реферат значительные дефекты вертлужной впадины, особенно сопровождающиеся нарушением целостности тазового кольца, являются серьезной проблемой ревизионного эндопротезирования тазобедренного сустава и создают дополнительные сложности для фиксации ацетабулярного компонента эндопротеза. одним из перспективных вариантов решения описанной проблемы является использование индивидуальных трехфланцевых вертлужных компонентов (cTac-custom Triflange acetabular component), проектируемых на основе предоперационной компьютерной томографии с учетом особенностей костных дефектов пациента. Цель исследования-оценить эффективность использования cTac при ревизионном эндопротезировании тазобедренного сустава. Материал и методы. проанализированы результаты лечения 12 пациентов, перенесших ревизионное эндопротезирование с применением аддитивных технологий компьютерного моделирования и 3d-печати cTac. Время наблюдения пациентов после эндопротезирования составило в среднем 7±3 мес. (от 1 до 10 мес.). у 7 пациентов из 12 были выявлены дефекты вертлужной впадины типа 3B по W.g. paprosky, у 4типа 3а и у одного-2с. Результаты. у 2 пациентов из 12 произошли вывихи эндопротеза, что потребовало проведения повторных оперативных вмешательств на тазобедренном суставе, одному из них-открытое вправление вывиха с санацией раны, другому-замена артикулирующей пары ацетабулярного компонента эндопротеза. суммы баллов по шкале Харриса и визуальной аналоговой шкале боли до лечения составили 28±7 и 7±1, соответственно, после эндопротезирования-76±9 и 3±1, соответственно. Выводы. применение аддитивных технологий при ревизионном эндопротезировании тазобедренного сустава у пациентов с обширными костными дефектами вертлужной впадины и таза позволяет провести точное предоперационное планирование, восстановить центр ротации сустава, восполнить дефицит костной ткани, надежно фиксировать индивидуальный трехфланцевый вертлужный компонент эндопротеза, что значительно улучшает результаты лечения и удовлетворенность пациентов операцией. Ключевые слова: ревизионное эндопротезирование тазобедренного сустава, дефекты вертлужной впадины, индивидуальный трехфланцевый вертлужный компонент, 3d-печать в медицине.
Periprosthetic fractures are one of the main reasons for revision surgery according to the data of large joint replacement registers. Treatment of patients with periprosthetic fractures is associated with a big number of complications and still keeps its relevance. Purposeof the study is to evaluate treatment outcome of patients with periprosthetic femoral fractures in hipreplacement. Material and Methods.The authors performed a retrospective analysis of medical histories of 76 patients whounderwent treatment of periprosthetic femoral fractures. The patients were divided into groups by the Unified Classification System (UCS). Follow up period was from 6 to 124 months (mean of 34.90±28.81). Results.3 cases (3.9%) of periprosthetic femoral fractures were the complications after primary hip arthroplastyand occurred intraoperatively, 75 cases (96.1%) were complications after revision surgery; 56 cases (71.8%) were reported with uncemented and 22 cases (28.2%) with cemented femoral components. In 30 cases (38.5%) fractures had a iatrogenic nature and occurred intraoperatively, in 48 cases (61.5%) — occurred due to high- and low energy trauma. Type B fractures were observed most often — in 53 cases (68%). Conservative treatment, fixation by cerclage or by plate and screws has proven to be the least effective operative options. In the group of patients with extended osteotomy of the greater trochanter the healing was achieved in 90.5% of cases, while in the group without osteotomy — in 75% of cases. Low healing rate of periprosthetic fractures was observed for A and B1 type fractures (65% and 66.7% respectively). Follow up of patients with B2, B3 and C type fractures demonstrated consolidation in more than 80% of cases. Various complications were reported in 17 cases (21.8%). Conclusion.Effective treatment of patients with periprosthetic femoral fractures was associated with extendedosteotomy of the greater trochanter (γ = 0.51;p= 0.032), absence of complications in postoperative period (R= 0.55;p= 0.00001), B2, B3 and C fracture types (γ= 0.40;p= 0.02) and use of revision uncemented femoral components withdistal fixation (γ = 0.35;p= 0.018). In the authors opinion use of sutures or cerclage wires are not effective in cases of trochanteric fractures and stable femoral components; it would be preferable to perform internal fixation by a plate with hooks such as Dall-Miles. In case of doubts in regard of stem stability the revision should rather stipulate use of uncemented femoral components, in particular long stems with distal fixation.
Treatment of avascular necrosis of the femoral head is an issue of current interest while it affects young and employable people. So far there is no well-defined strategy of management which would help to postpone hip arthroplasty and further revision procedure. Hip sparing surgical treatment of avascular necrosis of the femoral head by bone grafting prior to head collapse proved to be a viable option not only during early stages of disease but also at advanced stages. platelet-rich plasma (pRp) addition to treatment plan potentially helps improving bone regeneration in situ. In this article the authors present a case of a 37 years old patient with avascular necrosis of the femoral head at a fragmentation stage (type 4B by aRcO). The authors centrifuged 15 ml of autologous whole blood (1500 RpM) obtained by a special double-contoured syringe. during the surgical stage of treatment pRp and morselized bone graft were mixed to introduce and impact into the debrided zone of avascular necrosis. The authors also introduced 0.3-0.4 ml of pRp into the debrided zone of avascular necrosis after bone grafting. at 6 months follow-up cT images of the studied patient demonstrated signs of bone reorganization and no loss of femoral head sphericity. preoperative Visual analogue Scale (VaS), Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) prior to treatment were 60, 45 and 33 points respectively. postoperative VaS, HHS and HOOS scores were 10, 78 and 78 respectively. In the authors' opinion, impaction bone grafting enhanced by pRp helps obtaining good and excellent outcomes not only at early but also at advanced stages of avascular necrosis.
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