CFP 假体在微创全髋关节成形术中的应用

Hip Int(2010;:Suppl 7)S52-S5720THA: sHorT sTemINTRODUCTIONConservative surgery has played a decisive role in recent hip prosthesis development (1-5); only pathological tissue is removed and all healthy bone preserved. This is the main objective of resurfacing and short-stem prostheses. The bony architecture is preserved, especially the femoral neck and the accompanying endosteal circulation and mechani-cal stress distribution systems. This makes these devices the best solution to treat hip disorders in young and active patients according to many authors (1-5). The collum fe-moris preserving (CFP) system preserves the femoral neck and metaphyseal cancellous bone (6).In 2001 we began to use the CFP system to preserve the femoral neck during hip arthroplasty in patients without anatomical deformities. I hypothesized that the use of the CFP system would have good early results in active patients. I then asked whether this conservative system would influence the clinical and radiological results during our learning curve and reached initial conclusions. In addi-tion, I assessed the early complications. MATERIALS AND METHODSBetween October 2001 and October 2009, 138 consecuti-ve primary cementless total hip arthroplasties were perfor-med in 128 patients using the CFP system. All operationsLearning curve and short-term results with ashort-stem CFP systemMiquel PonsOrthopaedic Surgery Department, Sant Rafael Hospital, Barcelona, Catalonia – SpainA bstrAct. In conservative hip replacement it is important to remove only pathological tissue to pre-serve as much healthy bone as possible. The collum femoris preserving (CFP) system preserves thefemoral neck and metaphyseal cancellous bone. We present our learning curve with this system andour preliminary results and conclusions.During 2001-2009 we placed 138 CFP prostheses in 90 men and 38 women (10 bilateral). The meanage of the patients was 57.1 years (range 22-76 years) and the mean follow-up 38.3 months. Seventy-three patients were active workers at the time of surgery. All patients began partial weight bearing at24-36 hours and total weight bearing was allowed at 3 weeks postoperative. We have had 1 infection,2 intraoperative partial shaft fractures that did not require treatment, 1 acetabular loosening, and 2periprosthetic traumatic fractures treated by osteosynthesis in one case and femoral revision in theother. All but 3 active workers returned to work and 54.5% of the studied patients practice some sportor physical activity. The stem size was correct in 125 hips. Resorption at the prosthetic rim was foundin 9 out of 134 hips. No clinical symptoms were found in these patients. There have been no stemrevisions for aseptic loosening in the follow-up study. Although the current follow-up is too short toallow definitive conclusions, the CFP system has provided excellent short-term results.K ey W ords. CFP system, Short stem, Hip replacementPonstively collect data. Of the 138 hips, 4 cases were excluded because of death not related to the surgical process (1 hip) or because they were lost to follow-up (3 hips). Thus, 134 were available for this study with an average follow-up of 38.3 months (range 1-98 months).The stem of the CFP system (Waldemar Link, Hamburg, Germany) preserves the femoral neck and proximal can-cellous bone because the osteotomy is performed at the isthmus and the femoral canal is prepared by compressing the cancellous bone with a bone compressor. Two anato-mic stem curvatures with 5 different sizes ensure secure support of the stem at the medial cortex. The choice of the curve is chosen during pre-planning. The stem is compo-sed of titanium with aluminium and hydroxyapatite in the proximal part. It includes longitudinal crests and a mobile collar for primary fixation (Fig. 1).A posterolateral approach was used in all hips. The femur was prepared using the bone compressor without intrame-dullary reamers. A trial reduction was done with the final bone compressor in place. In all, 108 (78.2%) curve A and 30 (21.8%) curveB stems were implanted and the sizes used were extra small: 21 (15.2%); small: 44 (31.8%); me-dium: 60 (43.4%); large: 9 (6.5%), and extra large: 4 (2.8%). Two different types of cups were implanted: the trabecu-lae-oriented pattern (TOP) acetabular cup (Waldemar Link, Hamburg, Germany) with a polyethylene insert, and the Betacup system (Waldemar Link, Hamburg, Germany) with a ceramic liner (Biolox ® delta, Ceramtec AG, Plochingen, Germany), which has been inserted in younger patients since 2007. Twenty-eight-millimetre ceramic (Biolox forte, CeramTec AG, Plochingen, Germany) heads were used in all TOP cups and 36-mm ceramic heads (Biolox delta, Ceramtec AG, Plochingen, Germany) in Betacup cups of size from 50 mm (28 mm in smaller cups). The implanted femoral head sizes were 40 mm: 65 (47.1%), 43 mm: 48 (34.7%), and 47 mm: 25 (18.1%).Postoperatively, all patients received an antibiotic and low-molecular-weight heparin subcutaneously to prevent thromboembolic incidents. Partial weight bearing as tole-rated was allowed immediately with the use of crutches for the first 3 weeks and full weight bearing with 1 crutch or cane for the next 2-3 weeks.Patients were clinically evaluated for pain, function, and range of motion according to the Harris scale (8) in the immediate postoperative period and then at 6 weeks, 3, 6 and 12 months, and every year thereafter. Postopera-tive radiographs using standard anteroposterior and late-were done by the author. The number of CFP prostheses placed has been increasing over this decade (Tab. I). The cohort included 90 male and 38 female patients with a mean age of 57.1 years (range, 22-76 years) at the time of surgery. No specific age criteria were used for implant selection. The most common preoperative diagnosis was osteoarthritis (84.8%). Patients with anatomic deformities in the femoral head and neck such as developmental dy-splasia of the hip, slipped capital femoral epiphysis, post-septic and traumatic arthritis were excluded. Seventy-th-ree of the 128 patients were active workers at the time of surgery; this means they were included in groups 4 and 5 on Devane’s patient activity level classification (7). All CFP arthroplasties were entered into a joint registry to prospec-TABLe I - N UMBER OF CFP STEMS IMPLANTED FROM2001 TO 20092001 2002 2003 2004 2005 2006 2007 2008 2009*37791014163933*From January until October.A Fig. 1 - Photographs showing a view of a CFP femoral stem. A) An-teroposterior view; B) lateral view.Short-term results with the CFP systemditional treatment. No vascular or nervous complications occurred. Postoperative complications included 1 chronic infection by Staphylococcus aureus treated by 2-stage replacement with a standard primary stem, 1 acetabular loosening treated with cup revision, and 2 post-traumatic periprosthetic fractures at 3 and 102 days treated with fe-moral revision in 1 case (Fig. 3) and osteosynthesis in the other (Fig. 4). No implant dislocation occurred.ral projections were made following the same protocol as in the clinical evaluation to assess stem and cup position and status. The patient was positioned supine with his or her feet together. The X-ray tube was positioned over the symphysis pubis 1 m from and perpendicular to the ta-ble. Stem orientation was determined by the position of the stem relative to the contact of the tip to the medial or lateral cortex and was defined as neutral, valgus (contact between the tip and the medial cortex) or varus (contact between the tip and the lateral cortex). Stem size was de-termined by the medullary filling in the distal third of the stem and was defined as correct (gap between the stem and cortical bone 1-2 mm), oversized (hard contact betwe-en stem and cortical bone) or undersized (gap >2 mm). The response of the femoral bone to the implanted stem was evaluated according to the distribution of any radiolucent lines, or osteolysis or bone resorption on the anteroposte-rior radiographs using Gruen zones (9). Particular attention was paid to the state of the bone in the lateral and medial parts of the femoral neck immediately below the rim of the prosthesis (Gruen zones 1 and 7) (10).RESULTSIntraoperative complications included 1 fracture of the fe-moral diaphysis at the tip of the stem and 1 fracture at the femoral metaphysis (Fig. 2). Neither of these required ad-A A A B BBFig. 2 - A) Radiograph showing a methaphyseal fracture that did not require further treatment. B) Radiograph of the same patient 3 months later showing the healed fracture.Fig. 4 - A) Radiograph showing a periprosthetic fracture. B) Radio-graph of the same patient after the fracture was treated with osteo-synthesis.Fig. 3 - A) Radiograph showing a periprosthetic fracture. B) Radio-graph of the same patient after the fracture was treated with stem revision and cerclage.Ponscycling, swimming, etc) at an amateur level or physical activity (walking, Nordic walking) according to the Hip So-ciety surveys (11). There have been no stem revisions for aseptic loosening in the follow-up study in this series. Stem size was correct in 125 cases (90.57%), oversized in 5 (3.6%), and undersized in 8 (5.7%). Eleven of the 13 incorrect stems were among the first 60 cases treated (Fig. 5). The stem was implanted in neutral position in 128 cases (92.7%), aligned in valgus in 7 cases (5%), and aligned in varus in 3 (2.1%). There was no difference between the first 60 and subsequent cases. In 8 cases (5.7%) there was evidence of a small gap beneath the prosthetic rim in the immediate postoperative radiogra-ph without clinical relevance in the follow-up. In 2 cases complete resorption of the calcar was observed. One case was progressive resorption, while the other was an acute process between months 3 and 5 postoperative-ly (Fig. 6). Resorption at the prosthetic rim, resembling a rounded-off spur <3 mm, was found in 9 out of 134 cases (6.7%); in 7 cases it occurred at the medial part of the femoral neck in Gruen zone 1 below the rim, in 1 case at the lateral part in Gruen zone 7, and in the last case in both zones (Fig. 7). No clinical symptoms were found in these patients. Heterotopic ossification was ob-served in 8 of the 111 prostheses (7.2%) with a minimum follow-up of 6 months. All the ossifications were grade I according to the classification of Brooker et al (12) and were observed close to the acetabular rim.During the first weeks only 2 patients reported slight thi-gh pain and 2 reported pain in the trochanteric area; one of them required medication and physical treatment. The clinical results according to the Harris scale were 30.2 points (range, 18-48) before surgery, 76.4 points (range, 63-84) at 3 months, and 92 points (range, 88-100) at the last follow-up evaluation. Seventy out of 73 employed pa-tients (95.8%) returned to a full normal lifestyle and work activities (Devane groups 4 and 5) and 54.5% of patients were also able to practice sports (tennis, golf, skiing,A B CFig. 5 - Anteroposterior postop-erative radiographs of different hips with excellent clinical results showing radiographic osseointe-gration in all hips. A) Correct CFP stem; B) oversized CFP stem; C) undersized CFP stem.A BFig. 6 - Anteroposterior postoperative radiographs with excellent clinical results showing calcar resorption. A) Immediate postoper-ative radiography; B) radiograph of the same patient at 3 months postsurgery.Short-term results with the CFP systemand 1 to a periprosthetic fracture. Only 2 patients reported slight thigh pain and 2 reported trochanteric pain. No major intraoperative or postoperative complications due to the prosthesis occurred in our patients. The radiological results are quite similar to the results reported by the designer of this system (10, 13) with some differences: I found 2 calcar resorptions, due to an oversized stem and stress shielding in 1 case and to an unknown cause in the other (we su-spect a subacute infection with a low-virulence bacterium). In our series, resorption at the prosthetic rim resembling a rounded-off spur was more common in the medial part of the femoral neck than in the lateral part. Heterotopic ossi-fications were much less frequent in our series (7.2%) than in the Pipino series (44%) (10, 13). This difference may be due to the approach: Pipino used the Watson-Jones ap-proach and found ossifications on the greater trochanter close to the insertion of the musculi gluteus minimus and vastus lateralis, while we used a posterior approach and observed some grade I heterotopic ossifications close to the acetabular rim. We believe that an undersized yet well-aligned stem will provide a good mid- to long-term out-come, while an oversized stem may cause metaphyseal fractures or neck resorption by stress shielding, as Pipino has also reported (10).There were several limitations to our study. First, the rela-tively small cohort available for analysis. Second, the short follow-up combined with the small patient number also limited our ability to generate definitive conclusions, so our conclusions must be considered preliminary. Radiographic ingrowth is essential to obtain an excellent long-term clini-cal result and this radiographic finding can be detected at early follow-up evaluations; it has already been attained by all hips in our series.The primary aim of the study was to assess the early cli-DISCUSSIONHip replacement with preservation of the femoral neck re-establishes the natural offset, restores the hip to its natural equilibrium, and balances the tension of the medial and pelvitrochanteric muscles (13). Jasty et al (14), in a canine model, demonstrated that in a proximally coated stem that achieves immediate proximal stability the distal portion of the stem becomes useless. Whiteside et al (15) in adult human cadaver femora determined the effect of different neck resection levels on torsional resistance of the femo-ral component to investigate why loosening of the femoral component in total hip arthroplasty commonly results from inadequate resistance to torsional loads. They demonstra-ted that preserving the femoral neck provides an effective means of resistance. Maintaining the entire femoral neck is most effective in reducing micromotion at low loads, while maintaining the midshaft area of the femoral neck appears to be most effective in controlling micromotion at higher torsional loads. Resection below the midshaft of the neck markedly decreases the torsional load-bearing capacity of the proximal femur. Kim et al (16) studied a very short ex-perimental stem implanted in human cadaver femora and reported that this stem, which had a more anatomical pro-ximal fit without having a distal stem and cortex contact, could provide immediate postoperative stability. The au-thors found that pure proximal loading by the experimental stem in the metaphysis, reduction of excessive bending stiffness of the stem by tapering, and the absence of con-tact between the stem and the distal cortex could reduce stress shielding, bone resorption, and thigh pain.In our initial experience the results are encouraging in that we have not had any aseptic loosening and only 2 stem revisions have been necessary, 1 due to a chronic infection A B CFig. 7 - Anteroposterior postop-erative radiographs of different hips with excellent clinical re-sults showing resorption at the prosthetic rim. A) Resorption at Gruen zone 1; B) at Gruen zone 7; C) in both zones.PonsNo benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. The author has no financial relationship with any organisation that sponsored the research.Address for correspondence:Miquel Pons, MD Hospital San RafaelP . Vall d’Hebrón 107-117Barcelona 08035, Spain 23655mpc@comb.catnical and radiographic results after hip replacement with preservation of the femoral neck using the CFP prosthesis. Although the current follow-up in this series is too short to allow definitive conclusions, the CFP system has provided excellent short-term results. The lack of a sufficient patient number means that the present results can only be con-sidered as preliminary data in support of the hypothesis. Continued follow-up is required to determine if the use of CFP prostheses results in less osteolysis and loosening.REFERENCESLingard EA, Muthumayandi K, Holland JP . Comparison of 1.patient-reported outcomes between hip resurfacing and total hip replacement. J Bone Joint Surg Br 2009; 91: 1550-4.Killampalli VV , Kundra RK, Chaudhry F , Chowdhry M, Fisher 2.NE, Reading AD. Resurfacing and uncemented arthroplasty for young hip arthritis: functional outcomes at 5 years. Hip Int 2009; 19: 234-8.Daniel J, Pynsent PB, McMinn DJW. Metal on metal resur-3.facing of the hip in patients under the age of 55 years with osteoarthritis. J Bone Joint Surg Br 2004; 86: 177-84.Goebel D, Schultz W. The Mayo cementless femoral com-4.ponent in active patients with osteoarthritis. Hip Int 2009; 19: 206-10.Ghera S, Pavan L. The DePuy Proxima hip: a short stem for 5.total hip arthroplasty. Early experience and technical consid-erations. Hip Int 2009; 19: 215-20.Pipino F , Molfeta L, Grandizio M. Preservation of the femoral 6.neck in hip arthroplasty: results of a 13 to 17 year follow-up. J Orthop Traumatol 2000; 1: 31-9.Devane PA, Horne JG, Martin K, Coldham G, Krause B. 7.Three-dimensional polyethylene wear of a press-fit titanium prosthesis. Factors influencing generation of polyethylene debris. J Arthroplasty 1997; 12: 256-66.Harris WH. Traumatic arthritis of the hip after dislocation 8.and acetabular fractures: treatment by mold arthroplasty. Anend-result study using a new method of result evaluation. J Bone Joint Surg Am 1969; 51: 737-55.Gruen TA, McNeice GM, Amstutz HC. Modes of failure of ce-9.mented stem-type femoral components. Clin Orthop Relat Res 1976; 369: 59-72.Biggi F , Franchin F , Lovato R, Pipino F . DEXA evaluation of 10.total hip arthroplasty with neck-preserving technique: 4-year follow-up. J Orthop Traumatol 2004; 5: 156-9.Healy WL, Sharma S, Schwartz B, Iorio R. Athletic activity 11.after total joint arthroplasty. J Bone Joint Surg Am 2008; 90: 2245-52.Brooker AF , Bowerman JW, Robinson RA, Riley LH Jr. Ec-12.topic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am 1973; 55: 1629-32.Pipino F . CFP prosthetic stem in mini-invasive total hip ar-13. throplasty. J Orthop Traumatol 2004: 4: 165-71.Jasty M, Krushell R, Zalenski E, O’Connor D, Sedlacek R, 14.Harris W. The contribution of the nonporous distal stem to the stability of proximally porous-coated canine femoral components. J Arthroplasty 1993; 8: 33-41.Whiteside LA, White SE, McCarthy DS. Effect of neck resec-15.tion on torsional stability of cementless total hip arthroplasty. Am J Orthop 1995; 24: 766-70.Kim YH, Kim JS, Cho SH. Strain distribution in the proximal 16.human femur. An in vitro comparison in the intact femur and after insertion of reference and experimental femoral stems. J Bone Joint Surg Br 2001; 83: 295-301.Copyright of Hip International is the property of Wichtig Editore and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.。

人工关节置换治疗方法发布时间：2021-07-07T15:31:28.173Z 来源：《医师在线》2021年1月1期作者：雍雷[导读]雍雷（四川天府新区人民医院；四川成都610000）随着医学技术飞速发展，人工关节置换治疗方法逐渐得到许多患者的认可。

当前，人工关节置换治疗方法主要是采用金属、非金属等高分子化合物材料，对人体髋关节、膝关节、踝关节、肩关节等相关部位进行模拟，以此替代患者损伤较为严重的关节部位。

该种治疗方法主要应用于类风湿性关节炎、骨性关节炎、良性骨肿瘤以及股骨头无菌性坏死等病症。

人工关节置换治疗方法有效减轻患者疼痛感，改善患者关节功能，提高患者生活质量。

本文将以人工关节置换技术概述为着手点，分别对人工全髋关节置换方法与人工全膝关节置换方法进行分析探究。

一、人工关节置换技术概述20世纪40年代，人工关节置换治疗方法主要应用于肿瘤外伤以及骨病引起的关节损伤、坏损、畸形等症状，该种治疗方法可以消除患者骨关节疼痛，矫正患者关节畸形。

当前在人工关节置换治疗方法中，临床应用较为普遍的治疗方法为人工髋关节置换方法与人工膝关节表面置换方法。

随着医疗技术不断完善，髋关节疾病通过人工髋关节置换治疗方法得以有效治疗。

虽然人工膝关节置换治疗方法起步较晚，但随着医学领域对膝关节生物力学研究探索，人工膝关节置换治疗方法也逐渐得以完善且手术效果显著。

目前，我国对于肩关节、肘关节、腕关节、踝关节等人工关节置换治疗方法尚不成熟，临床治疗案例较少，与西方发达国家存在显著差距。

二、人工关节置换治疗方法（一）人工全髋关节置换方法人工全髋关节置换方法主要应用于股骨头坏死、类风湿性关节炎、髋骨关节炎、股骨颈骨折、髋部肿瘤以及先天性髋关节发育不良等病症。

在实施人工全髋关节置换手术之前，医护人员应对患者进行全面检查，详细询问患者以往病症史，对于身体状况较差，不具备手术耐受能力的患者，不能实施人工全髋关节置换手术。

同时对于患有脑瘫、帕金森、活动性感染等病症的患者，同样不能实施人工全髋关节置换手术。

SuperPATH入路微创人工全髋关节置换术的临床应用胡方煜;赖仁欢;梁木荣;安玉梅;胡田生【摘要】目的探讨SuperPATH人路微创人工全髋关节置换术的手术方法和临床疗效.方法行SuperPATH入路微创人工全髋关节置换术21例(23髋),观察手术切口长度、术中出血量、引流量、住院时间以及术前、术后3d、术后3个月和术后6个月的Harris评分.结果行SuperPATH入路微创人工全髋关节置换术患者的手术切口长度平均为6.73 cm,手术平均时间(102±11) min,术中平均失血量(274±53)mL,术后24h引流量平均(123 ±41)mL,平均住院时间为5.7d;术后Harris评分均低于术前,且逐渐增高,差异均有统计学意义(P＜0.05);术后髋关节功能恢复情况令人满意,无切口感染、假体脱位、骨折及双下肢长度不等长等严重并发症.结论SuperPATH人路微创人工全髋关节置换术治疗股骨头坏死具有切口小、损伤小、失血量少、术后活动快、可快速康复等优点,可以缩短住院时间,减轻术后疼痛和并发症的发生,患者满意度高,是一种真正意义上的微创髋关节置换术,值得在临床推广.【期刊名称】《微创医学》【年(卷),期】2016(011)003【总页数】3页(P416-418)【关键词】SuperPATH入路;微创;小切口;全髋关节置换;股骨头坏死【作者】胡方煜;赖仁欢;梁木荣;安玉梅;胡田生【作者单位】广东省连州市人民医院外科四区、康复医学科,连州市513400;广东省连州市人民医院外科四区、康复医学科,连州市513400;广东省连州市人民医院外科四区、康复医学科,连州市513400;广东省连州市人民医院外科四区、康复医学科,连州市513400;广东省连州市人民医院外科四区、康复医学科,连州市513400【正文语种】中文【中图分类】R684人工全髋关节置换术(total hip arthroplasty，THA)是治疗股骨头坏死、股骨颈骨折及骨关节炎等髋关节疾病的有效手段，其通过重建髋关节功能，不仅可减轻患者长期的疼痛，还能使患者恢复正常行走的能力，已经广泛应用于骨科临床[1]。

人工髋关节置换技术的国内外临床应用报告国内外临床应用报告显示，人工髋关节置换技术可以显著改善患者的疼痛症状和运动功能，提高生活质量。

根据国内外医学研究数据统计，人工髋关节置换技术的成败率在90%以上。

尤其对于老年患者，此项手术使得他们可以重新获得活动能力，恢复正常的生活和工作功能。

人工髋关节置换技术主要有两种类型：一种是全髋关节置换术，另一种是半髋关节置换术。

全髋关节置换术是最常见的一种，适用于髋关节发生了严重磨损或损坏的患者。

半髋关节置换术则适用于仅仅需要替换髋臼部分的患者，手术创伤相对较小。

人工髋关节置换技术在国内外的临床应用中，主要面临着以下问题：一是手术感染。

尽管术中和术后采取了多种预防措施，但仍有少部分患者会发生手术感染。

二是人工髋关节的寿命。

由于手术后人工髋关节的使用寿命有限，有的患者需要再次手术进行更换。

三是手术复杂度。

对于一些复杂病例，比如骨质疏松、骨折等，手术的复杂度较高，需要更加细致的手术操作和术前术后的护理。

为了提高人工髋关节置换技术的临床效果，国内外的医学界一直在不断探索和改进。

其中的一个研究热点是使用三维打印技术制造个性化的人工髋关节。

通过对患者个体骨骼结构的精确测量，可以制造出与患者骨骼结构完全匹配的人工髋关节，从而提高手术效果和髋关节的稳定性。

另外，国内外医学界还在探索利用干细胞治疗骨关节疾病的可能性。

干细胞具有自我更新和分化为骨细胞的能力，可以用于修复或再生患者受损的髋关节组织。

这一技术的研究尚处于实验室阶段，但具有巨大的发展潜力。

总的来说，人工髋关节置换技术在国内外取得了显著的临床应用效果。

随着医学研究和技术的进步，相信人工髋关节置换技术在未来会取得更大的突破，并为更多的患者带来康复和改善生活品质的机会。

CFP 假体在微创全髋关节成形术中的应用F. PipinoF. Pipino ( )Department of Orthopaedics andTraumatologyPoliclinico of MonzaVia Amati 11, I-20052 Monza (MI), Italy摘要：微创外科尽可能地保护机体的软组织和骨组组织，目的是为了减少外科创伤、减少失血量和促进术后功能恢复。

利用CFP假体（德国，汉堡，Waldemar Link）不但能够进行保留股骨颈的全髋关节置换，而且还能进行小切口微创手术。

本文报道了7年时限内331例接受非骨水泥型CFP假体置换病人（353例植入物）的短期和中期结果。

采用Harris评分进行临床效果评价，约96.6%的病人获得了良好或优秀的结果。

术后第一年只有2%的病人出现大腿痛。

大多数病人能够进行业余活动。

99%的病例形成了完整的骨长入。

影象学评价显示90%的病例具有好的骨重建；另外10%的病例在股骨干中下三分之一和外侧皮质出现了应力集中现象。

很少见应力遮挡。

也证实了压配型半球状髋臼杯的良好表现和双赤道设计的有效性。

关键词：Arthroplasty • CFP •Hip •Mini-invasive surgery引言在非骨水泥假体用于保护性全髋关节置换手术的进程中，微创外科技术扮演了一个决定性的角色。

在保护性的外科手术中，医生仅仅切除那些为完成关节置换所必需被去除病理性组织：软骨、骨赘、股骨头、某些时候包括一些关节滑膜，而尽可能保留所有的健康组织。

尽可能的保留骨结构，特别是松质骨、骨内膜的血液循环和应力分布系统（对日后的骨重建非常重要）。

因此，假体并不是用来替换关节，而是插入正常的骨性结构中并融为一体[1]。

根据以上原则，从1983年起，我和我的同事就倾向与在髋关节成形术中保留股骨颈，另外，为了保护髋臼骨我们采用生物动力型双赤道髋臼杯（Howmedica, Limerik, Ireland）[2-7]。

髋关节手术中使用不同手术入路对髋关节功能恢复的效果分析张全玉;杨玉峰;刘静新;戚世淦【摘要】目的分析髋关节手术中使用不同手术入路对髋关节功能恢复的效果.方法回顾性分析2014年3月～2015年3月我院诊治的髋关节置换100例患者临床资料,按手术方法分为两组,对照组45例行前入路治疗,观察组55例行后外侧微创入路治疗,比较两组治疗效果及Harris评分.结果观察组治疗后总有效率94.55％,高于对照组77.78％,P＜0.05,差异具有统计学意义.结论后外侧微创入路治疗对髋关节功能恢复效果优于行前入路治疗.【期刊名称】《中国继续医学教育》【年(卷),期】2016(008)002【总页数】2页(P120-121)【关键词】髋关节手术;髋关节功能;恢复效果【作者】张全玉;杨玉峰;刘静新;戚世淦【作者单位】453700 河南省新乡县人民医院骨科;453700 河南省新乡县人民医院骨科;453700 河南省新乡县人民医院骨科;453700 河南省新乡县人民医院骨科【正文语种】中文【中图分类】R61作者单位：453700河南省新乡县人民医院骨科临床医学中，对髋关节手术所使用不同手术入路对髋关节功能恢复的影响存在争议，且由于不用入路方式对患者治疗效果及预后影响重大[1]。

本研究以回顾性方式重点分析本院诊治的髋关节置换患者100例，具体报道如下。

1.1 一般资料回顾性分析2014年3月～2015年3月本院诊治的髋关节置换患者100例，按治疗方法分为对照组（45例）和观察组（55例）；对照组男性28例，女性17例，年龄37～75岁，平均年龄（47.72±3.68）岁，其中骨关节炎10例，类风湿性关节炎23例，股骨头颈骨折12例；观察组男性32例，女性23例，年龄38～77岁，平均年龄（46.53±3.32）岁，其中骨关节炎12例，类风湿性关节炎33例，股骨头颈骨折10例；两组基线资料比较差异无统计学意义（P＞0.05）。

人工髋关节的假体分类和应用人工全髋关节自上个世纪60年代上市以来，取得了巨大的成功，为上百万患有髋关节疾病的患者改善生活状况重返社会提供了保证，但由于人工髋关节的长期使用，它的使用寿命和与之相关的问题也越来越多，例如假体松动、骨溶解骨缺损、假体周围骨折…等。

因此，生产厂家根据临床医生的经验和要求，以及骨科生物力学和材料科学的发展，设计和生产出不同类型的人工全髋关节。

目前，国内市场上推出的人工全髋关节有几十种，每个厂家都有好几种。

如何选择假体？各种假体的特点如何？在临床应用中应注意的问题是什么？现将我们工作中的一些体会和经验介绍给各位同行，希望能对您的临床工作提供帮助。

骨水泥固定型假体按其柄的形态分为直柄和解剖柄，按股骨柄表面处理情况分为高抛光假体、亚抛光假体和粗糙面假体。

按是否带有颈领分为颈领型和无领型。

非骨水泥固定型假体按其固定的部位分为近端固定型、远端固定型和混合固定型假体。

按假体形态分为直柄型、解剖型和组配型。

按股骨假体表面处理的类型分为精钢沙表面、钛喷涂表面、珍珠表面、钛丝表面、小梁金属骨表面和羟基磷灰石（HA）表面，也有先喷涂钛或其他，再喷羟基磷灰石（HA），称为双涂层表面。

近年来又以对骨量保留的状况分为假体适配型和骨量保留性假体。

髋臼假体主要按固定方式分为骨水泥和非骨水泥固定型假体。

非骨水泥固定假体按形态分为球面压配固定型假体和螺旋固定型假体。

压配型又分为，单半径、双半径和周边齿状设计。

按表面处理不同分为精钢沙表面、钛喷涂表面、珍珠表面、钛丝表面、小梁金属骨表面和羟基磷灰石（HA）表面，也有先喷涂钛或其他，再喷羟基磷灰石（HA），称为双涂层表面。

聚乙烯又按其处理方式不同分为普通和高交联。

按关节的界面不同可以将其分为金属对聚乙烯、金属对高交联聚乙烯、陶瓷对聚乙烯、金属对金属和陶瓷对陶瓷界面。

由于骨水泥固定髋臼均采用高分子聚乙烯，因此在关节的界面上只有陶瓷对聚乙烯和金属对聚乙烯。

各类假体的设计特点Charney医生所采用的是一种经过多次改进的骨水泥固定的低摩擦型charney关节，关节表面为亚抛光，圆润光滑，颈部有一微领防止假体下沉，股骨头为22mm，头颈为一体。

微创全髋关节置换术的进展【关键词】全髋关节置换术全髋关节置换术(total hip arthroplasty，THA)成功地应用于矫形外科已经40多年了，15年假体存活率达到90％［1］，在这一段时间里，外科技术不断发展，术后康复时间也不断减少。

最近几年，许多文献报道了小切口THA技术，平均皮肤切口仅为6～10 cm。

初步研究显示这项技术与传统手术相比，在术中出血、术后疼痛和康复体现出优势，使得这项技术越来越受到重视。

本文就微创全髋关节置换术在适应证、手术入路、争议和未来展望等方面进行综述。

1 适应证和禁忌证目前并没有公认的手术适应证，一般认为理想的病人条件包括：初次全髋关节置换术，BMI&lt;30，股骨近端和髋臼轻度变形。

即使病人符合这些条件，医生也必须告知病人有可能依据术中情况来延长切口，不能因为刻意追求小切口而过分牵拉软组织，或导致假体位置欠佳。

Brett R［2］提出了微创小切口THA的绝对禁忌证：（1）疾病要求延长切口，全髋关节翻修术，初次复杂全髋关节置换术，髋臼发育不良Crowe 3、4级，髋臼严重畸形；（2)有手术史，骨不连或截骨术后，手术需取出假体；（3)手术要求使用骨水泥假体，骨质疏松，转移癌；（4)骨关节强直；（5)病态肥胖症。

相对禁忌证包括：肌肉发达，体重指数&gt;30。

2 手术入路微创手术的概念［3］不仅仅意味着切口小，重要的是如何减少软组织的损伤，尤其是肌肉和肌腱的损伤。

目前国内外学者描述的较多入路有：前侧入路、前外侧入路、外侧入路、后侧入路和双切口入路。

本文着重于不同手术入路在微创概念上的比较，而不介绍手术操作。

2.1 前侧入路Siguer等［4］描述了前侧入路行微创THR的手术方法，这是一个改良的Smith Peterson入路。

患者仰卧位于Judet牵引床，以股骨大转子为界(2／3在上方，1／3在下方)，平行于髂前上棘与腓骨头的连线后方2 cm为切口方向，切口长度限于5～10 cm。

人工髋关节置换技术的国内外临床应用报告世界上第一个人工髋关节置换是1891年德国医生Gluck用象牙做的股骨头完成的，而真正意义上的人工全髋关节置换可能是英国医生Phillip Wiles进行的，他用的是不锈钢假体并且先后完成了6例手术。

这些先驱者们为现代人工全髋关节置换作出了不可磨灭的贡献。

现代人工全髋关节假体的出现应当是1962年，英国医生Charnley 应用金属股骨头和高分子聚乙烯配伍创建了低摩擦的人工髋关节假体，并且聚甲基丙烯酸甲酯（骨水泥）的应用使得假体固定更加牢固。

Charnley医生也因其上述贡献而被誉为现代人工关节之父。

现在人工髋关节置换技术的适用对象广泛，包括各种严重髋关节疾患如股骨头坏死、股骨颈骨折、髋臼发育不良、类风湿性关节炎、强直性脊柱炎、骨关节病等。

并医学界已有完善的人工髋关节诊疗现世界上每年有近百万人在接受人工髋关节置换手术，重新恢复了行走能力，大大降低了病残率。

人工全髋关节置换15年以上的临床优良率已在90%以上。

1、假体固定方式的应用：不同的假体固定方式的效果是不同的，相同的假体固定方式对不同的病人效果也不尽相同。

目前分为骨水泥固定及非骨水泥固定假体，非骨水泥固定的假体有表面微孔（骨长入）、粗糙面（骨长上）、羟基磷灰石涂层（共价键结合）以及解剖髓内嵌锁型等。

有资料表明，表面微孔的髋臼要明显优于骨水泥固定的髋臼，而其它类型的髋臼暂时还不能得出相同结论。

而非骨水泥固定的股骨假体与骨水泥固定的股骨假体效果大致相同。

目前多数医生认为，有严重骨质疏松的患者宜用骨水泥固定的假体；对年龄在70岁以上，预期寿命15年左右者，可以使用骨水泥固定的假体；对于年龄在60岁以下，预期寿命25年以上的患者适合应用非骨水泥固定或杂交固定（骨水泥固定的髋臼和非骨水泥固定的股骨假体）。

而对于50岁以下的年轻病人，多数主张首选非骨水泥固定假体。

2、髋臼－股骨头的材料配伍：目前大量的人工髋关节是由坚硬的金属或陶瓷的股骨头与超高分子聚乙烯的髋臼杯组合成，许多证据表明这种组合产生的聚乙烯微粒是导致晚期假体无菌性松动的主要原因。

微创手术器械在髋关节成形术中的应用髋关节成形术是一种常见的手术方法，用于治疗髋关节疾病，如髋关节炎等。

随着技术的不断进步，微创手术器械在髋关节成形术中的应用越来越广泛。

本文将深入探讨微创手术器械在髋关节成形术中的应用，并分析其优势和挑战。

髋关节成形术是通过手术去除或修复受损的髋关节器官，以改善疾病症状，并恢复关节功能。

传统的开放手术需要较大的手术切口，对患者的身体造成较大伤害，术后恢复时间较长。

而微创手术器械的应用，可以显著减少手术切口的大小，并使手术过程更加精确和安全。

在微创髋关节成形术中，常用的器械包括微创手术器械、内窥镜和骨科手术机器人等。

微创手术器械是通过一系列特殊设计的工具和设备来完成手术，可以分为切割器械、吸引器械、照明器械和缝合器械等。

这些器械可以通过小孔或切口插入患者的身体，完成髋关节的修复或重建。

使用微创手术器械进行髋关节成形术具有许多优势。

首先，微创手术切口较小，可以减少手术创伤和出血，缩短患者的术后恢复时间。

其次，微创手术器械可以提供较好的术中视野，使医生可以更加清晰地观察手术区域，精确地进行髋关节的修复。

此外，微创手术器械的应用还可以减少感染和并发症的风险，提高手术的成功率。

然而，在微创手术器械在髋关节成形术中的应用过程中，也面临一些挑战。

首先，微创手术器械的高昂成本限制了其在一些医疗机构的应用。

其次，微创手术器械的操作技术对医生有较高的要求，需要医生具备良好的解剖学知识和手术技巧。

此外，微创手术器械的操作也存在一定的学习曲线，需要医生进行系统的培训和练习。

针对上述挑战，可以采取一些措施来提升微创手术器械在髋关节成形术中的应用。

首先，可以加强对医生的培训和技术支持，提高其操作微创手术器械的能力。

其次，可以通过技术创新和工艺改进降低微创手术器械的成本，使其更加普及和可负担。

此外，研究人员还可以进一步改进微创手术器械的设计和功能，提升其操作的精确度和安全性。

综上所述，微创手术器械在髋关节成形术中的应用具有显著的优势和潜力。

全髋关节置换微创手术研究进展摘要：目前，随着快速康复理念及手术设备的不断更新、完善，全髋关节置换微创手术的应用得到快速发展，其手术具有肌间隙进入，不切断肌肉，出血少、术后能早期康复、患者心里负担轻等优势，患者实施微创手术可以提高患者的生活质量，尽早解除、消减患者的痛苦，也可以促进患者髋关节功能快速康复。

文章就全髋关节置换微创手术入路展开研究和分析，分析微创手术的进展，为现代微创髋关节手术医师的临床实践提供参考。

关键词：髋关节；置换；微创手术；手术入路髋关节疾病是临床上比较常见的疾病，且随着晚期髋关节疾病的发展，国内的发病率不断上升，严重影响了患者的生活质量。

而随着微创理念的发展，髋关节疾病患者实施全髋关节置换术已经成为趋势[ ]。

全髋关节置换微创手术是近年来快速康复理念发展的结果。

1 全髋关节置换微创手术入路类型通常微创我们常想到小切口，但小切口并不等于微创。

真正意义上的微创指切口小、创伤少、不损伤肌肉肌腱，而且术后能很快康复。

全髋关节置换微创手术[ ]，从肌间隙入路，极大程度上减少了对髋关节周围组织肌肉的创伤，降低对患者生理（运动神经）的干扰[ ]，减少术后并发症的发生。

全髋关节置换微创手术入路包括直接前入路、前外侧入路和上方入路等多种类型[ ]。

2 全髋关节置换常见微创手术入路具体分析2.1 直接前入路（DAA）：微创直接前入路是指利用髋关节前侧神经、肌肉间隙介入髋关节进行操作[ ]，其切口是在髂前上棘下、后2cm开6~8cm的小切口，从臀阔筋膜张肌与股直肌间隙进入，直达关节囊，这种入路方式软组织损伤小，术后功能恢复快[ ]。

陈震东，高辉，何春耒[ ]对直接前入路微创手术的历史、手术禁忌症、手术操作方法以及文献研究等进行综述，研究发现直接前入路微创手术通过规范操作可以很好完成全髋关节置换。

吕杰，陈金伟，马金忠[ ]通过对全髋关节置换微创手术直接前入路放方法、优缺点进行综述，研究认为该种微创技术具有创伤小、术后假体脱位风险低、康复快等优点，但同时也具有学习曲线较长、操作难度较大以及可能损伤股外侧皮神经等缺点，因此要严格按照标准、规范进行手术。

全髋关节置换的新革命，真正的微创——SuperPATH全髋关节置换微创化是关节外科医生一直探索的目标。

SuperPATH的出现，让我们真正看到了微创全髋关节置换时代的到来。

切口长度150px~200px；不需要切断外旋肌，经犁状肌和臀小肌的间隙进入，几乎保存髋关节周围所有的肌肉功能；几乎保留了完整的关节囊；手术操作过程中不需要外科脱位（术中不造成肢体极度的旋转与扭曲）；手术由主刀和助力2人即可完成。

该技术由美国亚利桑那州凤凰城圣路加医学中心James Chow博士首创。

（St. Luke's Medical Center，Phoenix，Arizona，USA）SuperPATH入路（Supercapsular Percutaneously Assisted Total Hip）是经标准后侧入路改良而来，SuperPATHTM入路保留了标准后侧入路的所有优点；还可以进一步延伸，很容易的转换成标准后侧入路。

该入路容易学习，并且在术中给予外科医生完全的自由。

St. Luke's Medical Center官网：/该技术目前由Wright Medical Technology公司推广，技术介绍官网：/=========>>>手术操作<<<=========准确的术前模板测量需要良好质量的标准骨盆和髋关节X线片。

注意：术前模板测量仅用于估计的目的。

最终假体的大小和位置由术中决定。

1、患者体位患者取标准侧卧位，手术台高度调整至术者舒适的位置。

该技术操作不需要最大限度内收下肢，因此没有必要将患者的位置偏移至手术台的前缘。

最好是应用透射线挡板支架维持患者体位，在以下位置放置：1）耻骨联合2）骶骨3）胸部水平，乳房下4）肩胛骨–长钉为确保适当的骨盆旋转位置，髋部稍后倾。

患髋屈曲45°，患肢内旋10°~15°使大转子朝上。

患肢的足置于带衬垫的Mayo手术托盘车上，患肢轻度内收，肢体的重量将平衡髋关节，使骨盆旋转中立。