人工全髋关节置换术中自体骨重建髋臼骨缺损的临床研究

目的探讨人工全髋关节置换术中用自体结构性植骨重建髋臼骨缺损的疗效。方法患者共26例29髋,自体股骨头植骨23髋、自体髂骨取骨6髋。骨缺损以打磨的髋臼假体骨床半球面积计算,骨缺损最大者有1602mm2,最小390mm2,平均每例缺损874mm2。全部采用非骨水泥型髋臼假体、2～3枚螺钉固定髋臼假体。临床评价采用Harris评分,X线观察移植骨愈合、骨和假体间骨长入和髋臼假体的稳定情况等。结果随访6个月～8年6个月,平均随访时间为（4.2±1.7）年,本组Harris评分平均从（52.2±16.7）分提高到（86.7±6.2）分（P〈0.05）。所有病例髋臼假体稳定、周围无放射透亮影,假体髋臼骨面均有骨长入,移植骨愈合。X线片显示移植骨愈合时间3～6个月,平均为5.1个月。本组尚无术后翻修病例。结论采用自体骨进行结构性植骨或混合少量异体骨重建髋臼顶、前和后侧壁缺损（AAOS）髋臼缺损中Ⅱ、Ⅲ型缺损）,经过近中期随访,移植骨全部愈合良好,获得满意的疗效。     

Long-term results of bulk femoral head autograft in cementless THA for developmental hip dysplasia

We evaluated the fate of bulk femoral head autograft in cementless total hip arthroplasty (THA) for developmental hip dysplasia. Of 87 hips (80 patients) studied, 37 hips (32 patients) were available for follow-up at a mean of 18.5 years (range, 15-24 years) postoperatively. The mean age of these 32 patients at the index procedure was 53.8 years (range, 40-65 years). The initial diagnosis was osteoarthritis in all 32 patients. The degree of acetabular dysplasia according to Crowe classification was type I in 18 hips (48.6%), type II in 14 (37.8%), type III in 5 (13.5%). The mean percentage of horizontal coverage of the acetabular components with graft bone was 34% (range, 25%-45%). Trabecular bridging across the graft-host interface was seen at a mean of 4 months (range, 2-6 months) postoperatively. Trabecular reorientation of the grafted bone was seen in all hips at a mean of 27 months (range, 12-36 months) postoperatively. There was no evidence of collapse and bony resorption of the grafted bone in the weight-bearing portion. Acetabular component fixation was stable in all hips at final follow-up. Of the 37 hips (32 patients), 2 acetabular components required revision: 1 for a late postoperative deep infection and 1 for dissociation of the polyethylene liner. The survival rate was 94.5% (95% confidence interval, 91.3-96.5) for the acetabular component at 18.5 years of follow-up. This study found that bulk femoral head autograft in cementless THA for developmental hip dysplasia produces excellent long-term results.     

Incorporation of allograft for acetabular reconstruction: Single photon emission CT in 21 hip arthroplasties followed for 2.5-5 years

We studied 21 hips in 20 patients who had acetabular reconstruction with a femoral head allograft in primary (n 2) and secondary (n 19) total hip arthroplasty. The fate of the graft was evaluated by serial bone SPECTs (single photon emission computed tomography). With a mean follow-up period of 37 (30-60) months, 14 of the 21 hips showed evidence of incorporation at earliest 13 (6-18) months after operation. There was no correlation between the fate of allograft and the compatibility of A, B, 0 blood typing between host and donor, the use of bone cement in the fixation of acetabular component, or loosening of the acetabular component.     

Bone grafting in total hip replacement for acetabular protrusion

Total hip replacement combined with acetabuloplasty was performed in 43 hips in 40 patients with protrusion secondary to arthrosis, rheumatoid arthritis or trauma. Depending on the acetabular defect, the acetabuloplasty encompassed reinforcement of the medial wall with bone grafts, vitallium meshes, protrusio rings and cups. The clinical and radiographic results were uniformly good on average 2 years postoperatively. All grafts appeared to be united and incorporated, without evidence of resorption. The only patient suffering from pain had radiographic signs of progressive varus migration of the femoral component.     

Bone grafting in total hip replacement for acetabular protrusion

Total hip replacement combined with acetabuloplasty was performed in 43 hips in 40 patients with protrusion secondary to arthrosis, rheumatoid arthritis or trauma. Depending on the acetabular defect, the acetabuloplasty encompassed reinforcement of the medial wall with bone grafts, vitallium meshes, protrusion rings and cups. The clinical and radiographic results were uniformly good on average 2 years postoperatively. All grafts appeared to be united and incorporated, without evidence of resorption. The only patient suffering from pain had radiographic signs of progressive varus migration of the femoral component.     

Revision of the acetabular component without cement after a previous acetabular reconstruction with use of a bulk femoral head graft in patients who had congenital dislocation or dysplasia. A follow-up note

BACKGROUND: Revision of an acetabular component that has failed after a total hip arthroplasty in which a bulk femoral head autogenous graft or allograft was used as a structural graft for acetabular reconstruction is an uncommon but complex and challenging procedure. We previously reported the results for seventy hips at an average of 16.5 years after a total hip arthroplasty in which an acetabular reconstruction had been performed with a femoral head graft. In the present study, we evaluated a subset of nine hips from that series that had a subsequent revision of the acetabular component without cement. The purpose of the current study was to assess the usefulness of the bone graft in this revision. METHODS: The nine patients (nine hips) were followed clinically and radiographically for an average of seventy-six months (range, sixty-one to 114 months) after the index revision. In six hips the autogenous femoral head graft previously had been bolted to the lateral side of the ilium, and in one hip the femoral head allograft had been affixed in this manner. In the two remaining hips, the allograft had been placed within the acetabulum. The hips were classified according to the extent of acetabular bone loss, with use of criteria described previously. Three hips had stage-I bone loss; four, stage-II; and two, stage-IIB. A porous-coated hemispherical acetabular component was inserted without cement and fixed with screws in each hip. At least 70 percent of the porous coating was in contact with viable bone. RESULTS: At the time of the latest follow-up after the index revision, all nine acetabular components were functioning well without loosening or osteolysis and none had been revised. The average Harris hip score was 77 points (range, 61 to 98 points) compared with 49 points (range, 27 to 96 points) preoperatively. One hip had had revision of the femoral stem, and another had had exchange of the acetabular liner because of recurrent dislocations. There was no additional resorption of the residual bulk graft that was in contact with the metal shell in any hip. CONCLUSIONS: In this small series of complex acetabular revisions, the healed bulk graft provided valuable additional bone stock for the support of an acetabular component that was inserted without cement. Insertion of the acetabular component into the available bone, which consisted in major part of host bone and in minor part of united revascularized bulk graft, resulted in a well functioning hip after an intermediate duration of follow-up. In all except two hips, the enlarged bone stock allowed insertion of a larger acetabular component than had been used previously.     

Revision of the acetabular component with an uncemented Harris-Galante porous-coated prosthesis.

One hundred and forty revisions for loosening of the acetabular component were performed in 124 patients, with the use of an uncemented Harris-Galante acetabular prosthesis. A component was considered loose if there was a change in its position or vertical or horizontal migration, or both, of four millimeters or more, as demonstrated on serial radiographs. All patients were followed prospectively for a mean of forty-one months (range, twenty-four to seventy-six months). Bone-grafting was performed at the time of the revision in 127 of the hips. Identifiable failure of fixation of the acetabular component occurred in only two hips (1 per cent), which had both severe acetabular bone loss and pelvic discontinuity. In one of these hips, fixation of the component could not be achieved during the revision, and the component subsequently migrated. No other components migrated. Only one patient had a revision of the index acetabular operation. A continuous radiolucency developed at the bone-mesh interface of five acetabular components, and in one other hip a small portion of the mesh separated. This hip was reoperated on for a problem with the femur, and the socket was found to be rigidly fixed. No other evidence of loosening was identified. All of the bone grafts united, but partial resorption of the graft occurred in thirty-nine hips. Although there were substantial osseous defects that necessitated major bone-grafting, revision with the uncemented Harris-Galante porous-coated acetabular component provided superior fixation compared with that reported in other series in which cemented acetabular components were used for revision. Of the 140 hips, eighty-nine (64 per cent) had a postoperative score of good or excellent, according to the Harris hip-rating system. Twenty-eight (70 per cent) of the forty hips that had revision of the acetabular component alone were rated as good or excellent.     

The incorporation of morselized bone grafts in cementless acetabular revisions

The treatment of large osteolytic lesions is a challenge during acetabular revisions. Periprosthetic bone loss can compromise the stability of new implants. The purpose of this study was to evaluate the 5- to 10-year clinical and radiographic results of morselized bone grafting for acetabular osteolysis during cementless acetabular revisions. Ninety-nine patients (108 hips) who had an acetabular revision hip arthroplasty for osteolysis were retrospectively reviewed. There were 44 men and 55 women who had a mean age of 66 years. At the index revision, the acetabular defects were debrided of granulomatous tissue and packed tightly with morselized cancellous femoral head allograft. All the revision acetabular components were implanted using cementless fixation. At a mean followup of 85 months (range, 60-118 months), the results of 103 of 108 hips (95%) were clinically and radiographically successful. The mean preoperative Harris hip score was 37 points, which improved to a mean of 91 points at the last followup. All cavitary defects had complete radiographic incorporation of the bone grafts except for two lesions. The results of this study indicate that morselized bone graft incorporates into cementless acetabular revisions. This treatment method provided a stable reconstruction in 98% of patients at a mean of 7 years followup.     

Total hip reconstruction using frozen femoral head allografts in patients with acetabular bone loss

Major acetabular bone loss associated with failed total hip replacements can be managed successfully using frozen femoral heads as structural allografts during revision surgery. In 29 cases followed for an average period of 3.9 years, all of the grafts showed radiographic evidence of union. Five hips showed clinical or radiographic evidence for acetabular loosening. Three of these hips required reoperations for symptomatic loosening. In two of these, sufficient bone stock was present to permit another revision without further bone grafting. Twenty-five of the remaining 26 hips were functioning satisfactorily with a mean Harris score of 84 points. In view of the major bone loss following multiple previous operative procedures in these young patients, the results of revisions using structural femoral head allografts were clearly superior to those with resection arthroplasty, the most likely alternate solution. Graft resorption, lack of posterior coverage, and incomplete cement mantle contributed to the failures.     

Salvage total hip reconstruction in patients with major acetabular bone deficiency using structural femoral head allografts

We evaluated 38 hip reconstructions in 36 patients at a mean follow-up of 5.9 years (range 4 to 9.1) after femoral head allografts had been used to augment severely deficient acetabular bone stock. The patients were all relatively young and had many previous operations. Their pre-operative Harris hip rating averaged 46 points (range 18 to 73). All the allografts united and there were no infections. However, 12 acetabular components (32%) became loose; six of these had needed revision using the healed allograft, and two hips had required resection arthroplasty. The 30 surviving hips had a mean Harris hip score of 82 points. Some radiographic evidence of graft resorption was seen in 23 hips, though this was mild in 17. The extent of cover provided by the allograft and the severity of graft resorption both correlated with acetabular loosening. Although structural allografts had allowed successful hip reconstructions in many of these patients with major bone loss, the failure rate had increased from zero at four years to 32% at six years; clearly they provide only a short-term solution.     

非骨水泥臼杯加自体股骨头植骨全髋关节置换术治疗髋臼发育不良伴骨性关节炎

目的：评价非骨水泥臼杯加自体股骨头植骨的全髋关节置换术治疗髋臼发育不良继发骨性关节炎的结果。方法：回顾性分析20例(21髋)患者行全髋关节置换术治疗髋臼发育不良继发骨性关节炎。女性18例,男性2例,平均年龄50岁,采用非骨水泥臼杯加自体股骨头植骨螺钉固定重建髋臼侧。臼杯置于真性髋臼水平,所有病例由于髋臼缺损而需要行自体股骨头植骨。平均植骨块覆盖的臼杯比例为31％(10％～45％)。8髋植骨块覆盖小于25％,13髋位于25％-50％之间。平均随访时间4．7年(1．5—8年)。采用改良Harris评分对结果进行评估。术前及随访时进行摄片观察。结果所有植骨块均获得愈合。无植骨块塌陷和髋假体松动。改良Harris评分由术前平均46分增加到89分。术前除1例双髋发育不良外,下肢不等长均超过2cm,术后只有2例仍有双下肢不等长超过1cm。3髋的植骨块外侧非支撑臼杯部分出现轻微的骨吸收。3髋发现有BrookerⅠ度异位骨化,1髋Ⅱ度异位骨化。结论：使用非骨水泥臼杯加自体股骨头植骨重建髋臼侧的全髋关节置换术治疗髋发育不良继发骨性关节炎可获得良好结果。该方法在植骨块支撑臼杯不超过50％的情况下,髋臼固定可靠,可保留髋臼的骨量。     

Effect of osteonecrosis on bone density and its management on the results of revision arthroplasty of the hip]

128 hips after revision arthroplasty in 115 patients which had been operated in our Ward in 1990-2001 were retrospectively evaluated. There were 99 women and 16 men with mean age: 68.9 years old. The mean time of follow-up was 28.6 months (form 3 to 120 months). In 98 hips there were aseptic loosening of the both elements of the prosthesis, in 13 hips there were aseptic loosening of the stem, in 17 hips there were aseptic loosening of the cup only. Cement total hip rearthroplasty was made in 112 cases and cementless total hip rearthroplasty was made in 16 hips. In presented material there were used the acetabular bone grafts in 114 cases, and the femoral bone grafts in 97 cases--all with allogenic frozen bone grafts. The additional implants were used in 31 cases (meshwork, wire, screw). The bone defects in acetabulum and femoral stem was based on Paprovsky classification. There were good and excellent results in 90% and poor or bad results in 10% according to clinical and radiological evaluation. Mean clinical result was 78.5 p. in Harris Hip Score. The radiological results were poor in 13 hips (according to criterion proposed by joined committee of The Hip Society, SICOT and AAOS). Osteointegration of bone allografts was radiologically confirmed in 81% of cases. Complication rates is 20%. There is no correlation between the type of acetabular or femoral bone defects and results of revision hip arthroplasty. Poor results are correlated with use of SKT or Weller stem. Wagner femoral osteotomy and the lack of bone allografts healing.     

Femoral head autograft in simultaneous primary and revision total hip arthroplasty

Bilateral total hip arthroplasty during one anesthetic procedure can be beneficial in properly selected patients. For patients who have a failed hip arthroplasty requiring revision and a contralateral arthritic hip requiring primary arthroplasty, bilateral surgery permits the resected femoral head from the primary procedure to be used as a fresh autogenous bone—graft during the revision procedure. Four patients underwent combined primary hip arthroplasty and contralateral revision hip arthroplasty during one anesthetic procedure. The femoral head obtained during the primary procedure was used as a structural acetabular bone—graft in three patients, and bone slurry was used to fill cavitary acetabular defects in one patient. A femoral neck autograft was used to reconstruct a calcar defect in one of the patients. After an average follow-up period of 27 months, all hips were functioning well with healed bone—grafts and stable prosthetic components.     

Total hip arthroplasty with cementless cups and femoral head autografts for patients with hip dysplasia and osteoarthritis

Objective: To evaluate the outcome of total hip arthroplasty (THA) with cementless cups and femoral head autografts for patients with hip dysplasia and osteoarthritis. Methods: Between 1995 and 2002, we implanted 23 cementless cups and femoral head autografts in 20 patients with hip dysplasia and osteoarthritis. In this study, a retrospective study was made on 21 hips in 20 patients (18 females and 2 males, aged 50 years on an average) with developmental hip dysplasia treated by THA with a cementless cup and femoral head autograft. The acetabular cup was placed at the level of the true acetabulum and all the patients required autogenous femoral head grafts due to acetabular deficiency. The average rate of the acetabular cup covered by the femoral head autograft was 31% ( ranging from 10 % to 45 % ). Eight hips had less than 25 % cup coverage and thirteen between 25% and 50%. The average follow-up period was 4.7 years (range, 1-8 years). The replacing outcome was evaluated by modified Harri ship score. Preoperative and follow-up radiographs were made. Results: All the autografts were united to the host bones. No autograft was collapsed or no component from the hip was loosed in all the patients. According to the modified Harris hip score, the average hip score increased from 46 before operation to 89 at the final review. Before operation, the leg-length discrepancy was greater than 2 cm in all the patients except one with bilateral hip dysplasia. After operation, only 2 out of 20 patients had a leg-length discrepancy greater than 1 cm. Three hips showed minor bone resorption in the lateral portion of the graft, which did not support the cup. Three hips developed Grade 1 Brooker heterotopic ossification and one developed Grade 2. Conclusions: THA with a cementless cup and a femoral head autograft for patients with osteoarthritis resulted from hip dysplasia can result in favorable outcomes. This method can provide reliable acetabnlar fixation and restore the aeetabular bone stock in patients with developmental hip dysplasia when the cementless cup covered by the graft does not exceed 50 %.     

Cemented total hip arthroplasty with autogenous acetabular bone grafting for hips with developmental dysplasia in adults: the results at a minimum of ten years

We carried out primary cemented total hip arthroplasty (THA) on 25 hips in 21 patients with developmental dysplasia of the hip, using autogenous acetabular bone grafts. The socket was placed at the level of the true acetabulum and bone from the femoral neck was used as graft. Five hips were excluded, leaving 20 which were followed up for a mean of 12.9 years (10 to 18). The mean modified Merle d'Aubigné and Postel functional scores were 5.6 for pain, 4.3 for mobility and 4.2 for range of movement. Radiological examination showed aseptic loosening in three sockets but not in the stems. The bone grafts had united and showed no evidence of late failure.     

Uncemented acetabular components with bulk femoral head autograft for acetabular reconstruction in developmental dysplasia of the hip: results at five to twelve years.

BACKGROUND: Anterolateral acetabular bone deficiency is one of the technical problems associated with total hip arthroplasty in patients with developmental hip dysplasia. The purpose of this study was to evaluate the results of one method of acetabular reconstruction for hip dysplasia-placement of an uncemented socket in conjunction with a bulk femoral head autograft. METHODS: Forty-four hips in thirty-five patients (twenty-nine female and six male; average age, thirty-nine years) with developmental hip dysplasia were treated with primary total hip arthroplasty with use of an uncemented porous-coated titanium cup fixed with screws and an autogenous bulk femoral head graft. The patients were followed clinically in a prospective fashion for five to 12.3 years (mean, 7.5 years), and radiographs were analyzed retrospectively. RESULTS: Four acetabular components were revised: two, because of severe polyethylene wear and osteolysis; one, because of aseptic loosening; and one, because of fracture of the acetabular shell. The mean Harris hip score for the unrevised hips improved from 51 points preoperatively to 91 points postoperatively. No unrevised socket had definite radiographic evidence of loosening. Forty-three of the forty-four hips had no radiographic evidence of resorption of the graft or had radiographic evidence of resorption limited to the nonstressed area of the graft lateral to the edge of the cup. CONCLUSIONS: This method of reconstruction provided reliable acetabular fixation and appeared to restore acetabular bone stock in patients with developmental hip dysplasia. We use this technique for patients with moderate anterolateral acetabular bone deficiency requiring total hip arthroplasty.     

颗粒松质骨压紧植骨全髋关节置换术治疗创伤性髋关节炎的疗效

目的探讨颗粒松质骨压紧植骨全髋关节置换术(THA)治疗髋臼骨折继发创伤性髋关节炎的疗效。方法1998年12月-2005年5月,对15例髋臼骨折继发创伤性髋关节炎患者行颗粒松质骨压紧植骨THA,所有患者髋臼假体均采用骨水泥固定,颗粒骨均取自体骨,术后24h后开始被动活动,3个月后开始全负重锻炼。临床随访采用Harris髋关节评分(HSS)系统评分,对任何原因引起髋臼假体翻修均视为临床失败。根据Conn等影像学评价法观察颗粒骨长人情况,根据DeLee的三区法测量臼杯、骨水泥与移植骨间的界面宽度,臼杯的移位程度则依据其相对于泪点间线的距离而定。结果14例患者获得平均4．3年(1．0-7．5年)随访,HHS评分由术前平均42分(10-62分)提高到随访结束时平均84分(58-98分)。1例髋部有轻度疼痛,无患者行翻修手术。大部分髋部恢复了其正常的旋转中心,仅有2例高出对侧0．8 mm。大多数患者影像学表现稳定,2例在Ⅰ区和Ⅲ区出现进行性增宽的透亮带,1例在Ⅲ区出现非进行性增宽的透亮带。1例臼杯假体在术后7年出现明显移位(6 mm),但并没有行翻修手术。结论颗粒骨压紧植骨技术作为一种生物学髋臼重建方法,其联合THA治疗髋臼骨折后继发创伤性关节炎伴髋臼缺损的疗效令人满意,能够恢复髋关节的正常解剖和功能活动。     

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。     

The fate of acetabular allografts after bipolar revision arthroplasty of the hip. A radiographic review

We reviewed the radiographs of thirty-one patients (thirty-two hips) who had had revision of the acetabular component of a total hip arthroplasty with a bipolar socket supplemented by allograft and were followed for twenty-four to forty-eight months. The grafts were categorized according to their consistency (solid or crushed bone), the location of the acetabular defect (peripheral [rim] or central), and the extent of the acetabular defect (contained--the medial part of the acetabular wall was intact, or non-contained--it was deficient). We recorded the time to incorporation of the graft, the amount of migration of the socket in the superior and medial axes, and the percentage of graft remaining at the time of the most recent follow-up. The time to healing was similar for all categories of grafts. The central, contained, solid grafts had less resorption than did the central, contained, crushed-bone grafts, as evidenced by less migration of the socket during follow-up. The non-contained grafts, in both peripheral and central locations, were associated with high rates of migration and of instability of the socket.     

Heat generated by hip resurfacing prostheses: an in vivo pilot study

In order to determine the magnitude of temperature increases in resurfaced hips, temperature sensors were placed percutaneously in both hip joints of 12 volunteer patients who had 1 or both joints resurfaced. Temperature recordings were made with patients at rest (baseline) and after patients walked for 20 and 60 minutes. The hip resurfacing procedures were performed 12 to 36 months prior to this study using 9 different acetabular bearing surface components. At baseline (resting), a ceramic femoral prosthesis articulating with a poly-ether-ether-ketone (PEEK) acetabular prosthesis generated a temperature increase of 4°C compared to a normal contralateral hip. After 60 minutes of walking, a ceramic femoral prosthesis articulating with a polyurethane acetabular prosthesis generated a temperature increase of 5°C, whereas a ceramic femoral prosthesis articulating with a metal acetabular prosthesis generated a temperature increase of 6°C, a cobalt-chromium alloy femoral prosthesis on a polyethylene acetabular prosthesis generated a temperature increase of 7°C, and a cobalt-chromium alloy metal-on-metal prosthesis generated a temperature increase of 8°C. Resurfaced hips generate more heat than arthritic and normal hips, and arthritic hips generate more heat than normal hips. A resurfaced hip with a ceramic femoral and PEEK or polyurethane acetabulum generated less heat than a resurfaced hip of the same design using a cobalt-chromium femur and either cobalt-chromium, or polyethylene for the acetabulum. Frictional heat generated in a resurfaced hip is not immediately dissipated and may result in increased bearing surface wear. Extended periods of elevated temperature within joints may inhibit periarticular cell growth and perhaps contribute to bone resorption or component loosening over the long term.