Technical note for intraoperative determination of proper acetabular cup size in primary total hip arthroplasty

BACKGROUND Selecting the optimal size of components is crucial when performing a primary total hip arthroplasty.Implanting the accurate size of the acetabular component can occasionally be exacting,chiefly for surgeons with little experience,whilst the complications of imprecise acetabular sizing or over-reaming can be potentially devastating.AIM To assist clinicians intraoperatively with a simple and repeatable tip in elucidating the ambivalence when determining the proper acetabular component size is not straightforwardly achieved,specifically when surgeons are inexperienced or preoperative templating is unavailable.METHODS This method was employed in 263 operations in our department from June 2021 to December 2022.All operations were performed by the same team of joint reconstruction surgeons,employing a typical posterior hip approach technique.The types of acetabular shells implanted were:The Dynasty®acetabular cup system(MicroPort Orthopedics,Shanghai,China)and the R3®acetabular system(Smith&Nephew,Watford,United Kingdom),which both feature cementless press-fit design.RESULTS The mean value of all cases was calculated and collated with each other.We distinguished as oversized an implanted acetabular shell when its size was>2 mm larger than the size of the acetabular size indicator reamer(ASIR)or when the implanted shell was larger than 4 mm compared to the preoperative planned cup.The median size of the implanted acetabular shell was 52(48–54)mm,while the median size of the preoperatively planned cup was 50(48–56)mm,and the median size of the ASIR was 52(50–54)mm.The correlation coefficient between ASIR size and implanted acetabular component size exhibited a high positive correlation with r=0.719(P<0.001).Contrariwise,intraoperative ASIR measurements precisely predicted the implanted cups’size or differed by only one size(2 mm)in 245 cases.CONCLUSION In our study,we demonstrated that the size of the first acetabular reamer not entering freely in the acetabular rim corroborates the final acetabular component size to implant.This was also corresponding in the majority of the cases with conventional preoperative templating.It can be featured as a valid tool for avoiding the potentially pernicious complications of acetabular cup over-reaming and over-sizing in primary total hip arthroplasty.It is a simple and reproducible technical note useful for confirming the predicted acetabular cup size preoperatively;thus,its application could be considered routinely,even in cases where preoperative templating is unavailable.

Management of geriatric acetabular fractures:Contemporary treatment strategies

Acetabular fractures in the geriatric population are typically low-energy fractures resulting from a fall from standing height.Compromised bone quality in the elderly,as well as this population’s concomitant medical comorbidities,render the management of such fractures challenging and controversial.Non-operative management remains the mainstay of treatment,although such a choice is associated with numerous and serious complications related to both the hip joint as well as the general condition of the patient.On the other hand,operatively treating acetabular fractures(e.g.,with osteosynthesis or total hip arthroplasty)is gaining popularity.Osteosynthesis can be performed with open reduction and internal fixation or with minimally invasive techniques.Total hip arthroplasty could be performed either in the acute phase combined with osteosynthesis or as a delayed procedure after a period of non-operative management or after failed osteosynthesis of the acetabulum.Regardless of the implemented treatment,orthogeriatric co-management is considered extremely crucial,and it is currently one of the pillars of a successful outcome after an acetabular fracture.

Instability after total hip arthroplasty

Instability following total hip arthroplasty(THA) is an unfortunately frequent and serious problem that requires thorough evaluation and preoperative planning before surgical intervention. Prevention through optimal index surgery is of great importance, as the management of an unstable THA is challenging even for an experienced joints surgeon. However, even after well-planned surgery, a significant incidence of recurrent instability still exists. Non-operative management is often successful if the components are well-fixed and correctly positioned in the absence of neurocognitive disorders. If conservative management fails, surgical options include revision of malpositioned components; exchange of modular components such as the femoral head and acetabular liner; bipolar arthroplasty; tripolar arthroplasty; use of a larger femoral head; use of a constrained liner; soft tissue reinforcement and advancement of the greater trochanter.

Screw penetration of the iliopsoas muscle causing late-onset pain after total hip arthroplasty: A case report

BACKGROUND Postoperative pain following total hip arthroplasty(THA)may occur in a few patients but may pose a significant challenge to surgeons if the etiology is not identified.Herein,we report the case of a patient who developed late-onset pain following THA due to screw penetration of the iliopsoas tendon.CASE SUMMARY We report the case of a 77-year-old man who developed inguinal pain 7 years after THA.While the symptoms resembled that of iliopsoas impingement by the acetabular cup,the pain resolved only when the supplementary acetabular screw protruding through the ilium was decompressed.Decompression was performed using the pararectus approach.The patient was able to ambulate pain-free immediately after surgery.CONCLUSION A protruded screw through the ilium may penetrate the iliopsoas muscle,causing pain following THA.Pain may resolve with the decompression of the protruded screw.

泰森多边形多孔结构髋臼杯初始稳定性研究

目的 分析泰森多边形多孔结构髋臼杯与实体髋臼杯的初始稳定性差异,探究泰森多边形结构多孔层对髋臼杯初始稳定性的影响及其在预防松动脱位方面的作用。方法 通过Grasshopper设计孔隙率分别为60%、70%的泰森多边形多孔结构支架,利用选区激光熔化技术(selective laser melting, SLM)制备实体髋臼杯与孔隙率为60%、70%多孔髋臼杯样件,在相同条件的聚氨酯块模型中进行杠杆试验,分析对比3组样件的最大撬出力矩、偏转角度、界面刚度。结果 在压入力无明显差异的情况下,孔隙率为60%、70%多孔髋臼杯的最大撬出力矩分别比实体髋臼杯高278.82%、320.56%,偏转角度比实体髋臼杯高194.04%、269.23%,界面刚度比实体髋臼杯高18.58%、7.88%。杠杆试验完成后,多孔髋臼杯所用的聚氨酯块半球腔内出现明显磨损。结论 泰森多边形多孔结构髋臼杯的初始稳定性指标均高于实体髋臼杯,说明泰森多边形结构多孔层能提高髋臼杯的初始稳定性。研究结果能够为髋臼假体的设计与选型提供一定参考。

髋关节置换术治疗髋臼骨折继发创伤性关节炎的临床观察

目的:深入研究全髋关节置换术(total hip arthroplasty,THA)治疗髋臼骨折继发创伤性关节炎的临床疗效。方法:回顾性分析2019年10月至2022年6月,采用THA治疗15例髋臼骨折继发创伤性关节炎患者,男8例,女7例,年龄40~76(59.20±9.46)岁。记录术前及术后假体松动、髋关节脱位、髋关节活动度、神经损伤等情况,采用Harris评分、视觉模拟评分(visual analogue scale,VAS)、影像学检查评价髋关节功能及手术疗效。结果:15例均顺利完成手术,术中无神经、血管损伤,术后切口均Ⅰ期甲级愈合,无感染。随访时间6~39(18.33±9.27)个月。其中1例术后半年发生髋臼侧假体松动,经过翻修手术后恢复良好;1例髋关节脱位,经切开复位处理后治愈,无不良后果。术后末次随访Harris评分(88.60±4.01)分,与术前(47.20±11.77)分相比,差异有统计学意义(P<0.05)。术后末次随访VAS评分1(1)分,与术前8(2)分相比,差异有统计学意义(P<0.05)。末次随访时,本组所有患者疼痛症状减轻或消失,关节功能满意;末次随访影像学资料显示关节假体贴合良好,无异位骨化发生,假体无松动。结论:THA治疗髋臼骨折继发创伤性关节炎疗效可靠,能有效提高患者的生活质量。术前对患者全面评估、骨缺损评估,术中髋臼、股骨、内固定物与骨缺损的处理是手术成功的关键因素。

髋臼横韧带在全髋关节置换术中假体定位意义的研究进展

全髋关节置换术(total hip arthroplasty,THA)治疗终末期骨性关节炎及股骨头坏死等髋关节疾病有着较为显著的疗效,髋臼假体的准确定位成为手术的关键,诸多学者提出以髋臼横韧带为参考定位髋臼假体能降低术后脱位的发生率,这种定位方法无需额外器械辅助,具有简便、快速、经济的优点,能够避免高BMI及术中骨盆旋转对假体安置的影响,帮助初学者快速掌握全髋关节置换术中髋臼假体安置的技术要领。本文将阐述髋臼横韧带的基础解剖,并从髋臼假体的角度、覆盖率及旋转中心等方面对髋臼横韧带在全髋关节置换术中对髋臼假体的定位意义进行综述。

一种三维角度仪的设计及其在全髋关节置换术中的应用评价

目的设计一种三维角度仪,将其应用在全髋关节置换术(total hip arthroplasty,THA)中,以测量髋臼臼杯把持杆的倾斜角度,评估其是否能提高髋臼臼杯植入角度(外展角和前倾角)的精准度。方法将2020年9月至2022年10月武汉中西医结合骨科医院收治的30例患者分成测量仪组(采用三维角度仪辅助进行THA组,15例)和传统组(传统THA组,15例),两组术前规划髋臼臼杯置入的外展角为38º、前倾角为20º,比较两组术后X线片上所测得髋臼臼杯置放的角度(外展角和前倾角)与其术前所规划臼杯置入角度之间的误差。结果测量仪组术后髋臼臼杯置放的角度(外展角和前倾角)与术前所规划角度的误差明显小于传统组。结论相对于传统THA术中医生用肉眼瞄髋臼臼杯置入方向而言,采用此三维角度仪辅助进行THA,能在术中对髋臼臼杯置入的方向进行刻度化测量,能提高髋臼臼杯置入角度的精准度,其操作简单,值得推广。

Crowe Ⅲ型髋关节发育不良人工全髋关节置换髋臼解剖重建与非解剖重建髋关节生物力学有限元分析

目的:应用有限元分析研究CroweⅢ型发育性髋关节发育不良(developmental dysplasia of the hip,DDH)全髋关节置换(total hip arthroplasty,THA)髋臼解剖重建与非解剖重建髋关节的生物力学为临床THA髋臼解剖重建提供理论基础和实验依据。方法:选取1例因左侧CroweⅢ型DDH伴终末期髋骨关节炎于2020年4月就诊并行左侧全髋关节置换的患者,女,57岁。术前、术后分别行骨盆CT平扫三维重建。在Mimics和3-Matic软件里建立14组髋臼杯不同前倾角、外展角、旋转中心高度模型并进行材料赋值,在Abaqus软件里设置边界和负载条件,计算并观察髋关节应力峰值和分布。结果:对于CroweⅢ型DDH全髋关节置换术,当旋转中心解剖重建,髋臼杯外展角设置为40°时,髋臼杯前倾角5°~25°变化时,髋臼杯、聚乙烯内衬最低Von Mises值出现在前倾角20°;当旋转中心解剖重建,髋臼杯前倾角设置为15°时,髋臼杯外展角30°~55°变化时,髋臼杯、聚乙烯内衬最低Von Mises值出现在外展角35°;当髋臼杯前倾角设置为15°、外展角设置为40°时,旋转中心上移0~20 mm变化时,髋臼杯、聚乙烯内衬最低Von Mises值出现在旋转中心上移10 mm。在所有14组髋臼杯参数模型中,旋转中心解剖重建,髋臼杯前倾角15°、外展角35°时,髋臼、髋臼杯、聚乙烯内衬Von Mises值最低。结论:在CroweⅢ型DDH全髋关节置换术中,建议解剖重建旋转中心,髋臼杯前倾角15°、外展角35°,同时进行髋臼外上方植骨并增加螺钉以进一步减少髋关节应力峰值。

Application of Acetabular Reinforcement Ring with Hook for Correction of Segmental Acetabular Rim Defects during Total Hip Arthroplasty Revision

This study investigated the biomechanical micro-motion associated with the application of acetabular reinforcement ring with hook （Ganz ring） for the correction of segmental acetabular rim defects, by finite element analysis. The objective was to determine whether the Ganz ring is suitable for correcting segmental acetabular rim defects at different regions during total hip arthroplasty revision as well as the number of screws required to fix the Ganz ring. A finite element model of the hip joint was generated to simulate and evaluate the insertion and fixation of the Ganz ring and acetabular cup in the context of segmental rim defects in the anterior column, superior portion, and posterior column. Micro-motion was the greatest in the posterior column defect and the least in the anterior column defect. However, the peak stress distribution on the remaining portion of the acetabular rim was the highest in the superior portion defect, following the pos- terior column defect and anterior column defect. Increasing the number of fixations of the Ganz ring did not decrease the micro-motion. We found that the Ganz ring effectively provided biomechanical stability during the reconstruction of the segmental rim defect as long as the screws fixed the Ganz ring well to the host bone.

Fix and replace:An emerging paradigm for treating acetabular fractures in older patients

Acetabular fractures in older patients are challenging to manage.The "fix and replace" construct may present a new paradigm for the management of these injuries.We present the current challenge of acetabular fractures in older patients.We present this in the context of the current literature.This invited editorial presents early results from our centre and the ongoing challenges are discussed.

AI三维规划辅助全髋关节置换术前设计的研究

目的分析AI术前三维规划对全髋关节置换术(THA)预测假体型号及髋臼假体位置精准性的影响。方法回顾性收集术前使用AIHIP软件辅助完成初次THA的患者共148例,列为AI规划组;术前采用传统X线二维规划辅助完成THA的患者共87例,列为传统规划组。比较2组术前规划预测假体型号准确率,髋臼假体的外展角、前倾角及位于Lewinnek安全区、Callanan安全区的比例。结果AI规划组预测假体型号的准确率明显高于传统规划组(P<0.05);AI规划组与传统规划组术后髋臼杯假体的外展角、前倾角的差异均无统计学意义(P>0.05);AI规划组术后髋臼假体位于Lewinnek安全区及Callanan安全区的比例均高于传统规划组(P<0.05)。结论AI术前三维规划在预测假体型号方面明显优于传统X线胶片模板二维规划,提高了髋臼假体植入的准确性及髋臼假体位于安全区内的比例。

全髋关节置换术治疗髋臼骨折术后并发创伤性关节炎患者的临床效果

目的探讨全髋关节置换术(THA)治疗髋臼骨折术后并发创伤性关节炎(TA)患者的临床效果。方法回顾性分析27例髋臼骨折术后并发TA患者的临床资料,所有患者均行THA治疗。记录患者随访2年内影像学检查结果的变化情况、THA后1年内髋关节功能的恢复情况[髋臼假体外展角、髋臼前倾角、Harris髋关节功能评分(HHS)]和生活质量评定简表(SF-12)评分,以及术后1年内并发症的发生情况。结果27例患者均顺利完成手术,其中25例患者末次随访时影像学检查结果均提示髋臼假体位置良好,1例患者发生髋臼侧假体无菌性松动合并髋臼钢板断裂,1例患者发生髋臼陶瓷内衬碎裂。术后1年,患者的髋臼假体外展角为(40.49±4.07)°,髋臼前倾角为(13.70±4.94)°,伤口均愈合良好,均未出现下肢静脉血栓、关节感染、假体周围骨折、关节脱位等并发症,且患者的HHS,以及SF-12评分中的生理评分和心理评分均高于术前(均P<0.05)。结论THA是髋臼骨折术后并发TA的有效治疗手段,能够有效改善患者的髋关节功能,提高患者的生活质量,安全可靠,值得临床应用推广。

新型角度测量器在全髋关节置换术中的应用

目的探讨新型角度测量器在全髋关节置换术(THA)中的应用效果。方法对40例行THA治疗的患者按照术中是否使用新型角度测量器置入髋臼臼杯分为测量器组(使用新型角度测量器辅助置入髋臼臼杯行THA治疗,20例)和传统组(传统方法置入髋臼臼杯行THA治疗,20例)。记录两组切口愈合及并发症发生情况。比较术后第2天两组髋臼臼杯外展角、前倾角与术前规划的误差。结果患者均获得随访,时间1~6个月。术后第2天髋臼臼杯外展角、前倾角与术前规划的误差测量器组均明显小于传统组,差异均有统计学意义(P<0.01)。两组切口均一期愈合。除传统组1例出现肌间静脉血栓外,患者均未出现假体脱位、假体松动、深静脉血栓、感染等并发症。结论新型角度测量器结构简单、操作简便,在THA术中不仅能对髋臼锉杆操作方向进行刻度化测量或指引,利于髋臼锉对髋臼的同心圆磨锉,使臼杯与髋臼良好匹配,而且能对臼杯置入后的前倾角和外展角进行刻度化测量,有效减小了术中用肉眼评估的误差。

改良髋臼前倾角及外展角校验系统在不同入路全髋关节置换术中的应用

目的 探讨改良髋臼前倾外展角校准系统在不同入路全髋关节置换手术(total hip arthroplasty, THA)中的应用效果。方法 选取2020年1月至2021年12月武汉中西医结合骨科医院骨关节科行初次单侧THA的64例股骨头坏死患者为研究对象。按照手术入路,将患者分为直接前入路组(direct anterior approach, DAA)31例,其中男18例,女13例;年龄57~75岁,平均年龄(61.8±7.2)岁;后路入路组(posterior approach, PA)33例,其中男20例,女13例;年龄58~74岁,平均年龄(63.4±8.3)岁。使用改良髋臼前倾外展角校准系统,评价术中和术后1周髋臼假体位置情况,术后1周和6个月评估Harris髋关节功能评分。记录患者术后再次骨折,脱位及下肢静脉血栓的发生率。结果 两组术中及术后髋臼外展角及前倾角的比较差异无统计学意义(P>0.05)。两组术后Harris评分比较差异无统计学意义(P>0.05)。两组患者术后并发症的发生率比较差异无统计学意义(P>0.05)。结论 采用改良髋臼前倾外展角校准系统对PA入路和DAA入路的THA手术疗效进行评价,二者手术疗效相当。

Personalized image-based templates for precise acetabular prosthesis placement in total hip arthroplasty:a pilot study

Objective:In order to achieve accurate implantation of the acetabular prosthesis in total hip arthroplasty(THA),we designed individual templates based on a three-dimensional(3D) model generated from computed tomography(CT) scans.Methods:Individual templates were designed for 12 patients who underwent THA.A physical template was designed to conform to the contours of the patient's acetabulum and to confirm the rotation of the acetabular center.This guided the acetabular component orientation.Results:The preoperative and postoperative X-ray and CT scans were obtained to assess the location with respect to the accuracy of the acetabular component.For all patients,the abduction angle of the acetabular component was 46.7°o 54.3°and the anteversion angle was 11.3°to 18.5°.Conclusions:The assessment of postoperative CT scans demonstrated higher accuracy of the acetabular component bore when used with the individual template.Therefore,the individual template can be an alternative to the computer-assisted navigation systems,with a good cost-performance ratio.

Total Hip Arthroplasty Using Modular Trabecular Metal Acetabular Components for Failed Treatment of Acetabular Fractures： A Mid-term Follow-up Study

Background：Porous-coated cups have been widely used in acetabular reconstruction after failed treatment of acetabular fractures,and good results have been reported with the use of these cups;however,the durability and functionality of modular trabecular metal （TM） acetabular components in acetabular reconstruction after failed treatment of acetabular fractures remain unclear.This study aimed to examine the radiographic and clinical outcomes associated with the use of modular TM acetabular components for failed treatment of acetabular fractures to assess the durability and functionality of these components in acetabular reconstruction after failed treatment of acetabular fractures.Methods：A total of 41 patients （41 hips） underwent total hip arthroplasty （THA） using modular TM acetabular components for failed treatment of acetabular fractures at our hospital between January 2007 and December 2012.Among these patients,two were lost to follow-up.Therefore,39 patients （39 hips） were finally included in this study.The Harris hip score before and after the surgery,satisfaction level of the patients,and radiographic results were assessed.Results：The mean Harris hip score increased from 34 （range,8-52） before surgery to 91 （range,22-100） at the latest follow-up examination （P 〈 0.001）.The results were excellent for 28 hips,good for six,fair for three,and poor for two.Among the 39 patients,25 （64%） and 10 （26%） were very satisfied and somewhat satisfied,respectively.All cups were found to be fully incorporated,and no evidence of cup migration or periacetabular osteolysis was noted.Conclusions：Despite the technically demanding nature of the procedure,THA using modular TM acetabular components showed good durability and functionality and may be an effective reconstruction option for failed treatment of acetabular fractures.

贵州地区人群髋臼参数测量及临床意义

背景:不同地区、不同民族人群的髋臼解剖参数存在一定差异,其对髋臼疾病的诊疗至关重要。然而贵州地区人群髋臼影像学参数特征目前仍不清楚。目的:分析髋臼X射线平片的影像学参数特征,为髋臼疾病诊疗、假体设计和安放提供参考。方法:收集2015年1月至2017年2月在贵州医科大学附属医院拍摄双髋关节正位X射线片的成人患者,使用医学影像软件SIEMENS Syngo.Plaza PACS测量髋臼相关影像学参数,将数据按照年龄、性别、左右侧别进行分组分析,髋臼参数之间进行Pearson相关性分析,并将获得的数据与国内外研究同类型数据进行对比。结果与结论:(1)贵州地区人群Sharp角为(39.70±3.65)°,中心边缘角为(31.10±6.03)°,前倾角为(19.17±4.26)°,外展角为(39.71±3.67)°,髋臼深度为(1.16±0.22)cm,髋臼直径为(6.45±0.52)cm,改良髋臼指数为0.33±0.03,头臼指数为(84.72±4.19)%;(2)不同年龄之间,男性和女性Sharp角存在差异(P<0.05);男性外展角存在差异(P<0.05);(3)不同性别之间,Sharp角、中心边缘角、前倾角、外展角、髋臼深度、髋臼直径存在差异,其中男性Sharp角、前倾角、外展角小于女性(P<0.05);男性中心边缘角、髋臼深度、髋臼直径大于女性(P<0.05);(4)不同侧别之间,髋臼相关参数均无明显差异;(5)贵州地区人群髋臼相关影像学参数与国内外研究同类型数据相比存在差异;总的来说,贵州地区人群髋臼影像学参数具有一定的特征,在临床诊疗髋臼疾病时应充分考虑髋臼影像学的地域独特性,以期取得更大的临床获益。

应用个性化生物臼杯进行髋关节翻修的近期评估

背景:随着接受人工全髋关节置换的患者越来越多,出现髋臼侧松动伴不同程度骨缺损的患者日趋增加,治疗方式有多种,包括结构植骨、颗粒植骨加钛网重建、钽金属垫块重建、Jumbo杯、Cup-Cage技术等。目的:总结个性化生物臼杯翻修全髋关节置换后髋臼侧松动的近期临床疗效,为髋关节翻修提供一种可行的方法。方法:选择2017年3月至2019年3月解放军第九八九医院平顶山医疗区收治的全髋关节置换后髋臼侧松动11例患者,其中男7例,女4例;年龄55-71岁,均采用个性化生物臼杯进行髋臼侧翻修并进行3年随访,记录术前和末次随访的髋关节Harris评分、目测类比评分和双下肢绝对长度差,观察X射线片表现,评估髋关节功能恢复状态和骨长入情况。结果与结论:(1)所有患者均由同一医生主刀完成,随访满3年,无丢失病例,其中1例出现坐骨神经症状,口服甲钴胺片,6个月恢复;(2)末次随访的髋关节Harris评分、目测类比评分和双下肢绝对长度差与术前比较,差异有显著性意义(P <0.05);(3)末次随访X射线片显示有良好的骨长入;(4)结果表明,应用个性化生物臼杯翻修全髋关节置换后髋臼侧松动可获得假体的初始稳定性、恢复理想的关节功能和较好的骨长入,为髋关节翻修提供一种可行的方法。