全髋关节翻修术中髋臼假体的选择和髋臼骨缺损的处理

The selection of acetabular prosthesis and treatment of acetabular bone defect in the revision of total hip arthroplasty

目的探讨全髋关节翻修术中髋臼假体的选择和髋臼骨缺损的处理。方法2002年1月至2007年6月收治资料较完整的全髋关节翻修术患者共55例,其中行髋臼假体翻修术的患者有36例,男8例,女28例;年龄52～86岁,平均73岁。左髋13例,右髋23例。髋臼翻修原因:髋臼假体松动20例,髋臼和股骨假体均有明显松动12例;头臼不匹配2例;髋臼假体位置不良导致复发性脱位2例。髋臼骨缺损21例,按照美国矫形外科学会(AAOS)分类标准:Ⅰ型:节段性骨缺损6例;Ⅱ型:腔隙性骨缺损9例;Ⅲ型:混合型骨缺损6例。结果36例中,4例仅翻修髋臼侧假体,保留原股骨假体;3例更换了磨损严重的聚乙烯内衬,未予更换金属假体,其余29例均行全髋关节置换翻修术。髋臼骨缺损21例中,6例使用颗粒骨打压植骨+骨水泥假体,2例为结构性和颗粒性打压植骨+骨水泥假体,9例为结构性植骨+颗粒打压植骨后,使用金属加强环+骨水泥假体,1例为结构性植骨后,使用常规髋臼假体,3例仅对局部骨缺损部位进行植骨未予更换稳定的金属假体。随访时间6～68个月,平均39个月。Harris评分由术前的平均48分,提高至随访时平均89分。结论机械性磨损是人工髋关节松动翻修的主要原因;翻修时,假体的选择和骨缺损的处理要根据患者个体情况差异和术中具体情况综合考虑;周密的术前计划、准备多种类型髋臼假体供术中选择、充分自体和异体植骨是保证手术顺利进行的根本。

Objective To investigate the treatment of acetabular bone defect and selection of acetabular prosthesis in revision total hip arthroplasty. Methods Thirty six cases of revision acetabular prosthesis in 55 cases of revision total hip arthroplasty, including 8 males and 28 females, were studied from January 2002 to December 2007. The age was 52 to 86 years old, average 73 years old. There were 13 cases on left hip and 23 cases on right hip. Revision reasons： acetabular prosthesis loosening was 20 cases, acetabular and femoral prosthesis loosening at the same time were 12 cases, acetabulum mismatch with femoral head was 2 case, repeated relapse dislocation of hip prosthesis （caused by uncorrected position of acetabular prosthesis） was 2 cases. Acetabular bone defect was found in 21 cases. According to the separate criteria of AAOS, type Ⅰ （segment bone defect） was 6 cases; type Ⅱ （lacouna bone defect） was 9 cases ; type Ⅲ （ mixed pattern bone defect） was 6 cases. Results Revision total hip arthroplasty was done in 29 cases; only acetabulum was revised and primary femoral prosthesis was kept in 4 cases; only severe-weared polyethylene liner was replaced and primary metal acetabular prosthesis was kept in 3 cases. In total 21 cases of acetabular bone defect, impacted morselized bone grafting technique and cement pros-thesis were used in 6 eases; structural bone graft and impacted morselized bone grafting technique and cement prosthesis were used in 2 cases ; structural bone graft, impacted morselized bone grafting technique and metal-strengthening ring, bone cement prosthesis were used in 9 cases; structural bone graft and normal prosthesis in 1 case ; only local bone graft was done in 3 cases. All cases were followed up for 6 to 68 months, average 39 months. Compared with preoperative, the average Harris score increased from 48 to 89 points. Conclusions The main reason of revision total hip arthroplasty was mechanical abrasion of prosthesis. The treatment of acetabular bone defect and selection of prosthesis should be according comprehensive situation during operation. The careful operation plan, preparing different type prostheses and sufficient bone graft were the successful basis.