和功能锻炼,可以最大限度地降低并发症的发生。     

Granulomatous pseudotumors in total joint replacement

Fourteen patients (15 joints) developed a foreign body reaction to methylmethacrylate, polyethylene, or metal adjacent to a total joint implan, a condition we would like to term granulomatous pseudotumors. There were eight male and six female patients. Their average age was 61 years. The hip was involved in 14 joints (femoral component 11 times, acetabulum 7, and great trochanter once). One patient presented with granulomatous pseudotumors of the knee. The principal findings included increasing pain and radiographic evidence of loosening occurring on average 2.7 years following the implant. This was followed by a characteristic and gradually developing radiographic pattern of discrete rounded lucencies. These developed into large ovoid lytic areas, destroying both methylmethacrylate and bone. Histologically, the appearances were characterized by histiocytic infiltration and the presence of multiple foreign body giant cells. Foreign material was identified in 9 of 11 cases. The pathogenesis is unknown but appears related to micromovement or loosening of the implant.     

鲑鱼降钙素在老年患者全髋关节置换术中的应用分析

目的：观察鲑鱼降钙素对老年患者全髋关节置换术中骨代谢、关节功能恢复及生活质量的影响,评价其临床价值。方法对沈阳市骨科医院134例60岁以上行全髋关节置换术的老年患者随机分为观察组（67例）和对照组（67例）,观察组给予鲑鱼降钙素干预,随访6个月,检测骨代谢指标血清骨钙素（osteocalcin,OC）、骨碱性磷酸酶（bone alkaline phosphatase, BALP）、Ⅰ型胶原交联C端肽（C-terminal telopeptides of typeⅠ collagen,β-CTX）、Ca2+水平及骨密度（bone mineral density, BMD）,疼痛强度差（pain intensity difference,PID）关节功能及生活质量评分。结果术后1、3、6个月血清OC观察组均高于对照组（P＜0.05）;血清β-CTX观察组在3、6个月低于对照组（P＜0.05);血清BALP在术后1、3、6个月对比观察组均低于对照组（P＜0.05);血清Ca2+术后3、6个月观察组高于对照组（P＜0.05);BMD术后1、3、6个月观察组高于对照组（P＜0.05);观察组早期疼痛PID评分在3、6个月高于对照组（P＜0.05);直腿抬高30°时间观察组短于对照组（P＜0.05);髋关节外展45°观察组短于对照组（P＜0.01);Harris评分观察组高于对照组（P＜0.05);SF-36平均分观察组高于对照组（P＜0.05)。结论鲑鱼降钙素在老年人全髋关节置换术中应用可促进成骨过程,抑制破骨过程,减轻患者早期疼痛,促进关节功能恢复及改善生活质量。     

Three-phase bone scintigraphy pattern of loosening in uncemented hip prostheses

The three-phase bone scintigraphy pattern of loosening in uncemented hip prostheses (UHPs) has not previously been elucidated. We evaluated 28 patients with complicated UHPs who had undergone total hip arthroplasty a very long time previously (range 3–20 years, mean 8.4). All the patients were surgically reviewed: 26 UHPs were found to be loosened and two infected. Nine asymptomatic UHPs were taken as controls. The dynamic phase was invariably negative in both loosened and asymptomatic UHPs while markedly positive in the infected ones. The blood pool phase was positive to various degrees in 16 of the 26 loosened UHPs as well as in the infected UHPs, but was invariably negative in painless replacements. In the bone phase, areas of significantly (discrete to marked) increased uptake were observed in all the loosened prostheses as well as in two-thirds of the asymptomatic ones. However, the regions of the lesser trochanter and/or tip and/or shaft were involved exclusively in the case of the loosened UHPs, and diffuse periprosthetic uptake was found only with loosened or infected implants. Areas of slight methylene diphosphonate (MDP) uptake were found at every periprosthetic site and areas of discrete to marked MDP uptake were commonly found in the acetabulum and/or the greater trochanter with both loosened and painless prostheses and are thus considered to be nonspecific findings.     

非感染性人工髋关节翻修术28例

目的探讨非感染性人工髋关节翻修的原因、术中常见的困难及对策。方法1994年1月-2004年12月收治的28例中，男17例，女11例；年龄42～87岁，平均65．5岁。左侧13髋，右侧15髋似体松动14例、臼松动11例，柄松动3例；股骨侧假体下沉4例；髋臼磨透3例；股骨柄似体过长3例；合并股骨假体周围骨折1例；股骨柄穿通皮质1例；头臼不匹配1例；臼后倾1例。股骨柄假体15例取出顺利，13例取出困难，结果翻修成功27例。失败1例。全部患者经6个月-8年随访，平均3年7个月、Harris评分术前平均为45分，随访时评分平均为84分。结论（1）无菌性松动和医源性错误是非感染性人工髋关节翻修的主要原因；（2）人工关节翻修手术难度大，术前要做好周密的准备，没有手术经验的医师尽量不要尝试；（3）股骨柄假体取出困难是髋关节翻修中常见的难题，骨水泥型更为突出；（4）术后科学的康复锻炼对功能恢复十分重要.     

异体骨移植在全髋关节置换术后感染股骨翻修中的应用

目的 探讨异体骨植骨治疗髋关节置换术后感染股骨骨质缺损的有效性与可行性.方法 髋关节置换术后感染股骨侧骨质缺损患者20例,在二期翻修时采用异体植骨,其中16例股骨侧使用骨水泥固定假体结合打压植骨,4例股骨侧使用非骨水泥固定假体结合异体皮质骨支撑植骨.术后定期随访,根据X线片及Harris评分结果进行评价.结果 所有患者均获随访,平均随访时间20.3个月(4～61个月),X线片上无明显异体骨溶解征象,Harris评分从术前的平均34.2分提高到最后随访时的平均87.7分,患者满意率为90%,在最后随访时没有感染复发患者.结论 异体骨植骨治疗髋关节置换术后感染后股骨侧骨质缺损是有效且可行的.     

抗生素骨水泥间隔物在全髋关节置换术后感染Ⅱ期翻修术中的应用

目的 探讨在全髋关节置换术后感染Ⅱ期翻修术中使用抗生素骨水泥间隔物的方法和有效性。方法 采用抗生素骨水泥间隔物治疗30例30髋行全髋关节置换术后感染的患者，感染治愈后行Ⅱ期人工关节翻修术并进行随访。结果 29例用抗生素间隔物治疗，感染得到有效治疗，1例失败。其中27例患者行Ⅱ期翻修术，Harris评分由间隔物置人前的34．6分提高到Ⅱ期置换术后的81．8分，但1例感染复发。结论 抗生素骨水泥间隔物能有效地治疗感染，维持软组织的张力，为Ⅱ期翻修手术创造良好的条件。     

缝匠肌骨瓣修复人工全髋关节置换中髋臼缺损的实验研究

目的建立缝匠肌骨瓣修复人工全髋关节置换（THR）中髋臼节段性缺损的动物模型，并观察其初步修复结果。方法16只成年山羊进行左侧THR，并造成髋臼上方负重区40％的节段性骨缺损。随机分成2组，分别以缝匠肌髂骨瓣和游离髂骨瓣移植修复，术中行骨瓣血运、带血管蒂缝匠肌骨瓣活动长度的观察，术后行大体、X线和组织学观察。结果术中缝匠肌髂骨瓣血运良好，有足够的活动长度；术后X线显示移植骨块及置换假体位置良好，固定牢靠；缝匠肌髂骨瓣仍然保持基本正常松质骨结构，与髋臼可以形成类似骨折愈合的连接。结论缝匠肌骨瓣可以很好地修复髋臼节段性缺损，效果优于游离骨瓣。