人工髋关节置换术治疗非感染性髋臼骨缺损:附42例报告

目的探讨人工髋关节置换手术在非感染性髋臼骨缺损的治疗经验。方法回顾性分析42例人工髋关节置换术对非感染性髋臼骨缺损的处理结果,探讨植骨、固定和髋臼置换的方法。结果本组手术全部成功,术后无感染发生。随访6～63个月,平均33.4个月,随访时无假体松动,关节无疼痛,患者对手术结果满意,髋关节功能较术前明显改善。结论对非感染性髋臼节段性和混合性骨缺损进行大块植骨时应辅以颗粒骨,并选用牢固的钉板系统固定,并尽量采用非骨水泥型臼杯,短期疗效好。     

髋臼骨缺损髋关节置换31例

目的 探讨非感染性髋臼骨缺损的人工髋关节置换经验。方法 回顾分析31例非感染性髋臼骨缺损的髋关节置换经验，研究植骨、固定、髋臼置换和功能康复的新方法。本组男18例，女13例；年龄23—73岁，平均55．5岁。根据美国骨科学会(AAOS)的分类方法：节段型骨缺损5例，空腔型骨缺损7例，混合型骨缺损5例，骨折型骨缺损6例，关节融合型骨缺损8例。结果 本组手术全部成功，术后无感染发生。手术后随访24例，随访时间6—68个月，平均24．3个月，随访时关节无疼痛，对手术结果满意，髋关节功能较术前显著改善。结论 (1)对节段型和混合型骨缺损，大块植骨时应辅以颗粒骨，并尽量选用较稳固的钉板系统固定。(2)使用带缝匠肌髂骨瓣植入重建髋臼缺损为活骨移植，成骨较好。(3)建议对髋臼非感染性骨缺损的髋关节置换尽量采用非骨水泥型臼杯。     

全髋关节置换术中髋臼假体定位的研究进展

目前全髋关节置换术已成为治疗终末期髋关节疾病的有效手段,由于髋臼侧结构的特殊性,髋臼杯位置的定位方法尚有争议。髋臼假体定位方法主要有根据术前、术中影像学资料定位,根据髋臼局部解剖特征和(或)结合机械设备定位等,本文就髋臼假体位置定位的研究进展作一综述。     

Avascular osteonecrosis of the acetabulum

 Objective. To investigate the possible occurrence of osteonecrosis in the acetabulum in patients with non-traumatic necrosis of the femoral head. Design and patients. One hundred and seventy-nine patients with non-traumatic femoral head necrosis were assessed by MRI and radiography for the presence of acetabular necrosis. Three criteria were established to differentiate between osteonecrosis and osteoarthritic changes: (1) heterogeneous morphology and irregular contours of the lesion; (2) typical demarcation lines of osteonecrosis; (3) deficient accumulation of intravenous gadolinium in the affected regions. Results. In four patients histological confirmation of acetabular necrosis was obtained. The MR analysis of 22 acetabula (9.5% of those examined) showed changes which suggested osteonecrosis. No cystic lesions were demonstrated in the subchondral bone of any patient. Two cases of acetabular necrosis were found without an ipsilateral femoral head necrosis. In two patients of the 14 who had undergone total hip replacement following necrosis of the femoral head, aseptic loosening of the acetabular component was found. Conclusion. The study suggests that acetabular necrosis may be an accompaniment to aseptic necrosis of the femoral head. Further work is required to assess its importance in premature loosening of the acetabular element of total hip arthroplasty.     

Influence of acetabular component position in non-cemented total hip arthroplasty. A radiologic and clinical study

Radiologic grading of non-cemented acetabular components in HP Garches total hip replacements was used to evaluate the relationship between a lack of supero-lateral cover of the acetabular component and clinical outcome. In 63 hips, three to five years after total hip arthroplasty, we observed that the acetabular component was partially uncovered in 56 per cent of cases. The fact that several components were partially uncovered did not influence the clinical outcome. Although the follow-up time is short the present study indicates that non-cemented HP Garches total hip arthroplasty is a technique which allows for stable fixation of the acetabular component.     

Ⅰ期全髋关节置换治疗髋臼骨折

目的 探讨髋臼骨折后Ⅰ期全髋关节置换(total hip arthroplasty,THA)的手术适应证和手术方法,观察其临床疗效.方法 对11例髋臼骨折患者行Ⅰ期THA.其中前柱骨折3例,后壁骨折1例,后柱骨折2例,后柱合并后壁骨折2例,横形骨折1例,横形合并后壁骨折1例,两柱骨折1例.伤后8～37 d(平均24 d)接受THA.对新鲜髋臼骨折患者,先用重建钢板或螺钉固定骨折以恢复髋臼肇的形态,将切下的股骨头制成颗粒状或块状植于髋臼内后安置臼杯.陈旧性髋臼骨折有节段性髋臼骨缺损者,将切下的股骨头制成大块状进行髋臼内结构性植骨后再安置臼杯.结果 术后3个月完全负重,无人工关节脱位.随访时间6～45个月,平均28个月.Harris评分平均78分.髋关节屈伸平均活动度为95°.X线片示1例出现髋臼松动及骨溶解征象.结论 髋臼骨折移位明显,关节软骨面损伤严重,错过了手术复位时机,可以Ⅰ期行THA.如能创造稳定的髋臼杯结构,近期临床效果满意.     

Pelvic synovial cyst formation secondary to perforation of the quadrilateral plate: a case report

A seventy seven-year-old female presented to her gynaecologist with right-sided pelvic pain and irregular per vaginal bleeding. Ten years earlier she had undergone a right cementless total hip arthroplasty. The press fit acetabular component had been augmented by screws. Radiological investigation requested by her gynaecologist identified a right iliac fossa mass. This communicated with the hip joint via a screw track formed by a fixation screw that had penetrated the medial wall of the acetabulum at total hip arthroplasty. Following aspiration of the fluid within the cyst, microscopy demonstrated it to be of synovial origin. Her symptoms subsequently resolved. This condition has not been reported previously.     

Juxtaacetabular ganglionic (or synovial) cysts: CT and MR features

Radiographic findings include supraacetabular bone erosions, subchondral acetabular cysts, soft tissue masses with or without radiolucent inclusions representing nitrogen gas, joint space narrowing, and abnormal hip configuration. Associated tears of the acetabular labrum were confirmed by arthrography in two patients. Computed tomography and magnetic resonance imaging afforded improved delineation of soft tissue ganglia and their relationship to the acetabular bone, labrum, and hip joint. We report our experience with seven patients in whom various imaging examinations clearly documented the presence of soft tissue cystic lesions adjacent to the acetabulum; in six of the seven patients, significant clinical manifestations were evident in the affected hip. Such cysts, whether designated synovial or ganglionic in type, appear to be a frequently overlooked yet important cause of hip symptomatology.     

Kinematic radiography of the hip joint after hip resurfacing arthroplasty

This study aimed to evaluate the usefulness of dynamic radiography using a dynamic flat-panel detector (FPD) system after hip resurfacing arthroplasty (HRA). A total of 32 hips of 26 patients who underwent HRA were included. Sequential images of active abduction in the supine position and flexion in the 45° semilateral position were obtained using the FPD system. We examined the imaging findings of impingement between the acetabular component and femoral neck with cooperative motion at maximal exercise. Moreover, the central component coordinate of the acetabulum and femoral head sides was measured. For abduction motion, impingement was detected in two (6.3 %) hips between the superior portion of the femoral neck and acetabular component. For flexion motion, impingement was detected in 19 (59.4 %) hips. There were no findings of subluxation between the acetabular component and femoral neck after impingement, but cooperative motion of lumbar and pelvic flexion was observed. There was no significant difference in the center-to-center distance regardless of the presence or absence of impingement. Detailed postoperative kinematics of the hips after HRA showed that the proposed dynamic FPD system could reveal acquired impingement and cooperative motion as dynamic images and possibly reveal findings that would be unobservable using static images.     

成人髋臼发育不良并发骨囊变的影像学研讨

目的探讨成人髋臼发育不良（acetabulardysplasia,AD）并发骨囊变的临床及影像学表现特点,提高其影像诊断能力。方法回顾性分析66例成人AD的标准双髋关节前后位X线片、28例CT片、10例MRI片的影像学资料,并按有无髋周骨囊变进行分组：囊变组、无囊变组。测量方法有：髋臼指数、Sharp角、CE角、髋臼顶切线角、AHI（股骨头覆盖率）、髋关节内间隙、髋关节上间隙。数据均以平均值±标准差（x±s）方式表示,通过了检验进行统计学处理,以P〈O．05为具有显著性检验。结果66例成人AD中出现并发症的61例,占92．4％,其中髋关节脱位（含半脱位和脱位）49例,占74．2％,继发骨性关节炎18例,占27．3％。髋臼及股骨头囊状改变24例,占36．4％,其中单纯髋臼囊变14例,占21．2％,股骨头和髋臼同时囊变5例,占7．5％,单纯股骨头囊变5例,占7．5％．襞变组和无囊变组对照测量结果显示两组数据除髋臼指数和髋关节内间隙无差异外（P〉O．05）,其余均有显著性差异（P〈O．05）。结论成人髋臼发育不良易并发髋周骨囊变（软骨下假囊肿）,其发病率与年龄呈正相关,X线、CT、MRI检查是诊断成人AD并发髋周骨囊变（软骨下假囊肿）的有效检查手段,MRI在显示成人AD并发髋关节周围骨囊变方面优于x线平片和CT,尤其是早期显示软骨下小囊变。     

人工关节置换治疗晚期股骨头缺血性坏死合并严重股骨颈前倾角畸形

目的 探讨晚期股骨头缺血性坏死合并严重股骨颈前倾角畸形患者采用普通假体髋关节置换的手术方法及临床疗效.方法 本组男9例,女6例;年龄30～42岁,平均37岁.前倾角40°～50°,术前Harris评分(59±8)分,术中通过将股骨假体缩小前倾角20°～30°,同时将髋臼杯前倾角增大10°～15°,使其基本恢复正常对合关系,防止关节前脱位.术后定期影像学检查和临床疗效Harris髋评分.结果 术后15例患者均获得随访2.5～3.7年(平均2.9年),关节假体稳定性良好,关节活动度基本正常.术后2年Harris评分为(88±6)分,与术前相比,疗效显著(P<0.01).结论 晚期股骨头缺血性坏死合并严重股骨颈前倾角畸形患者手术中通过对普通的股骨假体及髋臼杯安放的角度的联合调整,使关节置换术后人工假体与髋臼的对合基本恢复正常,疗效显著,同时避免了使用小柄股骨假体、转子下截骨或使用特殊前倾角股骨假体等治疗方法.     

应用髋臼钉减少后外侧切口全髋关节置换术中坐骨神经损伤

目的 探讨在全髋关节置换术中应用髋臼钉等与坐骨神经损伤的关系.方法 回顾总结我院2001～2006年施行的360例(397髋)后外侧切口全髋关节置换术,进行髋臼置换时应用髋臼钉和(或)髋臼拉构暴露髋臼,比较应用和不应用髋臼钉坐骨神经损伤的情况.结果 187髋应用髋臼钉无坐骨神经损伤,210髋不用髋臼钉共有4例坐骨神经损伤, 两者统计学差异显著.术后平均随访17个月(6～ 37个月),2例坐骨神经挫伤完全恢复,1例部分神经切断和1例神经缝扎遗留严重的肢体功能障碍.结论 全髋关节置换中坐骨神经损伤并不常见,但属于非常严重的并发症.神经损伤多发生在显露和植入髋臼假体时,应用髋臼钉可以清楚显露髋臼,减少坐骨神经损伤.     

髋关节外伤螺旋CT重建技术的应用

目的：探讨螺旋CT多平面重建(MPR)、三维表面遮盖法重建(SSE))及容积再现(VR)在髋臼骨折及股骨头脱位中的临床应用价值。方法：对25例髋关节外伤的患者进行螺旋CT容积扫描，然后在工作站上进行MPR、SSD、VR成像，结合轴位扫描图像，观察这三种重建图像在显示骨折线、骨碎片以及股骨头脱位方向和程度的效果。结果：MPR对判断股骨头的脱位方向和程度有帮助；SSD显示髋臼骨折和股骨头脱位的立体效果较好；VR虽然立体效果稍逊于SSD．但能显示骨折的细微结构。结论：MPR、SSD、VR三种重建方法可互为补充，能够立体直观、整体地显示髋臼骨折和股骨头脱位．为决定治疗方案和选择适当的手术入路提供了依据.     

Grafted bone used in acetabular reconstruction: assessment by SPECT scintigraphy

Objective To investigate incorporation of the grafted bone used for acetabular reconstruction.Design Single photon emission computed tomography (SPECT) was carried out at the 1st, 6th, and 12th month after the operation and the uptakes on serial SPECT scintigrams were normalized. The horizontal histogram of scintigraphic activity at the level of the central grafted bone in the coronal image was designated the profile curve.Patients Seven patients who had undergone bipolar hip arthroplasty for osteoarthritis of the hip were randomly selected.Results and conclusion Five of seven profile curves obtained at the 1st month demonstrated a single peak at the host-graft junction. The profile curve obtained at the 6th month showed two peaks at the host-graft junction and the periphery of the grafted bone in all patients. The profile curve at the 12th month showed slightly increased activity in the center of the grafted bone. This preliminary study demonstrates that comparison of the serial profile curves on SPECT is valuable in evaluating the progress of incorporation of the grafted bone in hip arthroplasty.     

Bone scintigraphy in acetabular labral tears

BACKGROUND: Acetabular labral tears are an increasingly recognized cause of hip pain in young adults with hip dysplasia and older patients with degenerative disease of the hips. METHODS: The authors analyzed retrospectively bone scintigraphy in 27 patients with acetabular labral tears diagnosed by MRI/arthroscopy. Analysis was also made of scintigraphy in 30 patients without labral tears being investigated for other causes of hip pain for comparison. RESULTS: Patients with labral tears had hyperemia of the superior or superomedial aspect of the acetabulum and increased delayed uptake in either a focal superior pattern or in an "eyebrow" pattern of a superomedial tear. This pattern was not seen in any other sources of hip pathology. CONCLUSION: Uptake in the superior or superomedial aspect of the acetabular rim is characteristic of a labral tear. Absence of this pattern carries a high negative predictive value for the diagnosis.     

全髋关节置换术中采用直接前方入路放置髋臼假体疗效观察

目的通过测量髋臼假体的外展角与前倾角,探讨全髋关节置换术(THA)中采用直接前方入路(DAA)放置髋臼假体的准确性。方法选取2015年7月至2016年1月收治的THA中采用DAA放置髋臼假体的患者81例(100髋),手术均由同一名具有高级职称的医师完成,术中使用可透光手术床,结合透视与髋臼假体导向器放置髋臼假体。术后骨盆正位X线影像测量髋臼假体的外展角与前倾角,并与Lewinneck安全区(外展角30°~50°,前倾角5°~25°)进行比较,评估THA中采用DAA放置髋臼假体的准确性。结果患者术后髋臼假体的外展角为(39.00°±4.47°),前倾角为(14.29°±5.50°);91.0%(91/100)患者术后髋臼假体的外展角与前倾角均在Lewinneck安全区内;所有患者术后10个月均未见脱位。结论 THA中采用DAA放置髋臼假体安全有效,可准确地将假体放置在安全区内。     

Acetabular stress fractures in military endurance athletes and recruits: incidence and MRI and scintigraphic findings

OBJECTIVE: To evaluate the incidence and the MRI and scintigraphic appearance of acetabular stress (fatigue) fractures in military endurance athletes and recruits. DESIGN AND PATIENTS: One hundred and seventy-eight active duty military endurance trainees with a history of activity-related hip pain were evaluated by both MRI and bone scan over a 2-year period. Patients in the study ranged in age from 17 to 45 years. They had hip pain related to activity and had plain radiographs of the hip and pelvis that were interpreted as normal or equivocal. The study was originally designed to evaluate the MRI and scintigraphic appearance of femoral neck stress fractures. Patients had scintigraphy and a limited MRI examination (coronal imaging only) within 48 h of the bone scan. Twelve patients demonstrated imaging findings compatible with acetabular stress fractures. RESULTS: Stress fractures are common in endurance athletes and in military populations; however, stress fracture of the acetabulum is uncommon. Twelve of 178 patients (6.7%) in our study had imaging findings consistent with acetabular stress fractures. Two patterns were identified. Seven of the 12 (58%) patients had acetabular roof stress fractures. In this group, two cases of bilateral acetabular roof stress fractures were identified, one with a synchronous tensile sided femoral neck stress fracture. The remaining five of 12 (42%) patients had anterior column stress fractures, rarely occurring in isolation, and almost always occurring with inferior pubic ramus stress fracture (4 of 5, or 80%). One case of bilateral anterior column stress fractures was identified without additional sites of injury. CONCLUSIONS: Stress fractures are commonplace in military populations, especially endurance trainees. Acetabular stress fractures are rare and therefore unrecognized, but do occur and may be a cause for activity-related hip pain in a small percentage of military endurance athletes and recruits.     

Digital subtraction arthrography in preoperative evaluation of painful total hip arthroplasty

 Objective. The objective of this clinical study was to define the diagnostic value of plain radiography, digital subtraction arthrography and two-phase bone scintigraphy in patients with clinically loose or infected hip prostheses. Design. Digital subtraction arthrograms, scintigrams and plain radiographs of 70 consecutive patients who underwent revision hip arthroplasty were scored individually and in masked fashion for the presence or absence of features indicating loosening of femoral and/or acetabular components. The operative findings acted as the gold standard. Results. Digital subtraction arthrography was best (P<0.001) for predicting a loose acetabular component, while no significant additional predictive value was found for plain radiographs (P=0.24) and scintigraphy (P=0.27). Digital subtraction arthrography was also the most important modality for predicting a loose femoral component (P=0.001), while the plain radiograph was of significant (P=0.04) additional value and scintigraphy was of no additional value (P=0.13) on multivariate analysis. Conclusion. Digital subtraction arthrography gives the best results in the prediction of loosening of acetabular and femoral components. Plain radiographs give additional information on loosening of the femoral component, but scintigraphy offers no additional advantage.     

Allogenic bone graft viability after hip revision arthroplasty assessed by dynamic [18F]fluoride ion positron emission tomography.

The biological fate of allogenic bone grafts in the acetabular cavity and their metabolic activity after acetabular augmentation is uncertain but is most important for the stability of hip implants after hip revision arthroplasty. The aim of this study was to quantify regional bone metabolism after hip replacement operations. Dynamic [18F]fluoride ion positron emission tomography (PET) was used to investigate the metabolic activity of acetabular allogenic bone grafts and genuine bone, either 3-6 weeks (short-term group, n = 9) or 5 months to 9 years (long-term group, n = 10) after hip revision arthroplasty. Applying a three-compartment model, the fluoride influx constant was calculated from individually fitted rate constants (Knlf) and by Patlak graphical analysis (Kpat). The results were compared with genuine cancellous and cortical acetabular bone of contralateral hips without surgical trauma (n = 7). In genuine cortical bone, Knlf was significantly increased in short- (+140.9%) and long-term (+100.0%) groups compared with contralateral hips. Allogenic bone grafts were characterised by a significantly increased Knlf in the short-term group (+190.9%) compared with contralateral hips, but decreased almost to the baseline levels of contralateral hips (+45.5%) in the long-term. Values of Knlf cor-related with the rate constant K1 in genuine (r = 0.89, P<0.001) and allogenic bone regions (r = 0.79, P<0.001), indicating a coupling between bone blood flow and bone metabolism in genuine bone as well as allogenic bone grafts. Kpat values were highly correlated with Knlf measurements in all regions. In conclusion, [18F]fluoride ion PET revealed the presence of an increased host bone formation in allogenic bone grafts early after hip revision arthroplasty. In contrast to genuine cortical bone, allogenic bone graft metabolism decreased over time, possibly due to a reduced ability to respond to the same extent as genuine bone to elevated metabolic demands after surgery.     

Observer variation in the detection of acetabular bone deficiencies

 To determine observer variation in the detection of acetabular bone deficiencies, 42 pairs of frontal (AP) and lateral hip radiographs and CT studies for total hip arthroplasty patients obtained within an average of 4 weeks of each other were reviewed separately by five radiologists and one orthopedic surgeon. Interobserver variations were calculated for each individual reading the films using kappa values. The individual film readings were then compared with a consensus reading of the CT data. When separate observers were analyzed, agreement on plain film readings was slight to fair (av. kappa=0.1440±0.1047). The individual observers were not able to give readings which were very consistent with the CT consensus reading, resulting in a low sensitivity (65%) and specificity (74%) for acetabular defect classification with plain radiographs. The identification of acetabular bone defects from the AP and lateral views of the hip is highly subjective and variable from observer to observer.