人工髋关节置换术后翻修病例分析

目的分析人工髋关节置换术后翻修的原因,评价全髋翻修术的临床效果。方法本组33例34髋。初次关节置换类型:全髋置换21例,双杯髋关节置换1例,人工股骨头置换11例。翻修原因:无菌性松动23例24髋,髋臼位置不良1例1髋,股骨头置换后髋臼磨损5例5髋,感染4例4髋。翻修距初次手术时间:1年以内5髋,1～2年1髋,5～10年18髋,10～13年10髋。翻修假体类型:非骨水泥型假体20髋,混合型假体7髋,骨水泥型假体7髋。结果平均随访3.5年。1例术后半年发生股骨柄松动进行再翻修,其余病例假体保留,优良率为82.4%。结论翻修的最常见原因为无菌性松动,人工股骨头置换时髋臼磨损也是翻修原因之一,对较年轻的股骨颈骨折患者,如行假体置换,最好采用全髋关节置换。翻修术采用非骨水泥型假体较好。     

全髋关节置换翻修术中高位植入非骨水泥型髋臼假体的应用——对以往报道15年以上的简明随访

我们曾经报告采用高髋臼中心植入多孔涂层非骨水泥型髋臼假体的方法，对34例（36髋）全髋关节置换术后严重髋臼骨缺损的患者行翻修手术，术后随访平均10年的结果。本文将报告对21例（23髋）患者平均随访16．8年的结果。在最初的44例（46髋）患者中，39例（41髋；89％）患者仍使用原来的髋臼杯。2例（4．3％）髋臼杯因无菌性松动而翻修，3例（6．5％）髋臼杯因感染而翻修。6例股骨侧假体因为股骨骨溶解行翻修，另外7例无骨溶解但因无菌性松动行翻修。基于我们平均随访16．8年的结果，我们相信：在部分髋臼严重骨缺损的患者行全髋关节置换翻修时，高髋臼中心植入非骨水泥型髋臼假体仍然是一种优良的方法。 可信水平：治疗性研究，Ⅳ级，进一步可信度参见作者介绍。     

Charnley型人工全髋置换术后10年以上随访的X线分析

目的:通过对骨水泥固定的Charnley型人工全髋置换术患者10年以上X线随访,探讨骨水泥型人工全髋的固定效果、松动及影响寿命的因素等。方法:获得10年以上随访的38例45髋作为研究对象,平均随访14.6年。X线包括术后及最后随访时髋关节正侧位片。结果:髋臼假体松动有24髋(53％),其中明显松动(definite loosening)14髋(13％),可能松动(possible loosening)10髋(22％)。臼杯磨损共35髋(78％),平均磨损率为0.123mm/年;股骨假体柄松动有12髋(27％),其中明显松动8髋(18％),可能松动4髋(9％)。假体柄周围骨溶解18髋(40％)。本组45髋中8髋(18％)行翻修术,其中4髋因髋臼假体松动单纯髋臼假体翻修,其余4例行髋臼和股骨假体全部翻修。结论:骨水泥固定的Charnley型人工全髋置换术后10年以上长期随访结果,股骨假体的固定效果较好,但髋臼假体的固定效果并不满意。聚乙烯臼杯磨损不可避免,作为人工关节材料,聚乙烯对金属的关节组合应重新考虑。采用改良的骨水泥固定方法对人工全髋假体的早期稳定性和长期寿命非常重要。从髋臼假体的固定效果来看,金属臼(metal shell)假体的非骨水泥固定效果优于聚乙烯臼的骨水泥固定效果。     

Charnley型人工全髋置换术后10年以上随访的X线分析

目的：通过对骨水泥固定的Charnley型人工全髋置换术患者10年以X线随访，探讨骨水泥型人工全髋的固定效果、松动及影响寿命的因素等。方法：获得10年上随访的38例45髋作研究对象，平均随访14.6年。X线包括术后及最后随访时髋关节正侧位片。结果：髋臼假体松动有24髋（53％），其中明显松动（definite loosening）14髋（13％），可能松动（possible loosening）10髋（22％）。臼杯磨损共35髋（78％），平均磨损率为0.133mm/年；股骨假体柄松动有12髋（27％），其中明显松动8髋（18％），可能松动4髋（9％）。假体柄周围骨溶解18髋（40％）。本组45髋中8髋（18％）行翻修术，其中4髋因髋臼假体松动单纯髋臼假体翻修，其余4例行髋臼和股骨假体全部翻修。结论：骨水泥固定的Charnley型人工全髋置换术后10年以上长期随访结果，股骨假体的固定效果较好，但髋臼假体的固定效果并不满意。聚乙烯臼杯磨损不可避免，作为人工关节材料，聚乙烯对金属的关节组合应重新考虑。采用改良的骨水泥固定方法对人工全髋假体的早期稳定性和长期寿命非常重要。从髋臼假体的固定效果来看，金属臼（metal shell）假体的非骨水泥固定效果优于聚乙烯臼的骨水泥固定效果。     

金刚砂喷涂直锥形非骨水泥钛假体柄在55岁以下患者的应用：15～20年随访结果

全髋置换术应用于年轻患者常采用非骨水泥假体。作者分析了55岁以下全髋置换141例（154髋）,采用金刚砂喷涂直锥形非骨水泥钛假体柄和螺旋髋臼杯,随访15～20年。结果显示：41例假体柄过小,其中4例10年后松动,因疼痛而行翻修术;5例因假体周围骨折而翻修;7例见股骨近端溶解但没有症状。20年成功率达到90%。随访中67例髋臼杯进行了翻修。     

Titan型骨水泥假体柄中长期随访结果

目的观察Titan型骨水泥假体柄在初次全髋置换中的中远期结果。方法所有55例患者均进行术前术后以及临床随访功能评定,随访X线片了解假体情况,采用Harris评分系统进行临床功能评价。结果因其他疾病死亡5例,失访10例,40例得到随访。1名患者因髋臼侧松动行翻修后假体不匹配行股骨柄翻修术,股骨柄的生存率为97.5%。结论 Titan骨水泥假体因其特殊的设计取得了良好的临床效果,正确使用骨水泥技术,骨水泥固定股骨柄可以取得良好的中长期效果。     

人工全髋关节置换术后翻修的假体选择

目的探讨人工全髋关节置换术后翻修的假体选择. 方法 1995年1月～2002年6月进行全髋关节翻修术33例(33髋),其中男7髋,女26髋.翻修原因:无菌性松动22例,感染后松动8例(其中2例合并窦道形成);股骨头置换术后髋臼磨损3例,不伴有假体中心性脱位.对无菌性松动和股骨头磨损患者采用骨水泥固定型假体13例,生物固定型假体12例,股骨侧翻修假体均选择骨水泥固定型广泛涂层假体,8例感染患者均行一期骨水泥固定型全髋置换. 结果随访6个月～7年6个月,平均3年11个月.2例出现X线透亮带,但无临床不稳;4例遗留持续性疼痛,无假体脱位、断裂.本组Harris评分由术前的24～47分(平均38.6分),上升为术后的68～88分(平均82.4分),满意率87.9%. 结论无菌性松动是全髋关节置换术后翻修的主要原因.髋臼侧翻修假体可选择骨水泥型假体、也可选择生物型假体,股骨侧翻修假体均选择骨水泥固定型广泛涂层假体,感染后的翻修选择骨水泥假体较好.     

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。     

保留髋臼杯更换聚乙烯衬垫在全髋关节翻修术中的应用

目的 探讨保留髋臼杯更换聚乙烯衬垫在全髋关节翻修术中的作用.方法 1995年4月至2007年12月,80例(93髋)接受保留髋臼杯更换聚乙烯衬垫手术.男41例,女39例;年龄27～82岁,平均53.3岁.初次置换与更换衬垫手术间隔0.3～18.4年,平均10.9年.翻修原因:聚乙烯磨损及骨溶解78髋,聚乙烯接近完全磨损但无骨溶解5髋,聚乙烯磨损及股骨柄假体松动4髋,复发性关节脱位3髋,感染1髋,假体周围骨折1髋,衬垫脱位1髋.翻修衬垫采用高交联聚乙烯60髋、普通聚乙烯33髋,以骨水泥固定47髋、原锁定机制固定46髋.结果 随访5～15年,平均7年.术前Harris髋关节评分(86.0±16.9)分,终末随访时(89.4±11.6)分.并发症包括脱位10髋,感染2髋,假体周围骨折1髋,衬垫脱落1髋.10髋再次翻修:髋臼杯翻修5髋,普通聚乙烯磨损2髋,感染2髋,衬垫脱落1髋.普通聚乙烯组新发骨溶解12髋.以假体松动为终点,十年生存率骨水泥固定组100％、原锁定机制固定组84.8％;以再次翻修为终点,十年生存率分别为90.4％和65.0％.结论 以骨水泥或原锁定机制固定翻修衬垫均安全有效.高交联聚乙烯耐磨性较好,能降低骨溶解风险,假体存活率更高.     

髋关节发育不良的严重程度与骨水泥型全髋关节置换术后髋臼假体松动的相关性

目的探讨在骨水泥型全髋关节置换术髋臼假体的术后生存率和髋关节发育不良（development dysplasia of the hip,DDH）严重程度的相关性。方法应用骨水泥型全髋关节置换术治疗DDH合并创伤性髋关节炎患者92例103髋,女85例96髋,男7例7髋;年龄39～78岁,平均47．2岁。根据Crowe分级：42例46髋为Ⅰ度,21例24髋为Ⅱ度,16例18髋为Ⅲ度,13例15髋为Ⅳ度。49例56髋采用改良Gibson人路,43例47髋经直接外侧I-Iar-dinge人路。46例48髋使用自体股骨头进行髋臼骨移植,所有移植的骨块均用松质骨螺钉或Kirschner钢丝固定于髋臼上。进行骨移植的适应证主要是髋臼组成部分的上方未取得足够骨覆盖。结果62例76髋获得随访,随访时间2～19年,平均98个月。将因无菌性松脱而行髋臼翻修作为观察终点,10年随访髋臼假体生存率为86．8％～94．4％,平均90．6％;18年随访生存率为53．9％～72．O％,平均63．0％。结论随着髋臼发育不良严重程度的加重,随访年后骨水泥型髋臼假体有更高的失败率。     

Clinical and radiological outcome following total hip arthroplasty with an uncemented trabecular metal monoblock acetabular cup

Uncemented acetabular components are associated with a significant incidence of polyethylene wear and secondary osteolysis. The new tantalum/polyethylene composite (Hedrocel) acetabular component is designed to reduce the polyethylene wear and to increase the longevity of the acetabular cups. We report our short- term clinical outcome and patient satisfaction following use of an uncemented tantalum acetabular component in a single centre. During 1999 to 2002, 113 uncemented tantalum acetabular cups were implanted in 105 patients in our institution. The average age at operation was 56.8 years. All patients were assessed pre- and post-operatively with the Oxford 12 item hip questionnaire and standard radiographs of the pelvis. At a mean follow-up of 32 months (range: 18 to 48), 112 Hedrocel cups were assessed in 104 patients. Subjective patient's satisfaction was also assessed. At the time of evaluation, one patient had died due to an unrelated cause. Eight patients had bilateral acetabular cups implanted. The mean Oxford hip score improved from 45 preoperatively to 14 post-operatively. Subjectively 99% were very satisfied or satisfied. Only one patient expressed dissatisfaction about the outcome of this surgery. Radiologically, there were no signs of cup loosening or wear. This study shows that at short-term the new uncemented tantalum/polyethylene composite (Hedrocel) acetabular component can yield a satisfactory clinical and radiological outcome and has a high patient satisfaction. Although the short-term result from our centre is very encouraging, similar results from other centres and longer follow-up are required.     

A Long-Term Survivorship Comparison Between Cemented and Uncemented Cups With Shelf Grafts in Revision Total Hip Arthroplasty After Dysplasia

Long-term outcomes of cemented and uncemented cups were compared in patients with hip dysplasia who had undergone revision hip arthroplasty. Patients had uncontained superolateral acetabular defects reconstructed with a structural allograft. This retrospective study compared 18 cemented acetabular cups to 27 uncemented acetabular cups. Average follow-up was 216 months (range, 96-312). Nineteen acetabular cups (42%) failed due to loosening and were revised. The 10- and 20-year cup survival was 88% and 76% in the uncemented group and 67% and 36% in the cemented group. Log rank analysis showed this difference to be significant (P = .0077). Uncemented acetabular cups performed significantly better than cemented cups.     

Long-term results of the threaded Mecron cup in primary total hip arthroplasty

In the 1970s, high failure rates of cemented acetabular components, especially in young patients, in the middle- and long-term prompted a search for alternatives. The Mecring was one of the most popular first generation uncemented, threaded cups widely used in the 1980s for arthroplasty of the hip. First generation threaded cups commonly had smooth surface treatment and showed unacceptably high failure rates in the mid-term. In a consecutive series of 209 patients, 221 threaded uncemented acetabular cups with smooth surface treatment (Mecring) had been implanted in combination with one type of uncemented stem. Patients were followed up clinically and radiographically. The mean time of follow-up was 17 (range 15–20) years. In 91 (41%) hips the acetabular component had been revised or was awaiting revision: two hips for infection and 84 (38%) for aseptic loosening. Five hips were awaiting revision. The survival rate for all revisions including hips awaiting revision was 49% (95% CI: 41–57%) at 17 years. These results support the view that smooth, threaded acetabular components do not provide satisfactory long-term fixation and should be abandoned. Patients with these components must be closely monitored as the failure rate remains high in the long-term.     

A comparative study on medium-term results of cementless acetabular components with metal-on-metal and metal-on-polyethylene articulations

The purpose of this study was to evaluate the medium-term clinical and radiological outcomes of two metal-backed acetabular cups with metal-on-metal and metal-on-polyethylene joint couples, in patients unselected for age. Seventy-five metal-on-polyethylene CLS expansion cups were implanted in 70 patients and 66 metal-on-metal Fitek cups were implanted in 65 patients. The average age at surgery in the two groups was 63 years (range, 25 to 72 years) and 58 years (range, 32 to 68 years), respectively. Data regarding 64 of 75 CLS cups (85%) and 58 of 66 Fitek cups (88%) were collected at a minimum 36-month and maximum 144-month follow-up. The Harris hip score showed excellent results in 86% of the CLS cups, good results in 7%, and fair results in 7%. No poor results were recorded. For metal-on-metal acetabular components, excellent results were recorded in 84% of the cups, good results in 8%, fair results in 5%, and poor results in 3%. Fifty-five patients with 57 of 64 CLS cups (89%) and 50 patients with 51 of 58 Fitek cups (88%) were fully satisfied with their prosthesis. No acetabular reconstructions were revised for aseptic loosening. No radiolucent lines greater than 2 mm were observed, either about CLS or Fitek cups, and low incidence of osteolysis and polyethylene wear was noted in metal-on-polyethylene articulations. Post-operative three-phase bone scanning was obtained in 51 patients and this examination did not show increased uptake in blood pool or bone phase indicating aseptic loosening of CLS and Fitek cups. In conclusion, we found similar rates of excellent and good results using two acetabular components with different bearing surfaces, in patients of unselected age. Therefore, the less expensive implant should be selected for total hip arthroplasty in elderly or low-demand patients. Received: 25 January 2002/Accepted: 18 February 2002     

Uncemented total hip arthroplasty in patients 50 years of age or younger

The results of a consecutive series of uncemented total hip arthroplasties in patients 50 years or younger are reviewed. There were 41 total hip arthroplasties in 36 patients at an average follow-up period of 5.3 years. Average patient age was 42 years at the time of implantation. Preoperative Harris hip score (HHS) averaged ; the final HHS averaged 93. Radiographic evaluation revealed that the femoral stems were all solid, with no progressive subsidence, reactive lines, or osteolysis. Twenty of the hips (49%) demonstrated evidence of polyethylene wear. There was significant acetabular osteolysis in 12 of these 20 hips. Five of the acetabular cups were definitely loose; 1 was possibly loose. Three of the patients underwent revision surgery for acetabular loosening and/or osteolysis. It is concluded from this study that the femoral stem is excellent but that the original acetabular component and polyethylene locking mechanism are poor and made even worse with the use of a titanium femoral head.     

Revision of failed acetabular cups with extensive structural allografts

AIM: Structural allografts are used with encouraging results for revision of failed total hip arthroplasty and in the surgery of bone tumours. The aim of the present study is to describe the clinical and radiological results achieved with structural allografts in revision of a total hip arthroplasty. MATERIAL AND METHODS: 15 patients (12 female and 3 male patients) were revised with an acetabular defect situation of type 3 A or 3 B according to the Paprosky classification. Five fresh-frozen acetabula, nine distal femora and one proximal tibia were used for acetabular reconstruction. The rigid graft fixation was performed with 2 > or = AO screws. In one case a cemented acetabular ring was implanted, four cementless cups and ten cemented polyethylene acetabular components were used. The mean follow-up was 7.9 years (1.6-11.0 years). RESULTS: A stable osseointegration of fifteen transplanted structural allografts was achieved in thirteen cases. Two allografts (one aseptic loosening, one deep infection) failed to osseointegrate. In one case the migration of a cementless cup was registered. Revision surgery of this female patient was performed successfully with a cemented reconstruction ring. The mean Harris hip score at the latest follow-up was 81.4 points (70-99 points). CONCLUSION: For reconstruction of acetabular bone stock and restoration of the bone anatomy structural allografts can be recommended. The use of cementless cups in combination with structural grafts is to be evaluated as critical.     

Use of Jumbo Cups for Revision of Acetabulae With Large Bony Defects

Several methods of treatment are available for acetabular revision associated with bone loss. Jumbo cups (minimum diameter of 62 mm in women, 66 mm in men, or 10 mm larger than the normal contralateral acetabulum) are often useful for large defects. The purpose of this study is to report a large jumbo cup series with an average 10-year follow-up. A total of 196 jumbo cups in 186 patients with a minimum of 2-year follow-up were available for review. Harris hip score improved from 44 preoperatively to 72 postoperatively. Survivorship was 98% at 4 years and 96% at 16 years. Five revisions and two resection arthroplasties were performed for failure. In conclusion, porous jumbo cup acetabular revision with supplemental screw fixation provides good to excellent intermediate- and long-term outcomes.     

Cementless acetabular cup: 6-year follow-up

The aim of this study was to evaluate the long-term outcome of cementless acetabular cups used in primary total hip arthroplasty. From November 1993 to December 1998, we implanted 403 cementless acetabular cups. Here we present a review of 160 patients (97 women) who received cementless acetabular cups with a porous-coated surface. The average postoperative follow-up period was 6 years (range, 4–8 years). The mean age of patients was 68 years for cemented stems (65 hips) and 59 for uncemented stems (95 hips). A total of 104 patients received ceramic-polyethylene components and 56 had ceramic-ceramic components. One patient presented acetabular migration and needed revision after 5 months indicating a failure rate of 0.6%. We believe that our results provides quite good perspectives for future work with this acetabular component. Received: 3 May 2002, Accepted: 10 May 2002     

Acetabular reinforcement in total hip replacement

In 21 cases of severe secondary protrusio acetabuli with extensive or total destruction of the acetabular cortical structures, the double anchorage of conventional polyethylene cups with nine Müller acetabular reinforcement rings and 12 Burch-Schneider anti-protrusio reinforcement cages was carried out. They were applied in combination with reconstructive surgery of cancellous bone in three primary total hip replacements and in 18 revision operations for loosened acetabular cups following total arthroplasties. Indication for and technique of the acetabular reinforcement are described. The radiological and clinical results in 21 patients followed up were satisfactory. They confirm the efficiency of these screw-fixed reinforcement implants for the solid fixation of the plastic cup in patients with extreme acetabular deficiencies.     

Jumbo cups for revision of acetabular defects after total hip arthroplasty: a retrospective review of a case series

The treatment of acetabular bone defects presents a great challenge in revision total hip arthroplasty (THA). The purpose of this study was to evaluate the clinical and radiological outcome of revision THA using jumbo cups for acetabular reconstruction after applying the bone-grafting technique. We studied 17 patients with acetabular defects ranging from Type 2A to Type 3A according to Paprosky`s classification. According to the AAOS-score twelve patients were classified as Type II and five patients as Type III. Uncemented press-fit cups with an outer diameter larger than 64 mm were used in all cases. Fifteen patients received morselized bone allografts. In eight patients an additional screw fixation was necessary. The mean follow-up period was 82 months (range 33–149). The mean Harris Hip Score was preoperatively 62 and at the time of the last follow-up examination 83 points (p = 0.007). Two acetabular components failed, one due to aseptic loosening and another one due to septic loosening. There was a trend of displacement of the femoral head centre towards the infero-lateral position after using jumbo cups that approached statistical significance (p = 0.065). Closure of acetabular defects of Types 2A to 3A according to Paprosky’s classification and type II to III according to the AAOS-score respectively can be satisfactorily accomplished using jumbo cups after applying the bone-grafting technique.