广泛多孔涂层柄应用于初次髋关节置换术后假体无菌性松动翻修的短中期疗效分析

目的探讨广泛多孔涂层柄应用于初次髋关节置换术后假体无菌性松动翻修术的安全性及有效性。方法回顾性分析笔者自2009-01—2015-03应用同一广泛多孔涂层柄对25例初次髋关节置换术后假体无菌性松动行翻修术。观察翻修时间、出血量、术中骨性操作、术后并发症等。结果手术时间平均82.5(60~200)min,出血量平均750(400~2300)ml。1例因假体取出困难行扩大粗隆截骨术,4例行股骨远端开窗,1例因假体固定较好而强行打出假体时并发股骨近端骨折,1例在置入假体时假体末端突出皮质并发骨折。所有患者均获随访平均26(6~67)个月,均显示骨长入,末次随访时HSS评分平均84.4(82~94)分,无一例诉大腿痛。结论初次髋关节置换术后假体无菌性松动行翻修术对假体的选择提出更高的要求,应用广泛多孔涂层翻修柄可安全、有效地对PaproskyⅠ~ⅢA型骨缺损进行股骨重建。     

Bone mineral density and biochemical markers of bone turnover in aseptic loosening after total hip arthroplasty.

The aims of this study were to determine whether subjects with aseptic loosening after total hip arthroplasty (THA) have regional differences in periprosthetic bone mineral density (BMD) and systemic biochemical markers of bone turnover compared to subjects with successful implants.Proximal femoral and pelvic BMD were measured by dual energy X-ray absorptiometry and bone turnover markers were assayed in 49 subjects 12.6+/-4.3 (mean+/-SD) years after cemented THA. Femoral BMD was lower in Gruen zones 2, 5, 6, and 7 in subjects with a loose femoral implant (n=17) compared to those (n=32) with fixed femoral implants (P<0.05 all comparisons). This BMD difference was greatest (-31%, P=0.02) in the proximal and medial region of the femur. Subjects with femoral loosening had higher levels of the bone resorption marker N-telopeptides of type-I collagen (P=0.02) than those with a fixed femoral implant. No differences in pelvic BMD or bone turnover markers were found between subjects with loose (n=18) versus fixed (n=31) pelvic implants.This study suggests that failure of femoral components after cemented THA is associated with region-specific decreases in BMD and an increase in urinary excretion of N-telopeptide cross-links of type-I collagen. These surrogate outcome markers may be of value in monitoring response to antiresorptive therapies used to treat periprosthetic osteolysis, although the diagnosis of aseptic loosening remains clinical and radiological.     

人工髋关节置换术后假体无菌性松动的临床及影像学评估

人工髋关节置换术(THA)后假体无菌性松动问题始终是临床上存在并需要解决的问题。通过临床及放射学检查，观察分析假体松动的表现与过程，对于人工髋关节置换术后假体松动的及时临床处理及预防均有指导意义。本对人工髋关节置换术后假体无菌性松动的临床及影像学评估方法进行了回顾和分析，指出临床及各影像学评估方法的意义，提出正确的评估原则。     

依据Paprosky分型股骨侧假体无菌性松动的处理策略

目的研究全髋关节置换术后假体无菌性松动的治疗方法及疗效,探讨股骨侧假体无菌性松动的治疗原则。方法回顾性分析自2000-01—2014-12诊治的24例股骨侧假体无菌性松动,记录手术前后VAS评分、Harris评分。影像学指标包括假体松动表现、Paprosky分型、假体内翻角、Barrack分级、植骨方式、内固定位置、并发症情况等。结果所有患者均获平均15.3(13~68)个月随访。术前VAS评分平均为8.9(7.2~10)分,末次随访VAS评分4.3(2~10)分,与术前有较大改善,差异有统计学意义(t=2.361,P=0.027)。术前Harris评分平均为32.5(12~54)分,末次随访时为60.8(36~82)分,差异有统计学意义(t=2.213,P=0.032)。所有患者初次置换为骨水泥型股骨柄假体,22例透亮线位于骨水泥-骨界面间。翻修手术采用生物型翻修假体,骨水泥残留1例。术前Paprosky分型,Ⅰ型4例(16.7%),Ⅱ型6例(25%),ⅢA型8例(33.3%),ⅢB型4例(16.7%),无Ⅳ型。术中根据不同分型应用结构性植骨及打压植骨,术后骨长入良好。结论股骨侧假体无菌性松动的处理原则需要对患者骨质缺损、初次置换方式及质量等方面因素进行综合考虑。其处理以翻修手术为主,需根据不同骨缺损类型选择植骨方式及翻修方法。     

Role and regulation of VEGF and its receptors 1 and 2 in the aseptic loosening of total hip implants

It was hypothesized that vascular endothelial growth factor (VEGF) in fibroblasts participates in aseptic loosening of total hip replacement (THR) implants. Therefore, osteoarthritic (OA) samples (n = 11) were compared with synovial membrane‐like interface tissues from revision THR (n = 10). VEGF‐A and its receptors were stained using streptavidin‐immunoperoxidase method. Their regulation by hypoxia and cytokines were studied in cultured fibroblasts using quantitative real‐time polymerase chain reaction (qRT‐PCR). VEGFR1⁺ lining cells (p < 0.01), stromal fibroblast‐like cells (p = 0.001) and stromal macrophage‐like cells (p < 0.05) were more numerous in rTHR than in OA. As to VEGFR2⁺, only stromal fibroblast‐like cells in rTHR outnumbered those found in OA (p < 0.05). VEGFRs in synovial fibroblasts were not affected by hypoxia, but VEGF increased 2.4‐fold (p < 0.05). Interleukin‐4 up‐regulated VEGFR1 expression 23‐fold. This is the first study to describe a difference between rTHR and OA in VEGF receptors, particularly VEGFR1. Hypoxia increased VEGF, but the VEGFR1 increase in the lining and stroma is probably IL‐4 driven, in accordance with the M2‐type macrophage dominance in interface tissues. VEGF/VEGFR system is also affected by hypoxia and may play a role in angiogenesis and bone pathology in aseptic loosening of total hip implants. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1830–1836, 2012     

The role of hereditary hemochromatosis in aseptic loosening following primary total hip arthroplasty.

Hereditary hemochromatosis (HH) results in increased iron absorption and subsequent deposition in tissue. This condition occurs predominantly in individuals of Northern European and Celtic origin with Ireland having one of the highest allele frequencies in the world. This study examines the hypothesis that homozygosity for either the C282Y or H63D mutations in the HFE gene may be associated with aseptic loosening following total hip arthroplasty (THA). Two groups of individuals were screened for the C282Y and H63D mutations associated with HH. Group 1 were individuals who had undergone primary hip arthroplasty and group 2 were individuals who had undergone revision hip arthroplasty for aseptic loosening. Exclusion criteria included rheumatoid or other inflammatory arthropathies and revision due to causes other than aseptic loosening. Significantly more patients in the revision THA group were homozygous for the C282Y genotype (P = 0.014). Aseptic loosening occurred earlier in these patients (P = 0.009), in particular in the patients who had clinical signs of hemochromatosis. No association was seen with the H63D mutation and revision THA. The incidence of HH in the group of primary THA patients was no higher than the background incidence. Patients who require primary THA and who are homozygous for the C282Y mutation have an increased risk of developing aseptic loosening, leading to revision THA. Moreover C282Y homozygosity appears to be associated with earlier aseptic loosening than in individuals without the C282Y mutation.     

Total hip arthroplasty with acetabular reconstruction using a bulk autograft for patients with developmental dysplasia of the hip results in high loosening rates at mid-term follow-up

Purpose

Managing a deficient acetabulum in patients with developmental dysplasia of the hip (DDH) can be challenging. The purpose of the study was to determine the mid-term results of total hip arthroplasty (THA) using a bulk structural autograft for reconstruction of the acetabular roof in patients with DDH.

Methods

Between 1982 and 1999, 112 patients underwent THA with acetabular roof-plasty using a bulk structural autograft for secondary osteoarthritis related to DDH. A total of 106 patients (115 hips) met inclusion criteria and were followed for an average of 11.6 years (seven to 24 years). The mean age was 52.5 years at the index operation. Clinical and radiological evaluations were performed according to the methods of Merle d’Aubigné and Postel, Johnston et al. and DeLee and Charnley.

Results

The overall Merle d’Aubigné hip score significantly improved (3.7 vs 10.4, p < 0.01). The limb length discrepancy decreased from 30 to 6 mm (p < 0.01). The average distance that the hip centre was distalised was 22.3 mm (0–56 mm). However, radiolucent lines were observed in 27 % of patients at final follow-up, and the overall rate of revision for aseptic loosening was 16 %. Further, Kaplan-Meier survivorship curves predicted a rapid increase in the failure rate at 15 years.

Conclusions

The mid-term functional outcome of THA with an acetabular roof-plasty using a bulk autograft is satisfactory; however, the long-term results are questionable.     

Revision total hip arthroplasty with cemented femoral component

We reviewed retrospectively the results of 28 hips (25 patients) after revision of the femoral component with use of a cemented stem, because of aseptic loosening. The mean duration of follow-up was 4.43 years (range 2–12 years). Over the course of the study period, repeat revision was done in 4 hips after an average of 4.45 years. Three hips had a repeat revision of the femoral component because of aseptic loosening and one for a deep infection. The rate of loosening of the femoral component was 32.4% (9 hips) at an average of 5.22 years. The 5-year survival rate was 76.9% with mechanical failure as end point; and 90% with re-revision of femoral component because of aseptic loosening as end point. The cement mantle was the principal factor, which was significantly associated with a better survival rate of femur fixation (P < 0.05). No correlation was noted between quality of bone loss at the time of revision, bone graft or the use of long stems, and the survival rate of femoral component. By improving the cementing technique and in selected patients, the use of cemented femoral stem could be a good alternative for aseptic loosening THA.     

老年骨质疏松症患者全髋置换围手术期处理

目的 探讨老年骨质疏松症患者全髋置换围手术期注意事项。方法 回顾性分析76例行全髋置换的老年骨质疏松症患者的临床资料,入院及出院时均检测股骨颈部位骨密度值,术中谨慎操作,术后予以对症处理,随访髋关节的功能恢复及并发症情况。结果 76例患者入院、出院时T-score分别为-2.75±1.24和-0.88±0.96,自身前后对比差异有显著性(P<0.05)。平均随访时间为13.6月,根据Harris评分标准,优52例,良15例,优良率88％,与普通患者差异无显著性;出现并发症9例;伤口浅层感染1例;股骨干上段劈裂2例;下肢深静脉栓塞2例;中度髋关节疼痛4例。结论老年骨质疏松症患者病情复杂,围手术期应准确诊断,谨慎操作,术后给予严密对症处理。     

鲑鱼降钙素在预防人工股骨头置换术后假体无菌性松动的临床应用研究

目的：探讨鲑鱼降钙素在预防人工股骨头置换术后假体无菌性松动的临床应用效果。方法通过随访江门市五邑中医院骨伤科二区2010年1月至2011年1月146例人工股骨头置换术后患者,按照随机数字表法分为对照组和治疗组,各73例,对照组每天口服钙剂片（钙尔奇D,每片含元素钙600 mg,含维生素D 125u）;治疗组在对照组的基础上应用鲑鱼降钙素（密盖息50 u）,每日皮下注射一次,连续治疗6个月。两组均分别于术前、术后4、8、12和24周检测假体周围感应区（ ROI）骨密度（BMD）;于术前及术后4、12、24周行血清骨代谢指标检测：骨钙素（BGP）、I型胶原C端异构肽（β－CTX）,通过测量术后随访过程中假体周围骨密度、骨代谢和生化指标与术前上述指标对比,进行临床分析。结果术后24周,实验组假体周围局部感应区BMD增加近5％,而对照组假体周围局部感应区BMD下降了6％,两组比较有显著性差异（ P＜0．01）;骨代谢指标中,术后24周实验组的BGP、β－CTX稍有下降,但组内无显著性差异（ P＞005）,这些指标与对照组比较差异显著（ P＜0．05或P＜0．01）。结论鲑鱼降钙素（密盖息）联合基础治疗,能显著提高人工股骨头假体周围的骨量,是预防无菌性松动的有效方法之一,值得推广。     

载药骨基质明胶防治人工关节感染和松动的实验研究

目的探讨载药骨基质明胶（C-BMG）防治人工关节感染和松动的可能性。方法将C-BMG置入兔体内,于术后4h及1～15d每日采血,取骨组织和肌肉测定C-BMG体内释药浓度及持续时间。将C-BMG植入兔人工关节周围,术后4、6、8、10周不同时期测定兔人工关节周围的成骨情况。结果C-BMG体内释药时,局部组织早期浓度高(>32.5μg/g),以后为稳定的低浓度释放(<25μg/g)。C-BMG组人工关节周围成骨量及各时期股骨头拔出强度明显高于对照组(P<0.05)。结论C-BMG既能持续释放抗生素防治人工关节感染,又能加速其生物学固定防治松动。     

成人发育性髋关节发育不良的全髋关节置换的治疗

对于继发有创伤性髋关节炎且临床症状明显的成人发育性髋关节发育不良(DDH)患者,人工全髋关节置换(THR)是首选治疗方法。此类患者的髋臼及股骨解剖结构的异常具有特殊性,包括髋臼浅小、股骨头较小、股骨干近端髓腔狭窄等,因此其THR也与一般的THR有很大的区别且具有很高的难度。本文主要综述了对DDH的治疗很重要的临床分型,其THR尤其是髋臼重建、股骨假体的安放等过程中的难点以及解决方法。     

全髋关节置换术后脱位危险因素分析及防治措施

目的探讨人工髋关节置换术后脱位易发因素及其防治措施。方法回顾分析1998年1月～2002年12月来所进行的人工髋关节置换术共141例(151侧),年龄22～86岁,男66例,女75例,因股骨头坏死致手术64例,因股骨头/颈骨折者47例,其他30例,均采用后外侧切口。结果其中发生关节脱位7例(男3例,女4例),发生率2%。初次脱位时间于术后4天至半年不等。单次脱位5例,多次脱位2例,均为后脱位。保守治疗6例(10次),闭合手法复位成功;手术治疗2例(2次),1例术后1周发现脱位需手术切开复位并调整臼杯位置,1例手术松解软组织方可复位。结论手术避免假体安放不当及软组织失衡,术后正确护理可降低脱位的发生。     

全髋关节置换术治疗先天性髋关节脱位

目的 :探讨全髋关节置换术治疗成人先天性髋关节脱位伴骨性关节炎的经验。方法 :从 1996年 9月～2 0 0 3年 2月 ,对 14例 (2 0髋 )成人先天性髋关节脱位伴骨性关节炎患者 ,进行了全髋关节置换。其中双侧 10例 ,单侧 4例。病人全是女性 ,平均年龄 45岁 (3 5～ 67岁 )。双侧全髋置换 6例 ,单侧 8例。结果 :术后伤口均一期愈合 ,随访 6个月～ 6年 ,平均 4年 8个月 ;平均Harris评分由术前的 3 2 43分恢复到术后 1年的 90 15分。截止目前无 1例翻修。术后 6个月 ,患者均能下地行走 ,生活自理且恢复日常工作。结论 :全髋关节置换术是治疗成人先天性髋关节脱位伴骨性关节炎的有效方法 ,但手术难度较大。对于此类病人 ,充分理解全髋置换的复杂性和细致周密的治疗方案是成功的关键。     

自体血回输对全髋关节置换术患者免疫功能的影响

目的 比较回收式自体血回输和异体血输血对全髋关节置换手术患者免疫功能的影响. 方法 选择50例全髋关节置换手术,随机数字表法分为自体血回输组(A组)和异体血输血组(B组),每组25例.术中根据血容量丢失情况分别用自体血回输及异体血输血,于麻醉前、输血后第2天和输血后第5天采用流式细胞仪测定血浆CD4+T淋巴细胞(CD4+)、CD8+T淋巴细胞(CDx+)、自然杀伤细胞(natural killer cell,NK)的比例以及白细胞介素(interleukin,IL)-2(IL-2)和白细胞介素-6(IL-6)的值.结果 B组输血后CD4+、CD8+、NK细胞、IL-2的值在第2天[(35±6)、(22±6)、(7±3)％、(523±407) ng/L]和第5天[(35±6)、(26±8)、(6±4)％、(442±376) ng/L]均低于术前[(40±8)、(28±9)、(9±4)％、(839±472)ng/L] (P＜0.05);A组输血后CD4+、CD8+的值在第5天[(39±8)、(27±9) ng/L]、NK细胞、IL-2的值在第2天[(8±4)％、(807±534) ng/L]和第5天[(8±4)％、(821±437) ng/L]均较术前有所下降,但差异无统计学意义(P＞0.05);IL-6的值在第2天[(3198±698) ng/L]和第5天[(3076±703) ng/L]均较术前[(2593±784) ng/L]有所升高(P＜0.05). 结论 自体血回输对全髋关节置换手术患者细胞和体液免疫功能均无明显抑制作用,是安全、可靠的血液保护方式.     

Ultrasound examination of haematomas after total hip replacement

Summary We have used ultrasound after 84 total hip replacements to define the site and size of any haematoma present. Repeated examination after operation indicated when the haematoma had occurred. We have demonstrated that two suction drains were more effective than one in preventing haematomas around the prosthesis in the first week after operation. The early detection of a haematoma allows rational treatment which should reduce the risk of deep infection.

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Résumé L'ultrasonographie a été utilisée dans une série consécutive de 84 arthroplasties totales de hanche afin de préciser la localisation et l'importance d'un éventuel hématome. Il a été ainsi possible de démontrer que deux drains aspiratifs sont plus efficaces qu'un seul vis à vis de la prévention des hématomes péri-prothétiques durant la première semaine post-opératoire. La découverte précoce d'un hématome permet un traitement rationnel, susceptible de réduire le risque d'infection profonde.

     

Minimally invasive total hip replacement

Abstract At present, minimally invasive surgery is the main trend of orthopaedic surgery and involves almost all its fields, joint replacement included. A total hip arthroplasty should be considered minimally invasive only if bone resection is limited to pathologic tissues (conservative replacement) and the procedure is performed without major sacrifice of soft tissues. This last statement suggests that the term “mini-incisions” be substituted with “mini-approaches”, meaning surgical approaches that respect not only the skin, but also fascia, tendons and muscles. Bone preservation may be obtained through proximal load, neck-retaining and resurfacing implants. Evaluating bone sacrifice both on the femoral side and on the acetabular side, neck-retaining arthroplasties seem to warrant the most balanced maintenance of bone tissue. Neck-preserving implants through a lateral or posterior mini-approach seem to be the most consolidated solution in minimally invasive total hip replacement.     

Total hip replacement for arthritis following tuberculosis of hip

AIM: To present the results of total hip arthroplasty (THA) for post tubercular arthritis of the hip joint.METHODS: Sixty-five patients (45 male, 20 female) with previously treated tuberculosis of the hip joint underwent cementless THA for post tubercular arthritis. The average age at the time of THA was 48 years (range 29 to 65 years). Erythrocyte sedimentation rate, C reactive protein, chest X-ray and contrast enhanced magnetic resonance imaging were done preoperatively to confirm resolution of the disease and to rule out any residual disease. Intra-operative samples were taken for microbiological examination, polymerase chain reaction (PCR) and histological examination. Patients were started on anti-tubercular drugs one week before the operation and continued for 6 mo post operatively. The patients were followed up clinically using the Harris hip score as well as radiologically for any loosening of the implants, osteolysis and any recurrence of tuberculosis. Any complications especially the recurrence of the infection was also recorded.RESULTS: The mean interval from completion of antitubercular therapy for tuberculosis to surgery was 4.2 years (range, 2-6 years). Preoperatively, 17 patients had ankylosis whereas 48 patients had functional but painful range of motion. The mean surgical time was 97 min (range, 65-125) whereas the mean blood loss was 600 mL (range, 400-900 mL). The average follow up was 8.3 years (range 6-11 years). The average Harris Hip score improved from 27 preoperatively to 91 at the final follow up. Seventeen patients had acetabular protrusion which was managed with impaction grafting and cementless acetabular cup. The bone graft had consolidated in all these 17 patients at the follow up. Two patients developed discharging sinuses at 9 and 11 mo postoperatively respectively. The discharge tested positive for tuberculosis on the PCR. Both these patients were put on antitubercular therapy for another year. Both of them recovered and had no evidence of any loosening or osteolysis on X-rays. There were no other complications recorded.CONCLUSION: Total hip replacement restores good function to patients suffering from post tubercular arthritis of the hip.     

Iliopsoas bursitis following total hip replacement

We report the imaging features of a 52-year-old man presenting with a groin mass and gross lower limb oedema secondary to venous occlusion by massive cystic enlargement of the iliopsoas bursa 4 years after uncemented primary total hip replacement. Ultrasonography of the groin mass demonstrated a large cystic lesion extending into the pelvis. CT showed displacement of the external iliac vessels with venous compression. Bursography showed the bursas margins and no communication with the hip joint. Diagnostic aspiration excluded infection, but fluid recollection occurred subsequently. Complete resolution of symptoms, including limb swelling, followed surgical excision with no recurrence at the 5-year follow-up. We believe iliopsoas bursitis occurred as a tissue response to polyethylene wear within the prosthetic hip and occurred even in the absence of loosening or a direct communication between bursa and joint.