Morand F, Clarac J P, Gayet L E, Pries P
Service d'Orthopédie Adulte et Infantile, Hôpital Jean Bernard, C.H.R.U de la Milétrie, Poitiers.
Rev Chir Orthop Reparatrice Appar Mot. 1998 Apr;84(2):154-61.
Aseptic loosening of the acetabular component is the most worrying problem after hip arthroplasty. During revision surgery we prefer to rebuild a solid bony acetabulum close to the anatomy in which the implant will be cemented. On the basis of the first 48 acetabular reconstructions using deep-frozen bony allografts, we carried out a review of our results in a pathology which will surely increase in the future.
48 hips were operated according to this technique. It has been possible to review 38 of them, with an average follow-up of 7.3 years (extremes 5 years, and 9.6 years). The average age of the population at the time of surgery was 63 years. Two etiologies predominated: congenital hip dislocation sequelae and primitive hip arthritis. In 10 cases of massive deterioration, a Muller's ring was used to stabilize the allograft.
The results were analyzed at 6 months, 2 years, 4 years, and at maximum follow-up, clinically, according to Merle d'Aubigné grading system. Radiologically, Ranawat's criteria were used to assess the re-centering of the reconstructed hips. The development of radiolucent lines and implants migration were also assessed.
Clinically, the patients' comfort was always improved by pain relief. Radiologically, average acetabular upward migration of 5 mm and medialisation of 3.5 mm were observed. 24 hips presented radiolucent lines. 19 radiolucent lines were below 2 mm. 5 were greater than 2 mm and leaded to loosening. In 4 of these 5 cases of radiolucent lines, there were acetabular migrations with failure. The radiological image remained stable afterwards. In these cases there was a real loosening, necessitating further surgery. In all cases, partial resorption of the graft was observed.
Study of our first 38 cases shows that bony allograft and cemented acetabulum, sometimes including an armature, is one possible solution to the problem of difficult acetabular reconstructions. However, with an average follow-up of 7.3 years, we already have 5 (13 per cent) aseptic acetabular loosening, of which one has been operated on. Radiological analysis of these does not question the allograft, but rather imperfect re-centering. Analysis of the good results, 33 (87 per cent) stable acetabulum indicates re-fixing in quasi-anatomical position, in conditions close to those of a first time arthroplasty, with the aid of perfectly stabilized bony transplants, and where contact with the receiver acetabulum is maximal.
Our follow-up is one of the longest in literature. But with a migration rate already of 13 per cent, it is not yet sufficient for us to be permanently assured about the future of our patients, even if their age is greater and their activity less than those of patients having a first hip arthroplasty.
髋臼假体的无菌性松动是髋关节置换术后最令人担忧的问题。在翻修手术中，我们倾向于重建一个接近解剖结构的坚实骨质髋臼，并在其中植入骨水泥固定假体。基于最初48例使用深冻异体骨进行髋臼重建的病例，我们对结果进行了回顾，鉴于此类病理情况在未来肯定会增加。
48例髋关节采用此技术进行手术。其中38例得以进行回顾性分析，平均随访7.3年（最短5年，最长9.6年）。手术时患者的平均年龄为63岁。两种病因占主导：先天性髋关节脱位后遗症和原发性髋关节关节炎。在10例严重退变病例中，使用了穆勒环来稳定异体骨。
根据Merle d'Aubigné评分系统，在术后6个月、2年、4年及最长随访期进行临床结果分析。放射学上，采用Ranawat标准评估重建髋关节的复位情况。同时评估透亮线的出现及假体的移位情况。
临床上，患者的舒适度因疼痛缓解而始终得到改善。放射学上，观察到髋臼平均向上移位5mm，向内侧移位3.5mm。24例髋关节出现透亮线。19条透亮线小于2mm。5条大于2mm并导致松动。在这5例透亮线病例中，有4例髋臼移位且手术失败。此后放射学影像保持稳定。在这些病例中存在真正的松动，需要进一步手术。所有病例均观察到移植骨部分吸收。
对我们最初38例病例的研究表明，异体骨和骨水泥固定髋臼，有时包括一个金属加强结构是解决髋臼重建困难问题的一种可行方案。然而，平均随访7.3年，我们已经有5例（13%）出现无菌性髋臼松动，其中1例已接受再次手术。对这些病例的放射学分析并未质疑异体骨，而是认为复位不够完美。对33例（87%）髋臼稳定的良好结果分析表明，在接近初次关节置换的条件下，借助完美稳定的骨移植，在准解剖位置重新固定，且与接受髋臼接触最大化。
我们的随访是文献中最长的之一。但即使移位率已达13%，对于我们来说，也仍不足以让我们对患者的未来完全放心，即便他们的年龄较大且活动量比初次髋关节置换患者少。
