王北岳 周利武 張志強(qiáng) 郭亭 趙建寧

. 髖關(guān)節(jié)外科 Hip surgery .

大臼杯在髖臼骨缺損患者的髖關(guān)節(jié)翻修術(shù)中的應(yīng)用

王北岳 周利武 張志強(qiáng) 郭亭 趙建寧

目的探討大臼杯在 Paprosky II 型及 Paprosky III A 型全髖關(guān)節(jié)置換術(shù)后髖臼骨缺損翻修中的應(yīng)用。方法回顧性分析了 2007 年3 月至 2014 年5月，經(jīng)治的 24 例 Paprosky II 型及 Paprosky III A 型全髖關(guān)節(jié)置換術(shù)后髖臼骨缺損病例。其中男 13 例，女 11 例，平均年齡 61.46 (34～77 ) 歲。髖臼側(cè)行翻修的原因：無菌性松動(dòng) 21 例，髖關(guān)節(jié)習(xí)慣性脫位2 例，低毒性感染1 例。所有手術(shù)均為初次單側(cè)翻修，初次關(guān)節(jié)置換髖臼側(cè)：11 例為骨水泥固定的髖臼假體，10 例為非骨水泥型髖假體，3 例為人工股骨頭置換。髖臼骨缺損按 Paprosky 分型法：II A 型 7 髖，II B 型 6 髖，II C 型5 髖，III A 型 6 髖。采用大臼杯或聯(lián)合植骨對(duì)髖臼假體進(jìn)行翻修，對(duì)于 Paprosky II 型骨缺損在不影響假體穩(wěn)定性的情況下通過挫磨擴(kuò)大髖臼，植入顆粒骨或直接置入大臼杯髖臼假體。Paprosky III A 型骨缺損，采用適量植入打壓顆粒植骨，或結(jié)構(gòu)性植骨、臼底骨塊封堵技術(shù)以提高骨量，或直接采用高位球中心植入技術(shù)，配合大臼杯植入，而雙下肢平衡及偏心距均通過假體柄及頸的長(zhǎng)度來調(diào)節(jié)。術(shù)后定期隨訪，采用 Harris 方法及 VAS 評(píng)分評(píng)估髖關(guān)節(jié)功能及狀態(tài)，根據(jù) X 線片判斷假體穩(wěn)定性及植骨愈合情況。結(jié)果24 例平均隨訪 23.84 (12～83 ) 個(gè)月，Harris 髖關(guān)節(jié)評(píng)分：術(shù)前 (44.92± 10.53 ) 分，術(shù)后 12 個(gè)月 (84.75±4.61 ) 分 (P＜0.01 )，術(shù)后3 年 (88.88±5.70 ) 分 (P＜0.01 )。VAS 評(píng)分：術(shù)前 (4.58±1.69 ) 分，術(shù)后 12 個(gè)月 (0.71±0.91 ) 分 (P＜0.01 )，術(shù)后3 年 (0.50±0.66 ) 分 (P＜0.01 )。未出現(xiàn)假體修復(fù)失敗而需要再次翻修病例。X 線片顯示移植骨與宿主骨交界處有連續(xù)性骨小梁通過。患者下地行走步態(tài)良好，隨訪期間無假體脫位、松動(dòng)及髖關(guān)節(jié)異常疼痛影響行走，術(shù)后1 年患髖屈曲均能至少達(dá) 90°，術(shù)后3 年均能滿足日常生活需要并能慢跑、下蹲持物。結(jié)論在 Paprosky II 型及 Paprosky III A 型髖臼骨缺損翻修術(shù)中，采用大臼杯或聯(lián)合顆粒 / 結(jié)構(gòu)植骨，可以取得良好效果。假體的合理選擇及適當(dāng)?shù)捏y臼骨缺損的處理，可以降低髖臼側(cè)翻修手術(shù)難度并取得優(yōu)良效果。

髖關(guān)節(jié)；關(guān)節(jié)成形術(shù)，置換，髖；人工關(guān)節(jié)；髖臼

全髖關(guān)節(jié)翻修術(shù)中假體磨損產(chǎn)生的碎屑以及炎癥產(chǎn)生的骨溶解可以導(dǎo)致髖臼骨缺損，如何合理有效地處理髖臼骨缺損直接影響翻修效果和假體的使用壽命。髖臼骨缺損的處理方法較多，如采用大臼杯、骨水泥臼杯、加強(qiáng)杯、Cage、鈦網(wǎng)重建等，必要時(shí)聯(lián)合植骨，其核心是重建相對(duì)正常的髖臼及假體的長(zhǎng)久穩(wěn)定。2007 年3 月至 2014 年5 月，我院為 24 例髖臼骨缺損患者進(jìn)行了大臼杯 (Paprosky II～I(xiàn)II A 型[1]) 髖臼骨缺損人工髖關(guān)節(jié)翻修，取得良好效果，現(xiàn)報(bào)道如下。

資料與方法

一、一般資料

本組 24 例 (24 髖 ) 均采用大臼杯或大臼杯＋顆粒植骨 / 結(jié)構(gòu)性植骨進(jìn)行髖臼側(cè)翻修。其中男13 髖，女 11 髖，平均年齡 61.71±12.62 (34～77 )歲 (圖 1～3 )。髖臼側(cè)行翻修術(shù)的原因：無菌性松動(dòng)21 例 (包括外傷、骨溶解 )，髖臼假體位置不良致髖關(guān)節(jié)習(xí)慣性脫位2 例，低毒性感染1 例。所有手術(shù)均為初次單側(cè)翻修，兩次手術(shù)間隔平均 7.68 (0.5～27 ) 年。其中初次關(guān)節(jié)置換髖臼側(cè)：11 例為骨水泥固定的髖臼假體，10 例為非骨水泥型髖假體，3 例為人工股骨頭置換。本組中假體周圍感染術(shù)前未能診斷，術(shù)中取病理及組織培養(yǎng)為陽性結(jié)果而診斷，因術(shù)中懷疑可能存在感染并按感染 I 期翻修方案處理，故未影響手術(shù)效果。髖臼骨缺損按 Paprosky分型法 (表1)，II A 型 7 髖，II B 型 6 髖，II C 型5 髖，III A 型 6 髖。關(guān)節(jié)翻修前后均采用 Harris 評(píng)分及 VAS 評(píng)分評(píng)價(jià)其功能，術(shù)后根據(jù)髖關(guān)節(jié)正側(cè)位系列 X 線片評(píng)價(jià)植骨愈合情況，采用 Gill 等[2]提出的方法判斷假體的穩(wěn)定性。本研究中大臼杯由 Smith & Nephew 和 LINK 公司提供。

二、髖臼假體松動(dòng)的診斷及骨缺損的判定[3]

(1) 臼杯在 X 線片上顯示水平或垂直方向移位≥2 mm；(2) 旋轉(zhuǎn)移位合并螺釘斷裂；(3) 雖無移位，但各區(qū) X 線片透亮帶＞1 mm；(4) 髖臼杯旋轉(zhuǎn)＞5°。本組患者均符合診斷標(biāo)準(zhǔn)中的 1～4 條且存在活動(dòng)時(shí)疼痛，休息時(shí)無癥狀。

表1 髖臼骨缺損的 Paprosky 分型Tab.1 Paprosky typing of acetabular defciencies

三、手術(shù)方法

同組醫(yī)師完成該組手術(shù)。取健側(cè)臥位，采用Moore 入路，顯露髖關(guān)節(jié)假體并充分暴露髖臼緣，取出髖關(guān)節(jié)假體，徹底清除髖臼周圍瘢痕、界膜及骨水泥，術(shù)中盡量避免醫(yī)源性骨丟失，打磨骨質(zhì)至表面滲血，并探查潛在的腔隙性骨缺損，依據(jù) Paprosky 分類法確認(rèn)骨缺損分型，需植骨者制定植骨方案 (結(jié)構(gòu)性骨塊均為自體髂骨，顆粒骨可為異體骨與自體骨混合植骨。在骨量充足的情況下均選擇自體骨 )，打入生物型壓配臼杯，直徑 54～68 mm，術(shù)中常規(guī)透視確定假體臼杯是否在位。

圖1 患者，女，73 歲 a：左側(cè)全髖關(guān)節(jié)置換術(shù)后 13 年，右側(cè)全髖關(guān)節(jié)置換術(shù)后 11 年，左側(cè)假體松動(dòng)，右側(cè)假體未見異常；b：行左側(cè)全髖關(guān)節(jié)翻修術(shù)后1 年，臼底骨缺損采用髂骨片封堵及顆粒骨打壓植骨，大臼杯 (68 mm ) 翻修；c：術(shù)中取自體髂骨，并修剪松質(zhì)骨成粒狀，單皮質(zhì)髂骨片封堵臼底，顆粒骨打壓植骨圖2 患者，男，47 歲 a：左側(cè)全髖關(guān)節(jié)置換術(shù)后 24 年，假體松動(dòng)；b：左髖假體取出后，臼窩內(nèi)予以顆粒打壓植骨 + 大臼杯 (64 mm ) 翻修圖3 患者，女，57 歲 a：左側(cè)髖關(guān)節(jié)置換術(shù)后 27 年；b：左側(cè)全髖翻修術(shù)后1 年，臼頂植骨螺釘固定，60 mm 臼杯Fig.1 A 73-year-old female a: She had prosthetic loosening in the left side at 13 years after THA in the left side and no abnormity in the right prosthesis was noticed at 11 years after THA in the right 3bside; b: At1 year after THA in the left side, iliac bone fap was used to seal the acetabular notch, combined with compacted and morselized bone graft and jumbo acetabular cup revision (68 mm ); c: The autologous ilium was taken out during the operation, and the cancellous bone was cut to be granular. Unicortical iliac bone fap was used to seal the acetabular notch, combined with compacted and morselized bone graftFig.2 A 47-year-old male a: Prosthetic loosening was noticed in him at 24 years after he underwent THA in the left side; b: After the left hip prosthesis was taken out, compacted and morselized bone graft and jumbo acetabular cup revision (64 mm ) were performed in the acetabular fossaFig.3 A 57-year-old female a: The X-ray showed her conditions at 27 years after she underwent THA in the left side; b: At1 year after THA in the left side, a jumbo acetabular cup (60 mm ) was used for bone graft of the acetabular dome with the screw fxation

四、統(tǒng)計(jì)學(xué)分析

使用 SPSS 13.0 統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)處理。翻修前后髖關(guān)節(jié)功能采用 Harris 評(píng)分及 VAS 評(píng)分，獨(dú)立樣本 t 檢驗(yàn)，雙側(cè)。以 P＜0.05 認(rèn)為差異有統(tǒng)計(jì)學(xué)意義。

表2 術(shù)前與術(shù)后 Harris、VAS 評(píng)分方法的評(píng)定結(jié)果 (±s)Tab.2 The preoperative and postoperative evaluation results according to the Harris hip score and VAS score (±s)

表2 術(shù)前與術(shù)后 Harris、VAS 評(píng)分方法的評(píng)定結(jié)果 (±s)Tab.2 The preoperative and postoperative evaluation results according to the Harris hip score and VAS score (±s)

注：Harris 評(píng)分：術(shù)后 12 個(gè)月與術(shù)前比：t = 16.98，P＜0.01；術(shù)后3 年與術(shù)前：t = 17.99，P＜0.01；VAS 評(píng)分：術(shù)后 12 個(gè)月與術(shù)前比：t = 9.89，P＜0.01；術(shù)后3 年與術(shù)前比：t = 11.02，P＜0.01Notice: The preoperative Harris hip score was compared with the score at 12 months after the operation: t=16.98, P＜0.01; The preoperative Harris hip score was compared with the score at3 years after the operation: t=17.99, P＜0.01; The preoperative VAS score was compared with the score at 12 months after the operation: t=9.89, P＜0.01; The preoperative VAS score was compared with the score at3 years after the operation: t=11.02, P＜0.01

時(shí)間 Harris 評(píng)分 VAS 評(píng)分術(shù)前 44.92±10.53 4.58±1.69術(shù)后 12 個(gè)月 84.75± 4.61 0.71±0.91術(shù)后3 年 88.88± 5.70 0.50±0.66

結(jié) 果

本組平均隨訪 23.84 (12～83 ) 個(gè)月，翻修術(shù)后原髖關(guān)節(jié)疼痛癥狀均明顯緩解，髖關(guān)節(jié)功能明顯改善 (表2)。本組翻修術(shù)中未出現(xiàn)髖臼骨折、術(shù)后假體周圍感染、假體脫位、坐骨神經(jīng)損傷及下肢近端深靜脈血栓、肺栓塞等并發(fā)癥。術(shù)后 7 天，本組病例中有 13 例存在輕-中度小腿腫脹，通過血管彩超檢查有4 例存在腓腸肌間靜脈血栓，1 例為脛后靜脈血栓，通過低分子肝素鈣 (4000 U，皮下注射，2 次 / 日 ) 治療后均消失，術(shù)后1 年復(fù)查 X 線片可見3 例存在骨化性肌炎 (I 度 )，未作特殊處理。術(shù)后3 年仍有5 例翻修側(cè)大腿肌肉萎縮，肌力較對(duì)側(cè)減退，但均為 V 級(jí)。影像學(xué)顯示假體無松動(dòng)跡象，植骨愈合良好。

討 論

髖關(guān)節(jié)翻修常常面臨骨缺損，對(duì)于存在骨缺損的髖臼，影響因素主要為以下3 方面：翻修前對(duì)髖臼缺損的準(zhǔn)確評(píng)價(jià)、髖臼骨結(jié)構(gòu)的重建、髖臼翻修假體的選擇[4]。如何選擇手術(shù)方案和假體、是否需要植骨？如何植骨？均是必須面對(duì)的難題。松動(dòng)的髖臼假體，往往伴隨著不同程度的骨缺損、骨溶解，其主要原因有假體松動(dòng)或感染引起的骨質(zhì)吸收、初次手術(shù)時(shí)骨質(zhì)切除過多、原發(fā)疾病所致的骨質(zhì)缺損而初次手術(shù)時(shí)未予以處理、假體和骨水泥取出過程中所致骨缺失等，而植骨及假體的選擇均需基于對(duì)需翻修的假體取出后的骨性髖臼的正確評(píng)價(jià)。處理原則：Paprosky II 型，最常見的髖臼骨缺損類型，患者自身骨組織可以與假體表面的接觸面積至少 70%，可以通過植骨修復(fù)骨缺損，但是植骨在假體的初始穩(wěn)定中不起主要作用，可考慮術(shù)后早期下地負(fù)重活動(dòng)。Paprosky III A 型，如果骨缺損＜50%，使用非骨水泥的生物學(xué)固定髖臼假體，可能需結(jié)構(gòu)性植骨或打壓植骨；如果骨缺損＞50%，在可獲得良好的髖臼骨性重建的前提下，仍采用大臼杯，但需臥床至影像學(xué)植骨愈合。

術(shù)前高質(zhì)量的影像學(xué)資料直接影響對(duì)骨性髖臼的判斷，通常包括雙側(cè)髖關(guān)節(jié)正位片、患側(cè)髖關(guān)節(jié)正側(cè)位及 Judet 位片，必要時(shí)還需 CT 平掃加三維重建。盡管如此，影像學(xué)表現(xiàn)的骨缺損往往較直視下骨缺損的程度要輕，因而需要在術(shù)中，尤其是假體取出后對(duì)骨性髖臼的缺損程度再次評(píng)估。我們傾向于采用 Paprosky 分型，Paprosky 分型重點(diǎn)對(duì)髖臼緣、臼壁 / 頂、柱、髖臼中心移位及淚滴溶解作出描述，強(qiáng)調(diào)對(duì)髖臼的三維結(jié)構(gòu)，包括髖臼緣、前后柱以及內(nèi)側(cè)壁結(jié)構(gòu)的破壞程度進(jìn)行評(píng)估，對(duì)髖臼重建方法有很好的指導(dǎo)性[5]。在髖臼翻修術(shù)中，常常需要針對(duì)不同類型的骨缺損采用不同的修復(fù)重建方法。無論哪種類型的骨缺損，在術(shù)中取出髖臼假體及打磨髖臼后，必須再次評(píng)估骨缺損的程度和真性髖臼邊緣及前后柱的狀況。

在本研究中，主要是針對(duì) Paprosky II 型及Paprosky III A 型骨缺損的手術(shù)治療。Paprosky II 型骨缺損是髖關(guān)節(jié)翻修術(shù)中最常見的髖臼骨缺損類型，宿主骨與假體表面的接觸面積至少達(dá) 70%，該型骨缺損前、后柱尚存，且向上內(nèi)、上外及內(nèi)側(cè)移位均＜2 cm，對(duì)假體的支撐良好，如需要可以通過植骨或不植骨置入大臼杯髖臼假體。

Paprosky III A型骨缺損，髖臼緣、臼壁 / 頂部分或明顯缺損，缺損侵犯前后柱，髖臼中心向上外移位＜2 cm，淚滴中等程度溶解，宿主骨床與假體的接觸＜50% 或＞50%。對(duì)于接觸＜50% 的骨缺損，單純通過顆?；蚝?jiǎn)單結(jié)構(gòu)植骨均難以達(dá)到對(duì)假體的良好支撐，而接觸＞50% 的骨缺損仍然有機(jī)會(huì)通過結(jié)構(gòu)植骨、結(jié)構(gòu)植骨＋顆粒植骨來達(dá)到對(duì)假體的支撐[6-7]。因此，我們倡導(dǎo)適量植骨，并通過高位球中心植入技術(shù)[8]，配合大臼杯，使臼杯表面與骨床密貼接觸 50%～70%，以盡量避免采用單用大塊結(jié)構(gòu)性植骨或自體骨與異體骨混合植骨，因其血管化骨重建將導(dǎo)致植骨塊的吸收、塌陷，從而減弱對(duì)假體臼的支撐作用。我們采用適當(dāng)向近端挫磨并擴(kuò)大、加深髖臼，打入大臼杯，必要時(shí)于臼底植入自體髂骨制備的骨塊進(jìn)行臼底“封堵” 的方法使假體與自身殘留骨組織及植骨床接觸面積至少 50%，而雙下肢平衡及偏心距均通過假體柄及頸的長(zhǎng)度來調(diào)節(jié)。高位球中心對(duì)髖關(guān)節(jié)生物力學(xué)及假體壽命的影響尚存爭(zhēng)論[9-10]，且短期隨訪亦不能明確其影響大小，我們主張?jiān)谥亟y臼時(shí)，盡量恢復(fù)髖關(guān)節(jié)旋轉(zhuǎn)中心。

大塊的結(jié)構(gòu)性植骨的愈合存在骨吸收過程，并沒有長(zhǎng)入非骨水泥假體的潛力[11]，在其未完全重塑時(shí)對(duì)假體的穩(wěn)定有一定的影響，從而可能出現(xiàn)較高的遠(yuǎn)期失敗率，當(dāng)髖臼前后柱存在明顯骨缺損時(shí)，建議舍棄大臼杯假體，而選擇加強(qiáng)杯或鈦網(wǎng)重建。在 Paprosky II 型病例中，其前后柱及臼底均完整，通過挫磨使部分腔隙性骨缺損消失，可在植入大臼杯時(shí)達(dá)到緊密壓配，殘留的腔隙性骨缺損亦可通過顆粒植骨填充，從而簡(jiǎn)化手術(shù)，獲得早期下地活動(dòng)的機(jī)會(huì)；在 Paprosky III A 型病例中，其臼壁 / 底部分缺損、髖臼中心通常向上外移位，淚滴中度溶解，對(duì)于骨缺損＞50%，通過挫磨擴(kuò)大仍難以達(dá)到宿主骨與假體接觸面積至少達(dá)到 50% 者，須采用骨水泥翻修；對(duì)于骨缺損＜50% 的髖臼，采用加深和擴(kuò)大骨性髖臼的方案，增加與假體的骨性貼合，均可使假體表面與宿主骨接觸至少達(dá)到 70%，并對(duì)臼底有穿透的病例，采用削薄的髂骨單側(cè)皮質(zhì)骨塊“封堵”，結(jié)合顆粒植骨反挫、壓實(shí)的方法，增加骨儲(chǔ)備；而臼頂?shù)墓侨睋p，其并不對(duì)假體的初始穩(wěn)定性構(gòu)成明顯的威脅，挫磨擴(kuò)大髖臼后，缺損可明顯縮小，在缺損的骨質(zhì)表面打磨毛糙后卡入3 塊帶皮質(zhì)骨的髂骨塊，2～3 枚螺釘固定即可獲得重建。盡管結(jié)構(gòu)性植骨塊在愈合過程中均會(huì)有吸收發(fā)生(吸收范圍 2～5 mm )，減弱對(duì)假體的支撐，但其在治療中仍是一個(gè)有用的手段[12]，并對(duì)假體長(zhǎng)期穩(wěn)定有一定的作用。

采用大臼杯翻修髖臼，需通過加深、擴(kuò)大骨性髖臼來獲得更大的包容，術(shù)前及術(shù)中的評(píng)估十分重要，我們更強(qiáng)調(diào)術(shù)中的全面評(píng)估，避免出現(xiàn)髖臼擴(kuò)大后前后柱骨折及臼底的陷入，從而被迫換用骨水泥型髖臼假體或加強(qiáng)杯等。在選擇挫磨擴(kuò)大髖臼時(shí)應(yīng)十分慎重，主要考慮的因素包括臼底的厚度、前柱及后柱殘存量、淚滴的完整與否。對(duì)于一個(gè)已變形的髖臼，臼杯的放置亦相對(duì)困難，此時(shí)可采用髖臼橫韌帶參考及以術(shù)中拍片確定假體角度、深度。在大臼杯假體放置存在困難時(shí)，顆粒打壓植骨配合骨水泥聚乙烯臼杯，以及應(yīng)用鈦網(wǎng)聯(lián)合顆粒骨打壓植骨修復(fù)中重度髖臼骨缺損[13]，均是較好的備用方案。

大臼杯在國(guó)外通常是指直徑＞60 mm 的生物臼杯，因中國(guó)人體骨骼偏小，54～56 mm 以上即可認(rèn)為是大臼杯，近年來國(guó)外已將大臼杯廣泛應(yīng)用于髖臼存在骨缺損的髖關(guān)節(jié)翻修病例中，并報(bào)道獲得良好效果[14]。大臼杯可以被用來處理腔隙性骨缺損，亦可在前柱的節(jié)段性骨缺損及內(nèi)壁骨缺損中發(fā)揮良好作用，當(dāng)髖臼后柱及后壁完整，宿主骨能為假體提供至少 50% 接觸時(shí)，大臼杯可以作為髖臼翻修的首選。我們亦提倡根據(jù)髖臼骨缺損的程度及缺損類型，個(gè)體化選擇大臼杯[15]。

在髖關(guān)節(jié)翻修手術(shù)的病例中，髖臼無菌性松動(dòng)及骨溶解是翻修的主要原因，髖臼骨缺損 Paprosky分型法對(duì)選擇髖臼翻修重建方法有很好的指導(dǎo)性。Paprosky 分型 II～I(xiàn)II A 的髖臼，可通過采用大臼杯或聯(lián)合植骨來簡(jiǎn)化手術(shù)，避免大量植骨帶來的不利因素。但在準(zhǔn)備采用大臼杯時(shí)，挫磨過程中可能出現(xiàn)新的情況，如挫磨后缺損仍然較大致不能安裝大臼杯，打入大臼杯時(shí)出現(xiàn)骨折，前后柱薄弱支撐力不足等問題，此時(shí)應(yīng)果斷采用其他備選方案，以避免出現(xiàn)髖臼假體失敗。

[1]Paprosky WG, Magnus RE. Principles of bone grafting in revision total hip arthroplasty. Acetabular technique. Clin Orthop Relat Res, 1994, (298):147-155.

[2]Gill TJ, Sledge JB, Müller ME. The management of severe acetabular bone loss using structural allograft and acetabular reinforcement devices. J Arthroplasty, 2000, 15(1):1-7.

[3]Whaley AL, Berry DJ, Harmsen WS. Extra-large uncemented hemispherical acetabular components for revision total hip arthroplasty. J Bone Joint Surg Am, 2001, 83-A(9):1352-1357.

[4]馬文輝, 張學(xué)敏, 王繼芳. 假體置入及骨移植與髖臼翻修:理論與應(yīng)用. 中國(guó)組織工程研究與臨床康復(fù), 2010, 14(4): 680-683.

[5]Sheth NP, Nelson CL, Springer BD, et al. Acetabular bone loss in revision total hip arthroplasty: evaluation and management. J Am Acad Orthop Surg, 2013, 21(3):128-139.

[6]Moskal JT, Higgins ME, Shen J. Type III acetabular defect revision with bilobed components: five-year results. Clin Orthop Relat Res, 2008, 466(3):691-695.

[7]Civinini R, Capone A, Carulli C, et al. Acetabular revisions using a cementless oblong cup: five to ten year results. Int Orthop, 2008, 32(2):189-193.

[8]Christodoulou NA, Dialetis KP, Christodoulou AN. High hip center technique using a biconical threaded Zweymüller cup in osteoarthritis secondary to congenital hip disease. Clin Orthop Relat Res, 2010, 468(7):1912-1919.

[9]Dua A, Kiran K, Malhotra R, et al. Acetabular reconstruction using fresh frozen bone allograft. Hip Int, 2010, 20(2):143-149.

[10]Davis KE, Ritter MA, Berend ME, et al. The importance of range of motion after total hip arthroplasty. Clin Orthop Relat Res, 2007, 465:180-184.

[11]Dewal H, Chen F, Su E, et al. Use of structural bone graft with cementless acetabular cups in total hip arthroplasty. J Arthroplasty, 2003, 18(1):23-28.

[12]Kawanabe K, Akiyama H, Onishi E, et al. Revision total hip replacement using the Kerboull acetabular reinforcement device with morsellised or bulk graft: results at a mean followup of 8.7 years. J Bone Joint Surg Br, 2007, 89(1):26-31.

[13]郭亭, 趙建寧, 周利武, 等. 加強(qiáng)杯聯(lián)合植骨技術(shù)修復(fù)翻修術(shù)中巨大髖臼骨缺損. 中國(guó)矯形外科雜志, 2008, 16(5): 334-336.

[14]Lachiewicz PF, Soileau ES. Fixation, survival, and dislocation of jumbo acetabular components in revision hip arthroplasty. J Bone Joint Surg Am, 2013, 95(6):543-548.

[15]Wedemeyer C, Neuerburg C, Heep H, et al. Jumbo cups for revision of acetabular defects after total hip arthroplasty: a retrospective review of a case series. Arch Orthop Trauma Surg, 2008, 128(6):545-550.

(本文編輯：李貴存 )

Application of jumbo cups for acetabular deficiencies in hip revision procedures used in acetabulum defects of the hip revision procedures

WANG Bei-yue, ZHOU Li-wu, ZHANG Zhi-qiang, GUO Ting, ZHAO Jian-ning. Department of Orthopedics, Nanjing General Hospital of Nanjing Military Command, Nanjing, Jiangsu, 210002, PRC

ObjectiveTo investigate the application of jumbo acetabular cups for Paprosky type II and type III A acetabular defciencies after total hip arthroplasty (THA ).MethodsThe clinical data of 24 patients who were diagnosed as acetabular defciencies of Paprosky type II or type III A after THA from March 2007 to May 2014 were retrospectively analyzed. There were 13 males and 11 females, whose average age was 61.46 years old (range: 34-77 years ). As to the reason of acetabular revision, there were 21 cases caused by aseptic loosening,2 cases by habitual hip dislocation and1 case by low toxicity infection. Primary and unilateral revision was performed on all the patients. Cemented acetabular prostheses were used in 11 cases, cementless acetabular prostheses in 10 cases and artifcaial femoral head arthrolasty in3 cases. According to the Paprosky acetabular defect classifcation, there were 7 hips of type II A, 6 hips of type II B,5 hips of type II C and 6 hips of type III A. Jumbo acetabular cups or combined with bone grafts were used in acetabular revision with prostheses. For the patients with acetabular defciencies of Paprosky type II, the acetabulum was reamed and enlarged on the premise that the stability of the prosthesis was not affected, and then morselized bone graft was performed or the acetabular prosthesis with a jumbo cup was directly put in. For the patients with acetabular defciencies of Paprosky type III A, an appropriate amount of compacted and morselized bone graft was used. Structural bone graft or the acetabular notch sealing was carried out, so as to increase the bonemass. The implantation technique through the center of the high ball could be directly adopted, with jumbo acetabular cups embedded. The problems of the balance of both lower limbs and the eccentricity could be handled by adjusting the length of the prosthetic handle and neck. A regular follow-up was carried out after the operation. The Harris hip score and Visual Analogue Scale (VAS ) score were used to evaluate the hip function and state. The prosthetic stability and bone union were judged based on the X-ray. Results All the patients were followed up for a mean period of 23.84 months (range: 12-83 months ) to evaluate the hip function and the pain problem. The Harris hip scores were (44.92±10.53 ) points, (84.75±4.61 ) points and (88.88±5.70 ) points preoperatively and at1 and3 years after the operation (P＜0.01 ). The VAS scores were (4.58±1.69 ) points, (0.71±0.91 ) points and (0.50±0.66 ) points preoperatively and at1 and3 years after the operation (P＜0.01 ). No patient required a second revision because of the failure of prosthetic revision. The X-ray showed strong evidence of trabecular bridging between the bone graft and the host bone. The gait of the patients recovered to normal, and their walking was not affected by prosthetic dislocation or loosening or abnormal hip pain during the follow-up. At1 year after the operation, the hip fexion angel reached to more than 90°. And at3 years after the operation, the patients could complete daily activities, and even jog or squat. Conclusions Jumbo acetabular cups or combined with morselized or structural bone graft are effective for Paprosky type II and type III A acetabular defciencies after THA. The diffculty in acetabular revision can be reduced and the results are excellent, with reasonable selection of the prostheses and suitable management of acetabular defciencies.

Hip joint; Arthroplasty, replacement, hip; Joint prosthesis; Acetabulum

10.3969/j.issn.2095-252X.2014.06.004

R687.4

江蘇省臨床醫(yī)學(xué)科技專項(xiàng)資助 (BL2012002 )

210002 江蘇，南京軍區(qū)南京總醫(yī)院骨科 (王北岳，周利武，郭亭，趙建寧 )；蘇北人民醫(yī)院骨科 (張志強(qiáng) )

趙建寧，Email: zhaojianning.0207@163.com

2013-10-06 )