同种异体皮质骨板结合长柄翻修重建股骨严重骨缺损近期随访结果

髋关节置换术后需要进行翻修的患者中,PaproskyⅢ型和Ⅳ型股骨骨缺损的患者股骨干骺端存在严重骨缺损,不能为假体柄提供有效的近端支撑固定,单纯使用全涂层非骨水泥柄力学失败率较高.同种异体皮质骨支撑植骨可作为生物接骨板提供机械稳定性和生物稳定性.2006年1月至2008年12月我科使用同种异体皮质骨板移植结合长柄翻修PaproskyⅢ型和Ⅳ型股骨骨缺损23例,其中21例获得1～3年的随访,均取得满意的治疗效果,现报告如下.     

髓内打压植骨结合广泛多孔涂层长柄假体在股骨侧严重骨缺损（PaproskymA型）翻修术中的应用

目的 探讨股骨侧严重骨缺损（Paprosky ⅢA型）翻修中应用髓内打压植骨结合广泛多孔涂层长柄假体的临床疗效.方法 2006年3月～2010年9月,对38例（38髋）Paprosky ⅢA型股骨骨缺损患者行翻修重建,其中男24例,女14例,平均年龄62岁.翻修原因：骨溶解、无菌性松动29例,全髋关节置换术（THA）术后感染二期翻修6例,假体周围骨折3例（Vancouver B3型）.股骨侧干骺端骨缺损采用同种异体颗粒骨髓腔内打压植骨进行修复,股骨柄采用全涂层长柄假体（7～10英寸）.术后定期随访,髋关节功能评价采用Harris评分,影像学采用X线片及CT观察：假体柄有无松动下沉、股骨近端应力遮挡情况、植入的异体颗粒骨与宿主骨整合情况.结果 38例均获得随访,平均随访53.4个月（23～62个月）,Harris评分由术前平均42分（32～47分）,提高至末次随访时平均86分（69～95分）.无患者发生脱位、假体周围骨折.1例术后感染,行再次二期翻修;1例假体柄在术后6个月内下沉4.24 cm,再次翻修时选择更粗的假体柄,末次随访时假体柄稳定;其余所有患者假体柄均牢固固定.3例出现轻-中度应力遮挡.15例近端皮质骨密度及厚度有增加,厚度平均增加约1.8 mm（0.7～3.5 mm）,植入骨与宿主骨逐渐整合并增加了骨缺损区的骨质储备.结论严重骨缺损（Paprosky ⅢA型）的股骨翻修中,采用髓内颗粒骨打压植骨可以很好的修复股骨中上段骨缺损,重建股骨干骺端.依靠广泛多孔涂层长柄假体在远端的牢固压配固定,结合股骨干骺端髓内紧密打压植骨,使假体柄在股骨中上段及远端均能获得较好的初始稳定性,近期临床和影像学结果满意,远期疗效有待观察.     

远端固定型假体结合同种异体骨移植在髋关节股骨翻修中的应用

[目的]探讨应用远端固定生物型假体结合同种异体骨移植进行髋关节股骨侧翻修的临床效果。[方法]2008年7月~2014年5月,行非感染性假体松动股骨侧翻修11例(骨水泥假体10例,非骨水泥假体1例)。所有患者采用远端固定生物型假体结合股骨近端同种异体颗粒骨打压植骨,其中7例同时应用同种异体皮质骨支撑植骨。男4例,女7例;平均年龄65.3岁(48~79岁);左侧7例,右侧4例。初次置换原因:股骨头无菌性坏死6例,股骨颈骨折3例,骨性关节炎2例。翻修距原手术时间平均12.8年(3~21年)。依据Paprosky分型,Ⅱ型4例,ⅢA型4例,ⅢB型3例。临床功能评价采用Harris评分。翻修用假体:Restoration(Stryker)3髋,MP(Link)8髋。[结果]所有患者均获得随访,随防时间12~75个月,平均29个月。1例术后出现切口渗液,15d后愈合;1例术后6年并发假体周围螺旋形骨折(Vancouver分型B1),假体未松动,行切开复位内固定术。随访期内X线片显示移植骨均愈合良好,假体稳固,周围未见透亮带及松动、下沉征象;术前6例双下肢不等长患者均得到矫正(长度差1 cm);无感染、脱位及深静脉血栓形成等并发症;无假体再翻修病例。Harris评分从术前的平均(30.3±7.2)分提高到最后评估时的平均(82.4±5.9)分,Harris评分优良率为81.8%。[结论]在伴有广泛骨质缺失的股骨翻修中,远端固定生物型假体是较好的选择。术中采用股骨近端颗粒骨打压植骨重建干骺端骨缺损,并在股骨干部皮质薄弱或缺损时结合同种异体皮质骨支撑植骨,可使假体柄远近段均获得较好的初始稳定性,且中短期临床效果满意,远期疗效尚有待观察。     

远端固定生物型假体在股骨翻修术中的应用

目的探讨远端固定生物型假体结合干燥同种异体骨植骨在近端骨缺损股骨翻修术中的应用疗效。方法自1999年7月至2004年1月,对16例（17髋）非感染性股骨假体松动患者进行翻修手术,其中2例为再次翻修,采用远端固定生物型股骨假体结合干燥同种异体骨植骨。男7例,女9例,年龄58～77岁,平均63岁,术后平均随访时间为35个月（18～56个月）。翻修前人工股骨头置换5例,全髋关节置换12例,从初次关节置换到翻修手术的间隔时间最短7年,最长16年,平均13．5年。股骨骨缺损根据Paprosky分型,Ⅰ型8髋,Ⅱ型6髋,ⅢA型3髋。翻修用假体：MP（Link）1髋,AML（DePuy）9髋,Full—coated（Zimmer）5髋,Enchelon（Smith—Nephew）股骨距替代型假体2髋。结果Harris评分从术前平均37分改善至术后平均88分,无患者发生再次松动。术后X线片显示植入骨愈合良好,假体部位骨皮质密度和厚度明显增加。结论远端固定生物型假体可以在股骨远端髓腔内获得可靠的轴向及抗旋转初始稳定性,干燥异体骨植骨能有效修复骨缺损,恢复骨量,骨愈合率高,两者结合运用于伴有近端骨缺损的股骨翻修术中,中短期疗效满意,远期疗效尚待进一步随访。     

非骨水泥长柄假体结合同种异体颗粒骨植骨在股骨翻修骨缺损重建中的应用

目的 回顾性分析股骨髓内同种异体颗粒骨打压植骨结合非骨水泥长柄假体在髋关节翻修术中股骨侧骨缺损修复应用的近期临床效果.方法 2003年7月至2009年6月对27例股骨侧骨缺损患者采用同种异体颗粒骨打压植骨,其中男性15例,女性12例,年龄47～78岁,平均67岁.失败原因:骨溶解、无菌性松动20例,全髋关节置换术后假体周围感染二期翻修7例.按Paprosky分型标准,Ⅱ型骨缺损3例,Ⅲ型骨缺损2l例,Ⅳ型骨缺损3例.术中均采用同种异体颗粒骨打压植骨、非骨水泥翻修柄植入.定期随访复查,包括临床、影像学评估,观察假体有无松动、下沉,植入骨活化替代情况以及假体周围骨折等并发症.Harris评分术前平均43分(37～62分).结果 23例患者获得随访,随访时间3～47个月,平均26.4个月.术后末次随访时.Harris评分平均83分(67～97分).术中2例发生股骨大转子骨折,无一例发生术后假体周围骨折等并发症.1例术后发生关节脱位,1例发生深静脉血栓,1例术后2周发生急性感染,经扩创、置管冲洗、抗感染治疗成功保留假体;发生异位骨化1例,Brooker Ⅰ级.影像学所有患者股骨柄中置,无内翻或外翻,随访期内无一例发生股骨柄移位(内翻或外翻角度变化>3°).23例患者显示至少Ⅰ区股骨髓内移植骨与周围骨或与股骨柄整合.4例发生股骨柄假体下沉,平均下沉3.3 mm(2～6 mm).结论 股骨侧翻修中,良好的股骨髓内同种异体颗粒骨打压植骨结合合适的非骨水泥延长柄股骨假体,可以修复关节置换术后各种原因所导致股骨骨缺损、重建股骨完整性,具有很好的近期临床疗效.但中远期临床效果尚待进一步观察.     

生物型翻修加长柄在人工全髋关节翻修术中的应用

目的探讨生物型翻修加长柄治疗全髋关节置换术后股骨假体松动伴股骨骨缺损的早期疗效。方法对15例(15髋)全髋关节置换术后股骨假体松动伴股骨骨缺损采用生物型翻修加长柄治疗,对于骨缺损采用自体或同种异体颗粒骨植骨,自体大块髂骨结构性植骨,使用钢丝、钢缆固定。结果术后髋关节疼痛消失,关节功能改善。15例获随访6~22个月,平均18个月。末次随访时未发现假体周围骨折及假体远端出现新透亮带,Harris评分平均89.8分。结论人工全髋关节翻修术中使用生物型翻修加长柄治疗股骨假体松动伴股骨骨缺损早期疗效可靠,但远期疗效有待进一步观察。     

辐照深冻异体骨打压植骨在髋臼翻修中的应用

目的 研究辐照深冻异体骨用于髋臼翻修中严重骨缺损的打压植骨重建的临床效果.方法 2006年2月至2009年1月髋关节翻修术中共有20例21髋应用打压植骨技术结合金属网重建严重髋臼侧骨缺损,18例19髋获得随访.患者翻修时平均年龄为64.4岁(43～81岁).采用Paprosky分型,本组患者均有髋臼骨缺损,其中PaproskyⅡB型4髋,PaproskyⅡC型8髋,PaproskyⅢA型5髋,PaproskyⅢB型2髋.手术用金属网修复髋臼节段性缺损,采用辐照深冻同种异体颗粒骨打压植骨结合骨水泥臼杯完成髋臼翻修.患者术后定期进行影像学和临床评估,观察手术前后髋关节Harris评分变化,假体移位松动及异体骨骨整合情况,及术中、术后并发症等.术前Harris评分平均42.5分(31～56分).术前疼痛评分平均14.4分(10～20分).结果 患者平均随访时间22.4个月(12～48个月).术后Harris评分提高到88.6分(82～96分).术后疼痛评分提高至平均42.3分(40～44分).并发症:术后感染1例,经清创愈合.股神经损伤1例,术后1年随访时已恢复正常.1例患者术后出现股骨近端外侧皮质吸收,大粗隆骨折.有1例Paprosky ⅢB型患者出现金属网及髋臼杯明显移位等影像学松动表现,其余18髋的髋臼假体稳定,未发现臼杯在垂直和水平方向大于1 mm的移位,也未发现髋臼假体外展角的改变;植骨层和宿主骨床可见连续骨小梁通过、移植骨与周围骨床骨密度趋向一致等骨整合表现.结论 金属网与打压植骨及骨水泥髋臼技术联合应用能有效地完成髋臼的生物学翻修.辐照深冻异体骨用于打压植骨能与周围骨床很好的整合.     

打压植骨技术结合金属网罩在髋关节初次置换或翻修术骨缺损重建中的应用

目的探讨打压植骨技术结合金属网罩固定应用于髋关节初次置换或翻修中严重骨缺损重建的可行性和效果。方法回顾性分析自2005-01—2008-12应用打压植骨技术结合金属网罩固定治疗且资料完整的17例（髋）髋关节初次置换或翻修中严重骨缺损。采用金属网罩固定使节段性缺损变为局限性缺损,采用新鲜深冻同种异体股骨髁作为打压植骨材料。结果 17例均获得随访24~60个月,平均35.8个月。植骨层与宿主骨之间模糊,可见骨小梁通过,假体与植骨层之间亦未出现明显透亮线。末次随访时髋关节功能Harris评分平均85.4（81~90）分。结论打压植骨技术结合金属网罩固定是解决髋关节功能重建中关节周围骨缺损的较好方法。     

钽金属骨小梁臼杯结合同种异体骨植骨治疗髋关节翻修术中严重骨缺损

[目的]探讨在髋关节翻修术中采用钽金属骨小梁臼杯结合同种异体骨植骨技术治疗髋臼骨缺损的临床疗效。[方法]2008年2月~2012年10月采用钽金属骨小梁臼杯结合同种异体骨植骨治疗44例(44髋)因髋臼无菌性松动或感染后二期翻修合并严重骨缺损和髋臼严重骨溶解的患者,并进行回顾性研究。男23例,女21例,平均年龄58.5岁(34~78岁)。全部患者均采用组配式钽金属臼杯结合同种异体骨植骨重建髋臼骨缺损,其中15例(34%)髋关节的臼杯宿主骨覆盖率不足70%。临床结果采用Harris髋关节评分进行评价。影像学结果依据术后系列X线片进行分析。[结果]平均随访时间53.4个月(30~84个月),Harris髋关节评分从术前平均20.3分(8~36分)提高至术后最后一次随访的83.8分(39~98分)(P0.001)。末次随访时原有3髋的臼杯周围放射性透亮带持续存在,但并无扩大趋势,无新发放射性透亮带出现。术后并发症包括坐骨神经损伤1例、大粗隆不愈合1例。未发现假体无菌性松动患者。[结论]在髋关节翻修术中采用钽金属臼杯结合同种异体骨植骨治疗髋臼骨缺损技术的中期临床和影像学结果令人满意,具有较低的并发症发生率。     

髋臼加强环联合同种异体骨植骨在髋臼骨缺损人工髋关节翻修术中的应用

目的探讨髋臼加强环联合同种异体骨植骨在髋臼骨缺损人工髋关节翻修术中的应用效果。方法随机将48例髋臼骨缺损行人工髋关节翻修术的患者分为2组,各24例。对照组术中采用同种异体骨植骨术,观察组在对照组基础上联合使用髋臼加强环。结果随着随访时间的延长,2组髋关节功能Harris评分均随之增高。但观察组明显高于对照组,且并发症率明显低于对照组。差异均有统计学意义(P0.05)。结论髋臼加强环联合同种异体骨植骨进行髋臼骨缺损的人工髋关节翻修,术后并发症率低,效果可靠。     

Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate

BACKGROUND: Periprosthetic femoral fractures around hip replacements are increasingly common. When the femoral component is stable, open reduction and internal fixation is recommended in all but exceptional cases. The purpose of this study was to evaluate the outcome of treatment of fractures around stable implants with cortical onlay strut allografts with or without a plate. METHODS: A survey of our four centers identified forty patients with a fracture around a well-fixed femoral stem treated with cortical onlay strut allografts without revision of the femoral component. There were fourteen men and twenty-six women, with an average age of sixty-nine years. Nineteen patients were treated with cortical onlay strut allografts alone, and twenty-one were managed with a plate and one or two cortical struts. All of the patients were followed until fracture union or until a reoperation was done. The mean duration of follow-up was twenty-eight months for thirty-nine patients. One patient, who was noncompliant with treatment recommendations, had a failure at two months because of a fracture of the plate and graft. The primary end point of the evaluation was fracture union; secondary end points included strut-to-host bone union, the amount of final bone stock, and postoperative function. RESULTS: Thirty-nine (98%) of the forty fractures united, and strut-to-host bone union was typically seen within the first year. There were four malunions, all of which had <10 degrees of malalignment, and one deep infection. There was no evidence of femoral loosening in any patient. All but one of the surviving patients returned to their preoperative functional level within one year. CONCLUSIONS: Cortical onlay strut allografts act as biological bone plates, serving both a mechanical and a biological function. The use of cortical struts, either alone or in conjunction with a plate, led to a very high rate of fracture union, satisfactory alignment, and an increase in femoral bone stock at the time of short-term follow-up. Although this study did not address the potential for later allograft remodeling, our findings suggest that cortical strut grafts should be used routinely to augment fixation and healing of a periprosthetic femoral fracture.     

Cortical strut allografts for the treatment of femoral fractures and deficiencies in revision total hip arthroplasty

Thirty-three hips had revision total hip arthroplasty, using an average of three cortical strut allografts fixed to the femur with cables and followed-up for a mean of 4 years. The indications for strut allografts were ectatic femurs or segmental defects of the femoral diaphysis (22 hips), femoral fractures (10 hips), and severe proximal femoral osteolysis (1 hip). Twenty-one hips had an excellent or good clinical result, 6 had a fair clinical result, and 6 had a poor clinical result. Reoperation was done in six hips, but in only two hips was reoperation related to failure of the allograft. Nine of the 10 femoral fractures repaired with allograft struts healed by 3 to 6 months. Radiographs showed partial or complete bridging of the allograft to host bone with peripheral remodeling and minimal resorption in 30 of 33 hips. Strut allografts, fixed with multiple cables, are an important adjunct to femoral component revision for the restoration of deficient femoral bone stock and in the treatment of periprosthetic femur fractures.     

Revision total hip replacement using a cementless interlocking distal femoral stem with allograft-cemented composite and the application of intramedullary and onlay cortical strut allografts: two case reports

It is often difficult to perform repeated revision total hip replacement (re-THR) after prosthesis loosening stemming from infection, mechanical loosening, and osteolysis. Reasons for this include the size of the bone defect and poor quality of the remaining bone. We have previously performed revision surgery using a cementless interlocking distal femoral stem with segmental cortical allograft-cemented composite for reconstruction in the presence of circumferential bone loss of the proximal femur according to Gustilo classification type IV [1]. However, in the case where the distal femur had a stovepipe canal due to osteoporosis, osteolysis, and infection, it was difficult to achieve stable fixation to the distal femoral cortical bone using a cementless interlocking distal femoral stem. Therefore, a cortical strut allograft is inserted into the femoral bone canal on the medial side, followed by the insertion of an interlocking stem. A further cortical strut allograft is inserted on the lateral side of the distal femur. In addition, the distal onlay allograft should pass over the allograft–host bone junction. The two allografts are finally secured with interlocking screws. The bone allografting to augment femoral bone deficiency was performed using mainly cadaveric bone allografts obtained from our bone bank [2, 3]. In this report, we describe two cases of re-THR involving the use of intramedullary and onlay cortical strut allografts with a cementless interlocking distal femoral long stem to achieve favorable fixation stability. The two patients were asked if the data from the case could be submitted for publication, and both gave their consent     

Use of Cortical Strut Allograft After Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty

Background

Cortical strut allografts restore bone stock and improve postoperative clinical scores after revision total hip arthroplasty (THA). However, use of a cortical strut allograft is implicated in delayed healing of an extended trochanteric osteotomy (ETO). To date, there are no reports directly comparing ETO with or without cortical strut allografts.

Reconstruction of the failed femoral component and proximal femoral bone loss in revision hip surgery

Advances in implant technology and surgical techniques have greatly improved the results of femoral stem revision in total hip arthroplasty. The 10-year results obtained with extensively coated noncemented revision stems parallel those obtained with cemented stems revised by using contemporary techniques. Proximal femoral bone loss is an important consideration when planning and performing revision arthroplasty. Proximal femoral bone defects can be managed with either metal or bone. Insignificant defects can be reconstructed by using primary hip arthroplasty techniques. Proximal femoral replacement prostheses are best restricted to sedentary elderly patients. Cortical strut grafts can be used reliably to reconstruct noncircumferential segmental defects. Calcar allografts are associated with unacceptably high rates of resorption. Proximal femoral allografts with either noncemented or cemented long-stem prostheses have the potential advantage of biologic soft-tissue attachment and restoration of bone stock. Impaction allografting with cement is indicated for cavitary defects and may also restore bone stock.     

Use of Locking Plate and Strut Onlay Allografts for Periprosthetic Fracture Around Well-Fixed Femoral Components

Background

The purpose of this study was to determine: validated clinical and radiographic outcomes of periprosthetic femoral fractures around stable hip implants treated with plate fixation and additional cortical strut onlay allografts without revision of the stem; radiographic signs of fracture healing; allograft-to-host bone union; resorption of cortical strut allograft; and frequency of complications.

Proximal femoral allografts in revision hip arthroplasty

We followed prospectively 69 patients with 78 proximal femoral allografts performed for revision of total hip arthroplasty for an average of 36 months (range 29 to 68). Large fragment proximal femoral allografts and cortical strut allografts were successful in 85%. Grafts smaller than 3 cm in length (calcar grafts) were clinically successful in 81%, but 50% underwent significant radiographic resorption. We conclude that large proximal femoral allografts and cortical strut allografts provide dependable reconstruction of bone stock deficiencies during revision total hip arthroplasty.     

Cortical strut allografts in salvage revision arthroplasty: Surgical technique and clinical outcomes

BackgroundThe aim of this study was to present our clinical outcomes and surgical technique in strut allografts preparation using staggered holes to enhance osteointegration and demineralised bone matrix (DBM) as an adjunct to cortical strut allografts in salvage revision arthroplasty patients.MethodsRetrospective consecutive series of patients who required strut allograft femoral reconstructions with minimum 2 years follow up between 2012 and 2018. Frozen washed irradiated, cortical struts were used and prepared adding 2 mm staggered drill holes along the length of the strut and applying DBM paste on the graft-host interface. Outcome measures included radiographic strut union, graft resorption, infection and complications.Results15 patients included; 3 males and 12 females with median age 72 years (range 60–93). All had significant bony defects (Paprosky III/IV in 12 cases including 3 cases of periprosthetic hip fractures and further 3 cases of periprosthetic knee fractures around revision hinged implants). At final follow up, median 3.8 years (range 2.7–7.2), 14/15 (93.3%) struts had united at a median 6 months (range 5–8), complete incorporation with cortical round-off was seen at median 12 months (range 8–48) in 12/15 (80%) struts, 2/15 (13.3%) show radiographic evidence of proximal minimal graft resorptions although the remainder of the strut had integrated and were asymptomatic. There were no cases of infection.ConclusionsUse of strut allografts helps to reconstruct bone defects, restore bone stock, and provide stable fixation for complex patterns of periprosthetic fractures around hip/knee implants and salvage revision cases with 93.3% union rate at median 6 months.     

全髋关节翻修术中骨缺损的重建

目的观察异体骨移植在全髋关节翻修术中骨缺损重建的临床价值。方法对1996年6月～2000年12月收治的19例全髋关节翻修术的患者进行回顾性分析,其中男11例,平均年龄66.5岁,女8例,平均年龄63.2岁。髋臼骨缺损类型为Ⅰ型2髋,Ⅱ型10髋,Ⅲ型4髋;股骨骨缺损类型为Ⅰ型3髋,Ⅱ型11髋,Ⅲ型2髋;髋臼及股骨无明显缺损患者4例。骨缺损重建方法包括髋臼结构性植骨3例,髋臼内压紧颗粒骨植骨3例,髋臼内金属网垫植骨3例,髋臼、股骨压紧颗粒骨植骨6例7髋,股骨结构性植骨3例,金属网加强颗粒骨植骨2例,股骨压紧颗粒骨植骨4例,4例患者未行植骨。应用Harris评分标准及X线分别评价翻修术后临床转归及移植骨愈合情况。结果19例患者平均随访46个月(6～68个月),随访患者的Harris评分由翻修术前的平均42.7分(24～59分)增至术后的平均82.7分(55～99分),15例16髋异体骨植骨患者X线片显示1例髋臼结构性植骨部分吸收,髋臼松动,须行翻修术;1例髋臼松动,无症状;3例有X线透亮带。无感染发生。结论全髋关节翻修术中,根据骨缺损类型,选用相应的异体骨移植是一种可靠而有效的方法。     

Periprosthetic fracture of the femur after hip arthroplasty: The clinical outcome using cortical strut allografts

Between 1993 and 1998, 15 patients with periprosthetic fractures of the femur after hip arthroplasty were treated using deep-frozen cortical strut allografts as an adjunct support after internal fixation or revision arthroplasty. According to the Vancouver classification system, there were 7 type B1, 2 type B2, 4 type B3 and 2 type C fractures. Seven patients had severe osteopenia, 10 patients had bone defects between 2 to 7 cm and 2 were associated with infection. Nine patients had internal fixation of the fracture using a compression plate, and 6 had revision arthroplasty using a long-stemmed femoral prosthesis. The average length of the allograft was 13.9 cm. At an average follow-up of 31 months, all the patients had a satisfactory functional result except one who had a leg length discrepancy of 4 cm due to multiple operations. There were no non-unions, malunions or infections. The fractures healed between 10 to 24 weeks (average, 15.6 weeks). In conclusion, a cortical strut allograft associated with internal fixation can be an effective method of treating periprosthetic fractures of the femur after hip arthroplasty.