组织工程学在半月板修复置换中的应用

半月板大部或次全切除后并发膝关节骨性关节炎是导致膝关节病废的主要原因之一。采用组织工程学方法修复损伤的半月板组织,在几个重要环节上取得了较明显的进展,利用胶原构成的支架,加上自身的软骨细胞,此种支架密度低,有利于血管长入及与周边组织愈合。种子细胞以自身纤维软骨细胞最为理想,能够形成几何形状的半月板组织,但远期观察半月板组织的生物性能,尚缺乏足够的时间,有待于从基础到临床获得较为可靠的数据来证明组织工程学修复损伤半月板组织的作用。

The dimensional accuracy of preparation of femoral cavity in cementless total hip arthroplasty

Objective: To observe the accuracy of femoral preparation and the position of the cementless prosthesis in femoral cavity, and to compare the results between the computer-assisted surgical group (CASPAR) and the conventional group. Methods: Ten femoral components were implanted either manually or by CASPAR in cadaver femurs. The specimens were cut to 3mm thick slices. Microradiograms of every slice were sent to a computer for analysis with special software (IDL). The gaps and the medullary cavities between component and bone, the direct bone contact area of the implant surface, the gap width and the percentage of gap and bone contact area were measured in every slice. Results: In the proximal implant coated with HA of the CASPAR group, the average percentage of bone contact reached 93.2% (ranging from 87.6% to 99.7%); the average gap percentage was 2.9% (ranging from 0.3% to 7.8%); the maximum gap width was 0.81mm and the average gap width was only 0.20mm. While in the conventional group, the average percentage of bone contact reached 60.1% (ranging from 49.2% to 70.4%); the average gap percentage was 32.8% (ranging from 25.1% to 39.9%); the maximum gap width was 2.97mm and the average gap width was 0.77mm. The average gap around the implant in the CASPAR group was only 9% of that in the manual group; the maximum and average gap widths were only about 26% of those in the manual group. On the other hand, the CASPAR group showed 33% higher bone contact than the manual group. Conclusion: With the use of robotics-assisted system, significant progress can be achieved for femoral preparation in total hip arthroplasty.

Effect of proximal femoral osteoporosis on cementless hip arthroplasty: A short-term clinical analysis

Objective： The aim of this retrospective investigation was to explore the influence of femoral osteoporosis on short-term curative effects ofcementless hip arthroplasty and to evaluate the femoral metaphyseal bone mineral density （BMD） for femoral osteoporosis in order to guide prosthesis choice and rehabilitation. Methods： We performed 127 total arthroplasty operations between June 1999 to February 2003 and investigated 49 cementless hip replacements with the Metalcancellous cementless Lubeck Ⅱ system being used in all hips. There were twenty men and twenty-nine women whose mean age at the time of the operation was 60 years （range, 52-81 years）. The patients were divided into osteoporosis or normal groups according to the femoral metaphyseal BMD measured preoperatively. The average duration of follow-up was 30 months （range, 8-52 months）. We evaluated all of the patients from a clinical standpoint with use of a standard-terminology questionnaire with respect to the short-term curative effects and patients＇ satisfaction. Hip pain status and functional ability were important indicators of treatment efficacy. Results： Harris hip score and patients＇ satisfaction in femoral osteoporosis patients who underwent noncemented hip arthroplasty were lower （P=0.004, P=0.03） while the incidence of thigh pain was higher （P=0.03） than the patients with non-osteoporosis. Conclusion： The higher incidence of pain, as well as the decrease in function experienced by the patients in osteoporosis group, supports the case that cementless arthroplasty is not a better choice for those patients and that we had better select prosthesis based on the femoral metaphyseal BMD.

汉英骨科词汇（22）

毕表面关节成形术hemisurfacearthroplasty 尺骨切除插入关节成形术ulnarhemiresectioninterpositionarthroplasty 半关节成形术hemiarthroplasty 半月板成形术meniscoplasty 杯状关节成形术cuparthroplasty 表面置换关节成形术surfacereplacementarthroplasty 髌骨成形术patellaplasty 插入关节成形术interpositionarthroplasty 成角截骨关节成形angulationresectionarthroplasty

Cemented bipolar hemiarthroplasty with a novel cerclage cable technique for unstable intertrochanteric hip fractures in senile patients

Objective： To observe the clinical result and assess clinical value of cemented bipolar hemiarthroplasty with a novel cerclage cable technique for treatment of unstable intertrochanteric hip fractures in senile patients. Methods： Forty-eight consecutive patients with unstable intertrochanteric fractures were treated in our hospital from March 2001 to March 2006 （ Evans type Ⅲ in 11 cases, Evans type Ⅳ in 25 cases and Evans type Ⅴ in 22 cases）. All the cases were evaluated by Zuckerman functional recovery score （ FRS ） and operative risk assessment software 1 （ORAS1）, which were based on the patients ＇ physical and laboratory examinations preoperatively. Seventeen cases （19 hips） were treated with cemented bipolar hemiarthroplasty. There were 5 male cases （5 hips） and 12 female cases （14 hips, including 2 patients who suffered from additional slight injuries and resulted in contralateral hip fracture and were treated with the same procedure 3 months after the first operation ）. The average age was 85 years （78-95 years ）. All the operations were carried out under general anesthesia, through Southern incision and lateral approach by the same orthopaedic surgeon. All prostheses consisted of Link SPH femoral stem and bipolar femoral head. All patients were followed up for more than 30 days. Results ： The operative risks of all the 17 cases （ 19 hips） were calculated by ORAS1 preoperatively. The average preoperative FRS was 81.7 （ 80. 7- 82.7 ）. The average predictive value of operative morbidity was 10% （7 %-15 % ）. The average predictive value of mortality was 2.97 % （ 2. 1%-3.2 % ）. The average operation time was 1.5 hours. The average blood transfusion was 400 nd. There were no operative or anesthetic complications and no deaths within 30 days after operation. Sitting up was permitted 3 to 4 days after operation, and partial weight bearing was permitted 5 to 7 days after operation. Patients were allowed to walk with a walker 10 days after operation. The average FRS was 78.7 at 30 days postoperatively. No patient died during at least one year follow-up. Conclusions Although the value of the technique of cemented bipolar hemiarthroplasty in the treatment of unstable intertrochanteric hip fracture is not widely recognized, we have consistently achieved satisfactory results with strict preoperative risk assessment, strict indication selection and systematic postoperative rehabilitation.

Unconstrained shoulder arthroplasty

Objective: To evaluate the results of 36 unconstrained shoulder arthroplasties. Methods: In the series, 24 total and 12 hemi arthroplasties of the shoulders were performed with unconstrained shoulder prostheses in 29 patients who suffered from glenohumeral degenerative arthritis, rheumatoid arthritis, avascular necrosis and proximal fracture of humerus, respectively. Follow up averaged 6.2 years. All patients were evaluated pre and post operatively using the rating system of the Society of American Shoulder and Elbow Surgeons which assesses the severity of pain, strength of muscles around shoulder, stability, range of motion and functional activities of daily living. Radiolucent line and migration of prostheses were observed postoperatively on X rays. Results: Postoperatively, the rate of pain relief was 91.3 %, and active range of motion increased by 47° in forward flexion, 43° in abduction , 30° in external rotation, and 4 segments in internal rotation. Preoperatively the average points of 6 functional activities patients could perform was 0.8 , and postoperatively 3.1 . On postoperative X ray, proximal migration of the humerus was seen in 8 shoulders, 6 of which had either a torn or absent rotator cuff. Radiolucent lines were seen around 1 humeral component and 9 glenoid components. One humeral and 2 glenoid components loosened. Conclusions: These results suggest that unconstrained shoulder arthroplasty is a satisfactory and safe technique.

Short-term survival analysis of the all-polyethylene tibial component in total knee arthroplasty

Objective: To report the clinical and radiological results of 24 total knee arthroplasty in which all-polyethylene tibial components were used. Methods: Between December 2000 and December 2002, 24 cemented total knee arthroplasty in 21 patients were performed using all-polyethylene tibial components. The mean age of the 21 patients (9 men and 12 women) at operation was 55 years, ranging 48-61 years. The mean preoperative hospital for special surgery (HSS)score was 40.2 (range, 36-43). The diagnoses were degenerative osteoarthritis in 15 patients, rheumatoid arthritis in 5 and traumatic arthritis in 1. All the operations were performed by the same surgeon group and there were unilateral operations in 18 patients and bilateral operations in 3. Results: Eighteen patients were followed up with a follow-up rate of 85.7%. The mean follow-up is 2.5 years (range, 1-3 years) and mean postoperative HSS scores was 87.5 (range, 83-89). Among them, 18 were excellent, 3 good, 3 poor and none was fair (the results of three lost patients were classified as poor). Of those reviewed, the prosthesis was all in situ and no revision occurred. Radiological assessment of these patients revealed 4 ( 16.67%) tibial components with radiolucent lines (mean width≤2 mm) distributed mainly in zone 1 and zone 4. None of these knees was symptomatic. Conclusions: The result of total knee arthroplasty using all-polyethylene tibial components is encouraging. The operative techniques are similar to those in arthroplasty using metal-backed tibial component.

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 Harris hip 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 acetabular fixation and restore the acetabular bone stock in patients with developmental hip dysplasia when the cementless cup covered by the graft does not exceed 50%.

Femoral component revision using extensively porous-coated cementless stem

To evaluate the clinical and radiographic results of extensively porous-coated femoral stem in revision of total hip arthroplasty （THA）. Methods： From January 1999 to December 2003, fifteen hips of fifteen cases received revision of THA with extensively porous-coated femoral stem. There were six males and nine females. The average age was 66 years （ranging 58-82 years ）. The reason for the revision was aseptic loosening in 10 cases, septic loosening in 2, femoral shaft fracture around loose implant in 2, and femoral revision for malposition of the femoral component in 1. All the patients were clinically evaluated using Harris hip score and radiographically evaluated both preoperatively and postoperatively at regular follow-up intervals. Results： No patients were lost for follow-up. The average length of follow-up was 2.3 years （ range, 1-5 years）. The average preoperative Harris hip score was 42 points, which was improved to 89 points at latest follow-up. The latest follow-up showed that bone in-growth occurred in fourteen stems and solid fibrous fixation in one. Complications consisted of femoral shaft fracture in two cases （1 undisplaced distal femur fracture and 1 cortical perforation at the tip of the prosthesis）, and postoperative dislocation in one. There was no mechanical failure of the stem in this study. Conclusions ： Satisfactory results of short-term clinical and radiographic follow-up have been achieved in using extensively porous-coated femoral stem for revision of THA. It should be noticed that the straight, 203 mm stem should be used with caution in short people.

Treatment of comminuted trochanteric fractures and non-union of trochanteric osteotomy in revision total hip arthroplasty

Objective: To explore the clinical efficacy of the treatment of comminuted trochanteric fractures and trochanteric osteotomy non union in revision total hip arthroplasty with tension band fixation. Methods: A retrospective review of 295 revision total hip operations performed between 1992 and 1998 was undertaken. Twenty hips of 19 patients with comminuted fractures or nonunion of the greater trochanter were stabilized with tension band technique. Multiple 2.0 mm k wires and tension band wires were placed through the intact cortex distally and the abductor tendon proximally in the pattern "8". Results: The average follow up was 30 months. The Harris Hip Score improved on average from 45 preoperatively to 89 at follow up. Sixteen hips with intra operative trochanteric fracture through osteolytic bone and four hips with symptomatic trochanteric nonunion were approached with tension band fixation. Perioperative loss of fixation in one patient required a repeated surgery. The same fixation at the second operation achieved an uneventful healing. Two patients had a 2 cm proximal migration of one K wire without loss of bony fixation. The trochanteric fractures healed with no further proximal wire migration. One patient had loss of fixation with trochanteric escape at 6 weeks post operatively. The patient has abductor weakness with Trendleburg limp but without pain. On average, radiographic examination showed that healing occurred at 16.6 weeks postoperatively. Six patients developed grade 1 heterotopic ossification and two patients grade 3. All were asymptomatic. None of the 19 patients experienced a dislocation during the follow up. Conclusions: Tension band fixation for greater trochanter can enhance the success rate of revision total hip arthroplasty without a deficient abductor mechanism.