翻修手术时髋臼巨大骨缺损的重建

The reconstruction of massive bone defect in acetabulum in revision surgery

目的 通过总结分析作者所治疗的病例，提出髋关节翻修手术时髋臼巨大骨缺损的对策。方法 总结分析 32例 33髋髋臼巨大骨缺损的翻修病例，男 17例，女 15例，年龄 40～ 90岁，平均 61.5岁。第 1次翻修 28例 29髋，第 2次翻修 2例 2髋，第 3、 4次翻修各 1例 1髋。首次手术为股骨头置换者 8例 8髋，全髋置换者 24例 25髋。除行马鞍型假体置换的 2髋外，其余 31髋均行骨移植，以松质骨为主。 22髋为非结构性植骨， 9髋为大块异体股骨头或自体髂骨植骨。植骨后 9髋植入标准髋臼假体， 24髋选用特殊假体，主要为计算机辅助定制型髋臼假体，包括加侧翼假体、双层金属网罩、髋臼增强环罩、双球面假体、带嵴假体和马鞍型假体。结果 经 0.5～ 11年随访，无一例发生再移位或再发骨吸收。 Harris髋关节功能评分由术前的 17～ 48分提高到 54～ 89分。 计算机辅助定制型人工髋臼更能符合不同病情的需要，且使手术难度减小。结论 特殊假体具有更适合个体需要、可防止植骨块移位或塌陷、初始稳定性较好等优点。正确使用植骨和选择恰当的假体，以重建髋臼窝和周缘的完整性，将明显提高翻修手术的成功率。

Objective To propose measures to reconstruct the massive bone defect in acetabulum in revision hip arthroplasty on the basis of the experience in the cases treated by the authors. Methods Thirty- two hips of 33 hip revision cases with massive bone defect being operated on by the first author were summarized and analyzed. The patients included 17 males and 15 females, with the age of 40 to 90 years. 28 cases (29 hips) underwent revision for the first time, 2 cases (2 hips) for the second time,1 case (1 hip) for the third and the other 1 case (1 hip)for the fourth time. The primary surgery were artificial femoral head replacement in 8 cases (8 hips) and total hip replacement in 24 cases (25 hips). Except of 2 saddle protheses replacement, bone grafts, mainly cancellous bone grafts, were used in 31 hips, of which 22 hips were non- structural bone grafts and 9 hips were allografts of femoral head or autograft of ilium. After grafting, ready- made acetabular prostheses were implanted in 9 hips, while special prostheses were used in 24 hips, chiefly computer- aided custom- made acetabular prostheses, including winged prostheses, 2- layer metal mesh, acetabular reinforcing rings (ARR), bi- spherical prostheses, crested prostheses and saddle type prostheses. Results In the course of 0.5 to 11 years' follow- up, re- displacement or relapse of bone absorption was not found in any of the cases. The Harris hip function score rose to 54－ 89 from the pre- operative level of 17－ 48. The computer- aided custom- made acetabular prostheses could better meet the requirements of different conditions of disease, thereby reducing the difficulties of surgery. Conclusion Special prostheses have the advantages of better compatibility with the individual requirements, prevention of displacement or collapse of the bone graft and higher primary stability. The proper application of bone graft and choice of suitable prosthesis to achieve the reconstruction of acetabular fossa and the integrity of acetabular circumference will markedly improve the success rate of revision surgery.