Gravius Sascha, Mumme Torsten, Weber Oliver, Berdel Philipp, Wirtz Dieter Christian
Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany.
Oper Orthop Traumatol. 2009 Dec;21(6):586-601. doi: 10.1007/s00064-009-2007-x.
Objective Bone-preserving hip resurfacing in young and active patients using a soft-tissue-sparing, modified transgluteal, lateral approach.
Primary hip osteoarthritis in physically active, working patients aged < 65 years (males) and < 60 years (females). Good bone quality.
Male patients > or = 65 years of age, female patients > or = 60 years of age. Necrosis of the femoral head. Varus deformity of the femoral neck with a reduced horizontal femoral offset. Femoral head cysts (> 1 cm in diameter). Infection. Osteoporosis. Rheumatoid arthritis. Tumor. Reduced renal function. Leg length difference (> or = 1 cm). Metal allergy. Previous femoral neck fracture. Previous intertrochanteric femoral osteotomies.
Supine position of the patient. Modified transgluteal, lateral approach to the hip joint. Luxation of the femoral head. First, reaming of the femoral head to improve visualization of the acetabular cup. Central positioning of the guide wire in the femoral neck in a slight valgus position of approximately +5 degrees to the anatomic collodiaphyseal (CCD) angle using the mechanical targeting device. Overdrilling of the central guide wire to the appropriate depth for the implant. Central insertion of the guide rod. Preparation of the femoral head over the guide rod using cylinder cutters one or two sizes larger than the smallest possible femoral component. Cement-free implantation of the acetabular component according to the predetermined definitive size of the femoral component. Final preparation of the femoral head using profile, surface and forming cutter. Following cemented implantation of the femoral component, repositioning of the hip joint and conclusion of the surgical procedure.
Mobilization of the patient using two forearm crutches as of the 1st day after surgery. Removal of the Redon drains after 24 h. Partial weight bearing of 20 kg for 3 weeks under continuation of thrombosis prophylaxis. Limitation of hip flexion to 90 degrees during the first 6 postoperative weeks, and no adduction and forced external rotation allowed in order to avoid luxation. Avoidance of sports involving the loads of jumping and axial impact loading for 12 postoperative months.
Analysis involved the pre- and postoperative functions of 72 patients with a total of 82 prostheses and a mean durability time of 29.2 +/- 11 months based on the Harris Hip Score (HHS), the modified UCLA (University of California, Los Angeles) activity index, and the Merle d'Aubigné Score. Postoperatively, prosthetic angle and femoral offset as well as periprosthetic signs of loosening/lytic areas were assessed by means of radiology and compared with the preoperative CCD angle and femoral offset. Compared to the preoperative evaluation, follow-up yielded a significant increase in the average HHS values (94 +/- 4.6 vs. 40.1 +/- 7 points), the modified UCLA activity index (8.9 +/- 2.6 vs. 4.6 +/- 2.2), and the Merle d'Aubigné Score (17.9 +/- 1.9 vs. 7.3 +/- 2.4; p < or = 0.05). In 98.8%, a solid osteointegration of the cup and femoral components was observed. The average deviation of the physiological CCD angle (136.6 degrees +/- 3.6 degrees ) from the postoperative angle of the prosthesis (142.6 degrees +/- 4.9 degrees ) was 6 degrees +/- 2.8 degrees . The postoperative femoral offset was reduced by an average of 2.3 mm compared to the preoperative offset. During clinical follow-up n = 2 prostheses (2.5%) required revision (one femoral neck fracture; one periarticular ossification [Brooker III]).
采用保留软组织的改良经臀外侧入路，为年轻且活动量大的患者进行保骨型髋关节表面置换术。
年龄小于65岁（男性）及小于60岁（女性）、身体活跃且仍在工作的原发性髋关节骨关节炎患者。骨质良好。
年龄大于或等于65岁的男性患者，年龄大于或等于60岁的女性患者。股骨头坏死。股骨颈内翻畸形且股骨水平偏移减小。股骨头囊肿（直径>1cm）。感染。骨质疏松症。类风湿性关节炎。肿瘤。肾功能减退。双下肢长度差异（>或=1cm）。金属过敏。既往股骨颈骨折。既往股骨转子间截骨术。
患者仰卧位。采用改良经臀外侧入路至髋关节。股骨头脱位。首先，对股骨头进行扩髓，以改善髋臼杯的可视化。使用机械瞄准装置，将导针在股骨颈中心定位，使其相对于解剖颈干角（CCD角）呈约+5度的轻度外翻位。将中心导针钻至植入物合适深度。插入中心导杆。使用比最小可能的股骨部件大一号或两号的圆柱铣刀，在导杆上对股骨头进行准备。根据股骨部件的预定最终尺寸，无骨水泥植入髋臼部件。使用仿形、表面和成型铣刀对股骨头进行最终准备。股骨部件骨水泥固定植入后，复位髋关节并完成手术。
术后第1天开始使用双前臂拐杖辅助患者活动。术后24小时拔除雷东引流管。在继续进行血栓预防的同时，部分负重20kg，持续3周。术后前6周将髋关节屈曲限制在90度，且不允许内收和强制外旋，以避免脱位。术后12个月内避免涉及跳跃和轴向冲击负荷的运动。
分析了72例患者共82个假体的术前和术后功能，基于Harris髋关节评分（HHS）、改良的加州大学洛杉矶分校（UCLA）活动指数和Merle d'Aubigné评分，平均耐用时间为29.2±11个月。术后，通过放射学评估假体角度、股骨偏移以及假体周围松动/溶骨区域的体征，并与术前CCD角和股骨偏移进行比较。与术前评估相比，随访结果显示平均HHS值（94±4.6对40.1±7分）、改良的UCLA活动指数（8.9±2.6对4.6±2.2）和Merle d'Aubigné评分（17.9±1.9对7.3±2.4；p≤0.05）均显著增加。在98.8%的病例中，观察到髋臼和股骨部件的牢固骨整合。生理CCD角（136.6度±3.6度）与术后假体角度（142.6度±4.9度）的平均偏差为6度±2.8度。术后股骨偏移与术前偏移相比平均减少了2.3mm。在临床随访期间，n = 2个假体（2.5%）需要翻修（1例股骨颈骨折；1例关节周围骨化[布鲁克三级]）。
