远端固定型假体结合同种异体骨移植在髋关节股骨翻修中的应用

Application of distal fixation prosthesis combined with allogeneic bone graft for femoral revision in total hip arthroplasty

[目的]探讨应用远端固定生物型假体结合同种异体骨移植进行髋关节股骨侧翻修的临床效果。[方法]2008年7月~2014年5月,行非感染性假体松动股骨侧翻修11例（骨水泥假体10例,非骨水泥假体1例）。所有患者采用远端固定生物型假体结合股骨近端同种异体颗粒骨打压植骨,其中7例同时应用同种异体皮质骨支撑植骨。男4例,女7例;平均年龄65.3岁（48~79岁）;左侧7例,右侧4例。初次置换原因：股骨头无菌性坏死6例,股骨颈骨折3例,骨性关节炎2例。翻修距原手术时间平均12.8年（3~21年）。依据Paprosky分型,Ⅱ型4例,ⅢA型4例,ⅢB型3例。临床功能评价采用Harris评分。翻修用假体：Restoration（Stryker）3髋,MP（Link）8髋。[结果]所有患者均获得随访,随防时间12~75个月,平均29个月。1例术后出现切口渗液,15d后愈合;1例术后6年并发假体周围螺旋形骨折（Vancouver分型B1）,假体未松动,行切开复位内固定术。随访期内X线片显示移植骨均愈合良好,假体稳固,周围未见透亮带及松动、下沉征象;术前6例双下肢不等长患者均得到矫正（长度差〈1 cm）;无感染、脱位及深静脉血栓形成等并发症;无假体再翻修病例。Harris评分从术前的平均（30.3±7.2）分提高到最后评估时的平均（82.4±5.9）分,Harris评分优良率为81.8%。[结论]在伴有广泛骨质缺失的股骨翻修中,远端固定生物型假体是较好的选择。术中采用股骨近端颗粒骨打压植骨重建干骺端骨缺损,并在股骨干部皮质薄弱或缺损时结合同种异体皮质骨支撑植骨,可使假体柄远近段均获得较好的初始稳定性,且中短期临床效果满意,远期疗效尚有待观察。

[ Objective] To investigate the clinical effect of cementless distal fixation prosthesis combined with allogeneic bone graft in femoral revision in total hip arthroplasty. [ Method] A total of 11 patients undergoing femoral revision due to nonin- fectious prosthetic loosening （ cemented prosthesis for 10 and cementless prosthesis for 1 ） from rolled. All patients received femoral revision using cementless distal fixation femoral prosthesis to May 2014 were enwith morselized bone allograft in the proximal femur for impaction grafting,and among these patients,7 received aUogeneie cartical bone for bone graft and support at the same time. There were 4 male and 7 female patients with a mean age of 65.3 years （range 48 - 79 years）. Seven patients had the lesion on the left side, and 4 on the fight side. The reasons for primary replacement were aseptic necrosis of the femoral head （6 patients） ,femoral neck fracture （3 patients） ,and osteoarthritis （2 patients）. The mean interval between revision and original surgery was 12.8 years （range 3 -21 years）. According to the Paprosky bone defect classification, there were 4 type II patients,4 type IIIA patients, and 3 type IIIB patients. The Harris hip score was used for clinical function evalua- tion. As for the prosthesis for revision,3 patients received Restoration （Stryker） and 8 received MP （Link）. [ Result] All the patients were followed up for 12 -75 months （mean 29 months）. One patient experienced incision exudation, which was cured 15 days later. Another patient experienced periprosthetic spiral fracture （ Vancouver type B1 ） at 6 years after the surgery without prosthetic loosening and received open reduction and internal fixation. The radiographs obtained during follow - up showed good bone graft healing and a stable femoral prosthesis without any signs of radiolucency,loosening, or subsidence. The lower limb length discrepancy was corrected in 6 patients （ the difference in length less than 1 cm）. There were no complications such as infection, dislocation, and deep venous thrombosis. No pa-tients required the second revision. The mean Harris hip score was improved from 30.3 _＋ 7.2 points before surgery to 82.4 ~ 5. 9 points at the final evaluation, and the excellent and good outcomes rate was 81.8 %. [ Conclusion ] The cementless distal fixa- tion prosthesis is a good choice in femoral revision for patients with extensive bone loss. The application of morselized bone for impaction grafting in the proximal femur to repair the metaphysic bone defect and the allogeneic cortical bone for bone graft and support in ease of femoral shaft defects can achieve a better initial stability and satisfactory medium - and short - term clinical effects. The long - term efficacy still needs further investigation.