异体皮质骨支撑植骨在髋关节股骨翻修术中的应用

目的探讨异体皮质骨支撑植骨在髋关节股骨翻修术中应用的适应证及临床效果。方法从2001年10月至2007年12月，笔者对41例股骨严重骨缺损的患者在髋关节翻修术中应用了同种异体皮质骨支撑植骨。主要在以下三种情况下使用，一是采用延长股骨粗隆截骨（ETO）取股骨假体，而患者近端骨质疏松或原有严重的骨缺损，采用远端固定假体翻修，为增加股骨近端的强度或增加ETO后股骨近端的稳定性而采用，这类患者共20例；二是在采用打压植骨进行股骨重建时，因为股骨存在有节段性缺损，或因取股骨远端骨水泥而进行股骨开窗造成股骨节段性缺损时，为了封闭骨缺损，使其成为包容性缺损而采用，这类患者共6例；三是在有严重股骨骨质疏松的患者出现股骨骨折时采用，这类患者共15例。笔者进行了平均37个月（6～72个月）的随访。结果所有同种异体皮质骨在术后12个月可以看出有与宿主骨结合的征象，假体固定稳定。未发生感染、排异反应或假体松动征象，髋关节Harris评分从术前平均38分增加到术后的88．1分。结论异体皮质骨支撑植骨在某些股骨翻修情况下有其特殊的需要，能够作为生物接骨板提供机械稳定性和生物稳定性，目前有不可替代的作用。     

同种异体颗粒骨移植在关节翻修术中的应用

关节翻修术中骨缺损的重建是最具挑战的难题之一。随着Slooff-Ling技术的开展,同种异体颗粒骨移植广泛应用于髋关节和膝关节的翻修术中,其中长期临床效果令人满意。     

嵌压植骨技术在人工全髋关节翻修术中的应用

目的 探讨使用嵌压植骨技术进行全髋关节翻修术的临床效果。方法1998年12月至2003年9月,采用嵌压植骨技术对48例患者72侧髋关节进行了翻修,平均随访时间25个月,采用Harris评分及X线片观察进行临床疗效评定,并统计并发症的发生率。结果Harris评分从术前平均44．6分提高到术后87．4分,术后优良率为达90．3％;无假体松动及下沉;股骨骨折发生率为4．2％;关节脱位率为1．4％,感染率为1．4％。结论嵌压植骨技术是一种有效重建髋关节置换术后松动所致严重骨缺损的方法。采用冻干异体骨植骨及解剖柄股骨假体同样可以获得满意的临床效果。     

股骨皮质骨开窗技术在髋关节翻修术中的应用

目的 探讨股骨前外侧皮质骨开窗技术在髋关节翻修术中取出股骨远端稳定固定骨水泥的价值.方法 2005年5月至2009年6月,共14例(14髋)因各种原因致髋关节置换术后失败患者接受全髋关节翻修手术.其中男性10例,女性4例,年龄54～75岁,平均66岁.翻修原因为股骨头置换术后髋臼磨损5例、全髋关节置换术后假体周围骨溶解并松动6例、骨水泥柄股骨近端骨溶解柄断裂1例、髋臼骨溶解假体松动翻修同时行股骨柄翻修1例,感染后二期翻修时远端骨水泥取出困难1例.14例(14髋)股骨柄均为骨水泥同定.术中按术前计划开窗部位、开窗范围于股骨皮质骨开一长方形骨窗.通过骨窗直视下彻底清除髓腔内稳定固定的骨水泥,修整股骨髓腔.植入翻修柄后将皮质骨开窗骨瓣原位回植,双股钢丝捆绑固定.术后定期随访拍摄x线片.观察皮质骨开窗骨瓣与周围骨愈合情况、骨瓣有无移位、股骨柄有无下沉以及有无捆绑钢丝断裂等.结果 10例患者术后获得随访,平均随访时间24.6个月.股骨皮质骨开窗长度2.5～6.0 cm,平均3.4 cm,宽度0.8～1.4 cm,平均1.2 cm.股骨开窗远端以远部分发生纵形劈裂骨折1例.无术中皮质骨穿孔及股骨干骨折.向远段扩大开窗1例,扩大长度1.5 cm.开窗部位皮质骨骨瓣原位回植选择2～3道双股钢丝固定,平均2.3道.随访期间2例发牛假体柄下沉(平均2.5 mm),无皮质骨瓣移位以及捆绑钢丝断裂,术后3～5个月皮质骨瓣已于周围骨纤维愈合.随访期间无一例因各种原因致再次翻修.结论 股骨皮质骨开窗技术在髋关节翻修术中有助于直视下彻底取出股骨髓腔远端稳定固定的骨水泥,同时不会造成股骨骨丢失、不影响翻修柄植入后的稳定固定.     

低温冷冻异体骨移植在髋关节翻修术中的应用

髋关节因各种原因行人工关节置换术后，由于假体的磨损和松动常引起骨质腐蚀和溶解，导致严重的骨缺损。报道从１９７２年～１９９０年１月，应用大块冷冻异体骨移植的髋关节翻修术２１２例，获随访１年以上的１８７例（１９８个髋），总有效率达８５％。讨论了髋关节翻修术中常见的骨缺损类型及异体骨移植方法，以及异体骨的切取和保存，移植亏的免疫反应和转归等。     

关节镜下经膝逆行击出股骨侧假体在髋关节翻修术中的应用

目的探讨关节镜下经膝逆行击出法在股骨侧假体翻修术中的应用及疗效。方法对16例患者采用关节镜下经膝逆行击出法取出股骨假体柄、骨水泥,行髋关节翻修手术。结果16例均获随访,时间6-24个月,髋关节功能均良好。Harris评分82-98（92±4.35）分。结论采用关节镜下经膝逆行击打法取出股骨侧假体和骨水泥,手术时间短,创伤小,患者可早期功能锻炼,无需加长柄假体,手术效果良好。     

人工髋关节翻修术中使用同种异体骨

目的评价同种异体骨在人工髋关节翻修术中的应用价值，以及了解术前服药对人工关节翻修术的影响。方法回顾性分析25例全髋关节翻修术病例，所有病例术中均使用同种异体骨植骨，并按照术前有无特殊用药史，分为3组：A组为无特殊用药组、B组为消炎镇痛药组、C组为糖皮质激素组。比较各组术后一般情况、Harris功能评分。结果A、B组患者术后一般情况良好，C组术后部分患者出现持续伤口渗液；Harris关节功能评分比较：A、B两组优于C组。结论同种异体骨能有效修复髋臼侧骨缺损，人工关节松动引起疼痛的患者应避免使用糖皮质激素。     

大粗隆延长截骨在髋关节翻修手术中的运用

[目的]探讨大粗隆延长截骨在髋关节翻修手术中的实际应用及疗效.[方法]对2003～2008年13例接受髋关节翻修手术中进行大粗隆延长截骨的患者进行随访,共13髋,平均随访32.3个月.对患者翻修原因、术前术后Harris评分、截骨长度、截骨愈合时间等进行分析.[结果]13例患者中术前Harris评分平均38分(24～68分),术后Harris评分为77分(57～100分),平均提高39分.平均截骨长度从大粗隆顶点至截骨远端为12.4 cm(9～15.1 cm).11例患者在术后3个月时截骨端愈合,2例患者在6个月随访时截骨端愈合.[结论]大粗隆延长截骨在髋翻修手术中可以帮助充分暴露术野,取出固定良好的骨水泥和非骨水泥股骨柄,同时截骨愈合良好.     

非骨水泥假体髋关节翻修术随访报告

[目的]探讨非骨水泥假体在髋关节翻修术中的临床效果.[方法]对本科1997年11月～2007年8月行非骨水泥人工全髋关节翻修术36例(41髋)患者进行了随访,其中29髋行全髋关节翻修,8髋仅翻修髋臼,4髋仅更换股骨柄.随访X线片上的假体变化情况,分析AAOS、Paprosky骨缺损分类对翻修时假体选择的指导作用,对髋关节行Harris功能评定并分析假体生存率.[结果]24例28髋获得随访,平均随访4.6年(1～11年),患者平均Harris评分由术前的38分(11～76分)增加到末次随访时的88分(60～99分).21髋(75%)假体获得良好稳定性;1髋股骨1区形成2 mm宽的透亮线,临床检查无松动迹象;4髋发生骨溶解并假体移位(股骨1髋,髋臼3髋)而需要再翻修,失败率为12.5 %;8髋发生异位骨化;聚乙烯衬垫年平均磨损量为0.08 mm(0～0.25 mm),磨损率仅与外展角变化存在相关.AAOS分类术前、术中的一致性较Parprosky分类高.分别以任何原因进行了再翻修和影像学证明假体松动作为失败标准,利用Kaplan-Meier生存分析计算假体4.6年存活率分别为89%、81%.[结论]非骨水泥型假体可用于初次髋关节置换术失败的翻修.术中对骨缺损进行细致的评估并选择合适的假体固定,能达到令人较满意的临床效果.     

全髋关节股骨侧假体翻修术

目的 报道采用现代骨水泥和非骨水泥技术行全髋关节股骨侧假体翻修手术 26例的疗效。方法 翻修原因 :全髋关节股骨侧假体松动 23例 ,松动伴假体柄端股骨骨折 3例。翻修采用现代骨水泥技术固定者 10例 ,采用长柄股骨侧假体加自体植骨的非骨水泥固定者 16例。结果 骨水泥翻修组 ,平均随访 6年 ,优良 5例 (50％ ),尚可 3例 (30％ ),差 2例 (20％ )。其中再翻修 1例 (10％ );X线表现 :肯定松动 2例 (20％ ),很可能松动 1例 (10％ ),可能松动 5例 (50％ ),无松动 2例 (20％ ),多数患者早期即表现骨水泥－骨界面的广泛 X线透亮带、骨皮质进行性变薄和疏松等征象。非骨水泥翻修组 ,平均随访 5年 ,优 9例 (56％ ),良 6例 (38％ ),尚可 1例 (6％ ),无一例再翻修 ;X线表现 :骨性固定 12例 ,纤维性稳定 4例 ,无一例松动 ,骨皮质密度和厚度均显著增加。结论 非骨水泥翻修术的疗效显著优于骨水泥翻修术 ,自体植骨修复结构性骨缺损并采用长柄多孔表涂假体获得初始稳定 ,是其获得满意疗效的关键。     

全髋翻修术中髋臼骨缺损翻修重建

全髋关节置换术后髋臼失败的翻修重.是骨科医生面临的巨大的技术挑战.翻修时面对广泛的髋臼骨缺损,可能需要采用几种不同技术,尽可能使髋臼侧恢复到初次全髋关节置换术时的骨量.获得翻修假体初始稳定是翻修手术成功的关键.该文就全髋翻修术中髋臼骨缺损的分类、术前计划和翻修重建策略作一综述.     

颗粒骨打压植骨结合多孔非骨水泥臼杯在AAOSⅢ型髋臼大面积骨缺损翻修中的应用

背景：颗粒骨打压植骨是修复髋臼骨缺损的重要方法,对大面积髋臼骨缺损采用打压植骨结合非骨水泥臼杯重建仍然存在争议。目的：探讨同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术修复AAOSⅢ型髋臼大面积骨缺损的方法及近期疗效。方法：随访2005年6月至2010年4月收治的28例（28髋）AA0SⅢ型髋臼大面积骨缺损患者。男18例,女10例,年龄34-74岁,平均53．8岁。髋关节置换术后感染醐翻修9例,骨溶解及髋臼假体松动翻修19例。本组AAOSⅢ型髋臼骨缺损面积大,术中见髋臼骨缺损超过髋臼关节面的50％。全部采用同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术。术后定期随访,观察臼杯有无松动、植入骨与宿主骨整合情况,髋关节功能评分采用Harris评分。结果：28例均获得随访,术后随访时间为13-70个月,平均43个月。Harris评分由术前32-48分,平均41分,提高至末次随访时86-95分,平均90分。28例髋臼假体均固定牢固无松动征象,植入骨逐渐与宿主骨整合,无感染及坐骨神经损伤。结论：在获得臼杯初始稳定固定的情况下,大面积颗粒骨打压植骨（臼杯与宿主骨接触面积〈50％）结合多孔非骨水泥臼杯髋臼重建术修复AAOSⅢ型髋臼大面积骨缺损近期疗效较好,远期疗效尚待进一步随访。     

Cancellous impaction bone grafting of acetabular defects in complex primary and revision total hip arthroplasty

The reconstruction of major acetabular bone defects during revision, conversion, and primary total hip arthroplasties (THAs) is challenging. We reviewed a consecutive series of 168 THAs (108 revisions, 8 conversions, and 52 primary THAs) performed by 1 surgeon (S.B.G.) between 1997 and 2008 using impaction bone grafting for acetabular reconstruction. Autograft, cancellous allograft croutons, and demineralized bone matrix were used to fill bone defects as needed. The acetabular bone deficiency was classified according to the American Academy of Orthopaedic Surgeons: type I, segmental deficiency with significant rim defect; type II, cavitary defects medially or posteriorly; type III, combined cavitary and segmental deficiency; type IV, pelvic discontinuity; and type V, arthrodesis. According to this method, 56 hips had type I, 31 hips had type II, 48 hips had type III, and 27 hips had type IV deficiencies. Of the 168 patients, 19 subsequently died of causes unrelated to the THA, and 11 were lost to follow-up. All patients had at least 2 years of follow-up. Average Harris Hip Score improved from 45.5±17.9 preoperatively to 81.1±16.5 postoperatively (P<.05) for revision THAs, from 40.0±11.3 preoperatively to 85.0±12.8 postoperatively (P<.05) for conversion THAs, and from 42.3±14.9 preoperatively to 85.0±12.0 postoperatively (P<.05) for primary THAs. All impaction grafted bone (allograft, autograft, or a combination) incorporated radiographically, thus restoring bone stock. Complications included 1 early infection, which was managed successfully with debridement and liner exchange, and 2 late infections that were managed successfully with staged revision. Two revisions required subsequent re-revision for late loosening. Two hip dislocations occurred, 1 of which required surgical treatment to place a constrained liner.     

Cemented revision total hip arthroplasty with impaction bone grafting in Gaucher's disease

Total hip arthroplasty in Gaucher's disease has been associated with high rates of loosening after all types of arthroplasty. We present a patient with type 1 Gaucher's disease who underwent revision cemented total hip arthroplasty for aseptic loosening after 12 months of enzyme replacement therapy. Major osteolysis was managed by impaction morcellized bone grafting. An excellent clinical and radiographic result was obtained at 5-year follow-up. Enzyme replacement therapy combined with modern revision techniques may offer improved outcomes for patients with Gaucher's disease.     

Morselized bone grafting of defects in revision total knee arthroplasty.

In a prospective, multicenter study evaluating one revision knee system, 33 of 409 patients underwent morselized bone grafting for tibial and femoral defects. Fifty-four percent of defects were bicondylar and the defect volumes averaged 36 cc3. There was no difference in preoperative or postoperative knee scores between patients undergoing morselized grafting and the entire group. Radiographic evaluation showed remodeling of the grafted areas consistent with viable incorporation of the graft. The incidence of radiolucent lines, at 2 years followup, was not different between the patients who received grafting and the patients who did not receive grafting. There have been no clinical failures or reoperations in the patients who received morselized bone grafting. Morselized bone grafting seems to offer a viable alternative in the reconstruction of osseous defects in patients undergoing revision total knee arthroplasty.     

Results of Wagner SL revision stem with impaction bone grafting in revision total hip arthroplasty

Background:

As the number of total hip arthroplasties (THAs) performed increases, so do the number of required revisions. Impaction bone grafting with Wagner SL Revision stem is a good option for managing bone deficiencies arising from aseptic osteolysis. We studied the results of cementless diaphyseal fixation in femoral revision after total hip arthroplasty and whether there was spontaneous regeneration of bone stock in the proximal femur after the use of Wagner SL Revision stem (Zimmer, Warsaw, IN, USA) with impaction bone grafting.

Materials and Methods:

We performed 53 hip revisions using impaction bone grafting and Wagner SL Revision stems in 48 patients; (5 cases were bilateral) for variety of indications ranging from aseptic osteolysis to preiprosthetic fractures. The average age was 59 years (range 44-68 years). There were 42 male and 6 female patients. Four patients died after surgery for reasons unrelated to surgery. 44 patients were available for complete analysis.

Results:

The mean Harris Hip Score was 42 before surgery and improved to 86 by the final followup evaluation at a mean point of 5.5 years. Of the 44 patients, 87% (n=39) had excellent results and 10% (n=5) had good results. The stem survival rate was 98% (n=43).

Conclusion:

Short term results for revision THA with impaction bone grafting and Wagner SL revision stems are encouraging. However, it is necessary to obtain long term results through periodic followup evaluation, as rate of complications may increase in future.     

Reconstruction of major column defects and pelvic discontinuity in revision total hip arthroplasty

Acetabular reconstruction with severe bone loss after failed total hip arthroplasty is a difficult problem. Defects were defined as major segmental and cavitary loss (type III anterior or posterior) or pelvic discontinuity (type IV). Seventeen cases were treated, of which 7 were type III and 10 were type IV. Bulk allograft was used in 16 of 17 cases, of which 7 were whole acetabular grafts, 2 were posterior segmental acetabular grafts, and 7 were femoral heads. Fourteen of 17 patients were female. The extensile triradiate approach was used in 12 cases. Long pelvic bone plates were applied to the posterior column and anterior brim of the pelvis in most cases. Allografts united to host-bone in 15 cases. Average follow-up was 83 months. The overall revision rate was 47%, of which 3 of 7 press-fit and 2 of 10 cemented cups had failed. The dislocation rate for the extensile approach was 50%; 2 patients had excisional arthroplasty for infection, and 2 patients had exploration of the sciatic nerve for release from migrating pelvic plate screws. Because of the overall poor results, this approach cannot be recommended for general use.     

Femoral impaction grafting in revision hip arthroplasty with irradiated bone

We evaluated the results of femoral impaction grafting with the Exeter stem (Stryker Howmedica Osteonics, Newbury, UK) and irradiated bone-graft. We followed 57 hips for an average of 27 months. Endo-Klinik grading showed 8 grade 1, 22 grade 2, and 27 grade 3 hips. Radiographic analysis revealed cortical repair in 34% and graft incorporation in 39% but no evidence of trabecular remodeling. Moderate subsidence (5-10 mm) occurred in 7 patients (12.5%), and massive subsidence (>10 mm) occurred in 4 patients (7%). Complications included 6 dislocations, 3 periprosthetic fractures, and 2 stem revisions. Impaction grafting with the Exeter system produces satisfactory results for most patients, but a few hips perform poorly, and the reasons for this are unclear. We have concerns about irradiated bone-graft because the characteristic changes of graft remodeling are not seen.     

全髋关节翻修术中髋臼骨缺损的处理方法

目的探讨全髋关节翻修术中对于髋臼骨缺损重建的方法及其术后疗效。方法回顾性分析自2007-03—2011-12的75例（76髋）全髋关节翻修术,髋臼骨缺损根据Paprosky分型：Ⅰ型9髋,ⅡA型21髋,ⅡB型18髋,ⅡC型11髋,ⅢA型10髋,ⅢB型7髋。髋臼骨缺损采用不同方式修复,术后定期随访。采用髋关节功能Harris评分评估髋关节功能,根据X线片判断假体是否松动、植骨是否融合。结果 75例（76髋）均获得平均36（16~73）个月随访。术后12个月不同类型骨缺损患者髋关节功能Harris评分较术前明显提高,差异有统计学意义（P〈0.05）。术后症状和关节功能明显改善,未出现髋臼骨折、感染、下肢深静脉血栓形成、坐骨神经损伤等严重并发症。X线片可见移植骨与宿主骨质交界处有连续性骨小梁通过,假体未见松动迹象。结论髋臼假体无菌性松动及骨溶解是需要进行全髋关节翻修的主要原因,而髋臼骨缺损Paprosky分型法对髋臼翻修重建方法有指导意义,正确选择假体类型及合理选择植骨方式是全髋关节翻修术后取得满意疗效的保证。