CFP 假体在微创全髋关节成形术中的应用
CFP 人工髋关节假体手术的学习曲线
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
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
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
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
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
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
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<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>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。
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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]。
该方法的优势已经通过实验证明和临床验证：我们的经验是进行了长期随访的498例假体（[6，8]结果还未公开发表）。
该经验对CFP股骨假体和TOP髋臼杯的发展做出了贡献（德国，汉堡，Waldemar Link），2种产品在1997年第一次进行临床实验（(Orthopaedic Clinic, University of Genoa, Italy)。
CFP假体的革新性设计包括：纵行嵴、活动颈领（neckpiece）、前扭转和自带前倾角。
CFP假体由钛、铝和羟基磷灰石构成，有20个型号可选：假体柄有2种曲度，每种又各有5种不同型号可选。
CFP假体的命名来自于“股骨颈保留”技术-一种尽可能多的保留关节结构（骨储备和软组织）的微创外科技术。
CFP的植入具有创伤局限和失血量少，功能恢复快和初始稳定性好的特点[4，5]。
由于CFP假体是非骨水泥固定，未来的翻修手术会更容易进行，至少对于假体型号较小的假体是如此。
另外，没有骨水泥意味着界面的宿主骨处在更好的生存环境中。
上述特点为非骨水泥假体在年轻人和活动需求高的病人中应用提供了基础，因为这些人预期寿命较长更容易出现无菌性松动。
由于不用暴露大转子，通过小切口就能显露股骨颈，所以可以微创置入CFP假体。
TOP杯是一个骨小粱朝向模式的双赤道髋臼假体，由于该假体不需要过深地磨锉髋臼也没有突起，能够最合理地保留髋臼骨质；其固定的方向也与髋臼的骨小梁朝向一致。
在本文中，总结了我在意大利Genoa和Monza医院骨科7年中使用CFP假体进行全髋关节置换的临床经验。
病人和方法1997年4月至2004年7月，总共368例病人（22例进行了双侧置换）进行了CFP假体的全髋关节置换。
2002年前的手术都在意大利Genoa大学的骨科医院实施（303例病人），之后的手术都在意大利米兰的Policlinico di Monza 进行（65例病人）。
术后即刻和中期的结果根据2002年12月获得的在Genoa 治疗病人的临床资料和2004年7月获得的在Monza治疗病人的临床资料来评估。
由于病人较好的骨质条件：特别是几乎完整的股骨颈，这些病人都适合做微创关节置换。
微创外科的主要问题是：仔细处理软组织，分离肌肉而不是切断肌肉、仔细止血减少血液丢失，正确的引流以避免血肿形成。
手术过程术前2天，Genoa的病人预留1单位的自体血。
手术前，病人预防性应用抗生素和抗血栓药物。
CFP股骨假体曾和3种不同的髋臼假体配合进行全髋关节置换手术，3种髋臼假体都是双赤道设计。
在前50例（98年前）手术中使用的是Meros 杯（(Gruppo Bioimpianti, Peschiera Borromeo (MI), 意大利)；33例运用的是Plasmacup SC髋臼杯(蛇牌, Tuttlingen, 德国) ；接下来的338例手术均采用TOP杯(Waldemar, Link,德国汉堡)。
髋臼杯通过压配固定，除外两例病人，其他所有病人均未使用螺钉：这两例病人髋臼出现骨折（一例采用Meros杯，一例采用Plasmacup SC杯），必须应用螺钉固定。
手术采用经臀肌的直接外侧切口：在Genoa治疗的病人手术切口长12-15cm, 在Monza治疗的病人手术切口只有8-10cm。
股骨颈截骨在股骨颈峡部进行（股骨颈最细的部分）（图1），截骨面垂直股骨颈的长轴，距大转子基部约1.5cm（最小为1cm），这正是保留股骨颈所需要的长度[ 9，10]。
术后下肢长要在术前做好计划和术中仔细检查，，根据医生个人经验决定是否采用臀小肌截断（未发表）。
图1股骨颈的骨切除在股骨颈峡部进行，距大转子基底部约1.5cm。
截骨面和股骨颈的长轴垂直失血量有限，平均失血量术中约150ml术后约450ml。
术后6小时从引流管中引流出的血回输到病人体内。
4%在Genoa和6%在Monza的病人接受了同种异体血输入。
同种异体血的输血需要和切口长度没有关系。
术后第一天即开始康复锻炼。
外科引流在术后第2天拔除。
部分负重在术后第3天开始，全负重在术后第30天开始。
临床和影象学评价术后即刻、术后2月和术后1年对病人进行评价。
每一次随访病例都进行临床和影象学评价。
临床结果根据Harris评分进行，<70为差、70-79为中等、80-89为良好、>90分为优秀。
使用标准前后位和外侧位的X片进行影象学评价。
术后即刻评估假体杯的位置和假体柄的力线以及和髓腔的匹配程度。
由于髋臼杯是双赤道设计，假体外杯相对于水平面的最佳外翻角为55°±5° [2]。
评价骨对假体的生物学反应和验证假体在不同时期可能出现的变化。
异位骨化根据Brooker进行分类[11]。
在DeLee和Charnley区评估髋臼杯的位置，特别外展角和置入的深度[12]。
采用改良的Gruen’s分区评估股骨对假体的反应[13]，该分区法适用于保守性髋关节镜术后的股骨颈评价(T.Gruen, 个人交流)。
1区和7区均被分为2个部分,a和b:1a和7a区分别代表股骨颈的外侧和内侧部分，而1b和7b分别代表1和7区剩下的部分。
出于研究的目的，对假体颈领正下方的股骨颈内外侧部分的骨质给予特别关注。
结果7年中，有386例病人进行了基于CFP假体的微创全髋关节置换（表1）。
由于接受手术的病人是有选择性的：骨质量较好、股骨颈未发生结构性变化，在手术适应症范围之内的骨发育不良病人非常少见，另外男性比例非常高。
331个病人（353例）的结果在1-7年的随访时限中被评价，37个病人失访。
表 1 基于CFP假体进行全髋关节置换的病人特征(德国，Waldemar Link, )，37个病人失访.治疗组随访组病人数, n 368 331植入物数,390 353年龄, 60 60男性, n (%) 220(60) 199(60) 诊断, (在所有治疗例数中的百分比%)髋关节骨性关节炎82 80股骨头坏死8 8髋关节炎和发育不良 6 8其他 4 4 髋臼杯假体数量, nMeros 50 50Plasmacup 2 2TOP 338 301 随访时限，年1-7A22例病人进行双侧置换; b均值临床结果没有出现普通的术中和术后并发症；特别是没有出现血管和神经并发症，也没有发生假体脱位。
局部并发症包括术后2月出现1例假体柄尖端的股骨干骨折和2例股骨干骺端螺旋形骨折。
2例干骺端骨折用DallMiles缆捆绑或用Dall Miles板固定(Styker 意大利,)。
骨干的骨折是由于股骨管钻孔导致的皮质的强度减弱（这实际上是CFP的禁忌症）。
该病人进行了接骨处理，假体松动，进行了二次植入。
一例病人出现了金葡菌的深部感染，该菌对新青Ⅱ敏感；术后2月，该病人一期去除感染假体，并植入新假体。
在术后头几月，7个病人（2%）出现大腿痛。
其中6例的症状在一年内消失。
下肢<1cm的不等长出现在28个病例中（8%），没有出现>1cm 的肢体不等长。
利用Harris评分的进行的长期随访临床结果，在表2中列出。
总的来说，超过90%的治疗髋在最后的评价中得到了优秀的结果，有4例评价为差：-1例金葡菌感染需要二次植入-1例假体柄尖端股骨干骨折的病人也接受了二次植入-1例病人有持续的大腿痛-一例病人术后几月后出现进行性、大部的假体柄与股骨分离。
术后2月该病人确诊为胃癌。
96%的病人完全恢复了正常的生活并能进行业余水平的运动（如，网球、高尔夫、骑车、散步）（12%）。
术后即刻的影象学分析术后即刻，髋臼杯的外翻在18例中<50°(5%)，353例治疗髋中(92%)为50°-60°，11例>60° (3%)。
342例（97%）髋臼杯在髋臼中处于正确位置，表明软骨下松质骨板的保留。
4例（1%）髋臼杯的位置太深，而7例（2%）杯的位置太浅从髋臼缘突起。
2例能在杯和髋臼骨之间看到小的间隙（0.5%）.332例假体位置良好（94%），18例（5%）出现了内翻和3例（1%）出现外翻。
328例治疗髋假体选择合适（93%）；14例（4%）偏大，11例偏小（3%）。
中期的影象学结果在随访期内，植入的髋臼杯没有出现分离、移位和松动，没有出现骨溶解或透亮线。
关于假体，我们观察到2例无菌性松动（骨-假体接触面退变），由纤维组织替代。
影像学上表现为放射性透亮线，表示有应力遮挡存在。
假体和骨的整合在剩下的351例（99%）中都比较好。
假体周围的骨质重建在上述351中的316例（90%）都比较好，均未出现股骨颈的吸收（图2）。
转子间的干骺区具有均匀一致的结构，假体尖端下方的皮质等厚，和对侧股骨完全相同。
这种放射学表现甚至出现尺寸较小但位置良好的股骨假体中。