【专题文献】之人工髋关节置换——髋关节翻修术中内植物的取出

【专题文献】之人工髋关节置换

全髋翻修讲座之一：全髋关节置换疼痛的评估 By: 宋兵乙
全髋翻修讲座之二：髋关节翻修术中内植物的取出 By: 宋兵乙
全髋翻修讲座之三：髋关节翻修术中髋臼失败的重建和翻修 By: 宋兵乙
全髋翻修讲座之四：髋关节翻修术中股骨失败的重建和翻修 By: 宋兵乙
全髋翻修讲座之五：全髋关节置换术后髋关节脱位的处理 By: 飘洋过海
全髋翻修讲座之六：全髋关节置换术假体周围感染的处理 By: shiitake
全髋翻修讲座之七：下肢假体周围骨折的处理 By：宋兵乙

MINI-SYMPOSIUM: REVISION HIP SURGERY
小讲座：髋关节翻修术之二

(II) Implant removal in revision hip surgery
(II) 髋关节翻修术中内植物的取出

Andrew R J Manktelow

Abstract
Implant removal is a major part of revision hip surgery. A complication, such as fracture or perforation during implant removal, more common in the presence of surrounding osteopenia, can compromise subsequent reconstruction. Similarly, care must be taken to avoid additional bone loss during implant removal. Various techniques are available on both the femoral and acetabular sides that can facilitate the procedure. Recent developments in instrumentation can prove helpful.
In this article the techniques are reviewed. In addition, the importance of pre-operative planning and exposure is discussed. The techniques used to remove both cemented and uncemented implants are detailed with examples, illustrations and practical tips. The overall aim of the article is to make this potentially complicated procedure less challenging for the surgeon, but more importantly, to reduce complication rates in implant removal, improving clinical outcomes for patients.

Keywords cemented and uncemented implant removal; revision hip surgery

摘要：
内植物的取出在髋关节翻修术中是一个重要部分。在内植物的取出过程中的一个并发症如骨折或穿孔，该并发症多常见于内植物周围骨量减少的情况下，能影响随后的重建。相似的，在内植物取出的过程中，应仔细避免额外的骨量丢失。对于股骨或髋臼侧有不同的技术，使手术简便。最新的器械发展证明对操作有帮助。
在本文中，对内植物取出技术进行回顾。另外，术前计划和入路的重要性也加以论述。取出骨水泥或非骨水泥假体的技术通过举例、图表和操作注意事项进行详细论述。本文的主要目标是减少可能的复杂的手术程序对于骨科医生的挑战，但更重要的是，减少内植物取出术中并发症发生率，提高病例的临床效果。

关键词：
骨水泥和非骨水泥假体的移除，髋关节翻修术。






Introduction
While much of the interest and development in revision hip arthroplasty surgery surrounds the techniques available to effect femoral and acetabular reconstruction, the potential complexity of implant removal should not be disregarded. Indeed, successful revision hip reconstruction starts with careful removal of the implants. This requires planning. During implant removal the surgeon must ensure that no additional bone loss occurs, and that the technique and exposure used do not compromise reconstructive options. Thus, implant removal is an extremely important and frequently challenging component of revision hip arthroplasty surgery.

引言
当更多的兴趣和发展关注于髋关节置换翻修术的技术以达到更有效的股骨和髋臼重建，内植物取出时可能的复杂性不应该被忽视。的确，成功的髋翻修术由仔细小心的内植物取出开始。需要对此进行计划。在内植物取出时，外科医生应该确保不发生额外的骨丢失，手术技术和暴露不应该影响到重建选择。因此，内植物取出是极重要的，并且常常是髋关节翻修中具有挑战性的一部分。


A number of systems and instruments are available for implant removal, with different techniques available for the removal of cemented and uncemented components. It is important that any surgeon in training, or in practice in this area, should be aware of and have experience in these techniques.

The complexities involved in surgical exposure, implant removal and subsequent reconstruction support revision hip surgery being performed by surgeons with specialist training and experience.

内植物取出有一些方法和工具，对于取出骨水泥型或非骨水泥型组件有不同的技术。任一位在此领域的外科医生应该知道或对这些技术有一定的经验，这很重要。
复杂性包括手术入路，内植物的取出和随后的重建技术，使髋关节翻修术应该当由特别训练和经验的外科医生实施。


When planning the procedure, it is helpful if the surgeon is able to identify the component to be removed. Numerous implants have been used over the years in hip arthroplasty surgery. Some are uncommon, used locally and for a relatively short time. Many of the components were implanted many years prior to revision. Identification of the type of implant can assist the surgeon to determine the extent, nature and quality of component fixation. While there might be specific instrumentation available to remove particular implants, there are other component design features that the experienced surgeon can exploit to facilitate removal. This might reduce the requirement for more extensive/destructive surgical approaches.

当计划手术时，如果外科医生能够识别需取出的假体，这是有帮助的。在髋关节置换的过去数年内，有很多种内植物使用于临床。许多内植物在翻修前己经使用多年。识别假体的型号能帮助外科医生决定范围、性质和内植物固定的质量。特定的内植物取出应该有特制的工具可以使用，另一些假体设计特征使有经验的外科医生很容易取出。这可以减少更广范更破坏性的手术入路。

The surgeon must assess pre-operative radiographs carefully and should be aware of radiological features that directly or indirectly indicate the degree of ongoing implant fixation. From that point of view, radiographs should visualize the entire implant, on both AP and lateral views.

外科医生就仔细评估术前的放射学图片，应该了解直接或间接的证明内植物固定程度的放射学特征。从此点看，放射学图片应该包括完整的内植物，在前后位上和侧位片上。

Surgical exposure in revision hip arthroplasty can be complicated and can influence implant removal. Indeed, the choice of surgical exposure and approach should only be made having considered both the planned reconstruction and the technique to be used for implant removal. While surgical exposure will not be dealt with specifically in this article, a surgeon performing significant numbers of revision hip procedures should be aware of, and familiar with, the various approaches and techniques available.

髋关节翻修术的外科入路是复杂的，能影响到内植物的取出。的确，外科入路和暴露的选择应该包括计划的重建方案和内植物取出使用技术两方面的考虑。当本文并没有关注于特定的外科暴露，实施了很多髋关节翻修手术的外科医生应该知道、熟悉不同的入路和技术。

The surgical procedure should be discussed with anaesthetic colleagues, to ensure that relevant techniques are employed to provide sufficient time and a satisfactory surgical field to facilitate surgery.

手术操作应该同麻醉同事讨论，以确保使用相关的技术以提供足够的时间和满意的手术野，保证手术顺利。

The overall aim of planning is to make this technically challenging procedure both less stressful and time-consuming for the surgeon. Additionally, and more importantly, careful planning can reduce complication rates and improve clinical outcomes for our patients.

计划的总体目标是为了帮助外科医生，将技术性的挑战性的操作，其紧张度和耗时都减少一点。另外，更重要的是，仔细的计划能减少并发症发生率，提高病例的临床效果。

Implant removal technique differs on the acetabular and femoral sides, and according to whether cemented or uncemented fixation was used at the time of index surgery. In this article, removal of cemented and uncemented implants will be discussed in separate sections, further subdivided into the acetabulum and the femur. Subsequently, specific and potentially challenging situations will be discussed.

内植物取出技术在髋臼侧和股骨侧是不同的，依据前次手术使用的是否骨水泥或非骨水泥固定。在本文中，骨水泥和非骨水泥型内植物的取出将在不同的章节讨论，更进一步细分为髋臼和股骨。随后，特殊的或能的挑战性状态也将讨论。

Removal of implants
Removal of cemented implants
While there has been a more recent increase in the number of uncemented implants used in hip arthroplasty surgery in the United Kingdom, cemented implants still remain more common. In planning to remove cemented implants, it is important to determine whether the implant is loose and if so, whether loosening has occurred at the bone-cement interface, cement-implant interface or both. This can be identified easily when the implant has migrated or the orientation has changed over time. Otherwise, radiolucency around the implant should be identified, along with its location, extent and any progression. This provides corroborating evidence of component loosening. Similarly, an assessment of the surrounding bone quality should be made to reduce the potential for additional bone loss with implant removal.

内植物的取出
骨水泥型内植物的取出
在英国近年来，非骨水泥型内植物在髋关节置换术有使用有增多的趋势，骨水泥型内植物仍然是非常常见的。在计划骨水泥型内植物取出时，判断内植物是否松动，如果松动了，松动是否发生在骨－骨水泥界面，骨水泥－内植物界面或两者都有，这很重要。当内植物移位或在不同的时间段其位置改变，这时很容易鉴别。其他情况下，内植物周围的放射学表现应该识别，沿着内植物的位置、范围和任何进展。这提供了内植物松动的确切证据。相似的，应该进行周围骨质量的评估以减少内植物取出时额外骨丢失的可能性。



A wide variety of instruments are required to remove cemented components safely and within a reasonable time. Standard cemented revision instrument trays should include curved and straight osteotomes, curettes, rongeurs and drills (Figure 1). Additional equipment such as high speed burrs, flexible reamers, ultrasound devices, ballistic chisels and external light sources are also helpful.

需要很多不同的工具以安全的在合理时间内取出骨水泥内植物，标准的骨水泥翻修工具盒应该弯曲和直柄的骨凿，刮匙，咬骨钳和钻头（见图1）。另外的工具如高速髋臼锉，可屈式扩孔钻，超声装置,冲击凿，和外光源同样有用。

图1

Removal of the cemented acetabulum
The removal of any acetabular component starts with full exposure of the entire acetabulum, including the rim. Adequate visualization, both proximally and distally, must be achieved. Retractors should be used with care, to avoid damaging the surrounding bone.

骨水泥型髋臼的取出
任何髋臼组件的取出应该先完全暴露髋臼，包括髋臼缘。足够的视野，包括近端和远端，应该完成。拉钩应该小心使用，避免损伤周围骨质。


Subsequently, where the implant is loose, any peripheral soft tissue ‘securing’ the implant around the rim should be removed. Residual areas of fixation can be released using sequentially longer curved osteotomes. The implant should be completely detached before it is removed. Devices such as the Moreland extractor (Figure 2) can be attached to the socket to facilitate removal, though this should be used with care. If an attempt is made to remove an implant that remains sufficiently fixed with this device additional bone loss can result.

随后，内植物松动的地方，任何在髋臼缘周围“固定”内植物的软组织应该切除。残留的内固定区域连续使用长弯的骨凿切除。在取出前，内植物应该完全显露。如Moreland拨出器这样的工具（图2）应该接触到齿槽以方便取出，可是这应该小心使用。如果试图取出仍然固定十分牢固的内植物，能产生额外的骨丢失。

图2

Removal of a well-fixed cemented acetabular component can be more difficult. A number of techniques have been described. In principle, my practice in this circumstance is first to remove the socket from the cement. Once this has been achieved, the cement mantle is visualized and can then be sectioned, carefully and under direct vision. The cement can then be released from the bone using straight and curved osteotomes or a high-speed burr, and removed in small segments. This ensures that no additional bone loss occurs as the implant is removed from frequently osteopenic surrounding host bone.

取出固定良好的髋臼假体是很困难的。对此有数种技术。原则上，对此种情况，我们的做法是首先从骨水泥上移除髋臼杯。一旦这个工作完成，骨水泥壳就能看见，可以仔细小心的在直视下被切开。骨水泥可以通过直的或弯的骨凿或高速的髋臼锉从骨质上切除，和分解成小块清除。这确保了没有额外的骨量丢失，而内植物取出经常发生从宿主骨上的骨丢失。

When removing a well-fixed cemented socket, the initial step is to remove the ‘flange’ of the socket. This is done using straight osteotomes. Subsequently, curved osteotomes are introduced at the implant-cement interface, carefully releasing this so that the socket can be extracted. The well-fixed mantle is then ‘sectioned’, with sharp straight osteotomes. Curved osteotomes are then introduced at the bone-cement interface, gently elevating the cement, which is removed in sections. The entire technique is demonstrated in Figure 2.

当移除一个固定良好的骨水泥型的髋臼杯，最开始的步骤是移除髋臼杯的边缘。这需要使用直的骨凿。随后使用弯曲的骨凿，在内植物－骨水泥界面上，仔细剥离，使髋臼杯拔出。然后切割固定良好的骨水泥壳，使用锋利的直骨凿。再使用弯骨凿用在骨－骨水泥界面上，轻柔的撬起骨水泥，使其一片片取出。完整的技术在（图2）显示。

Small residual cement plugs can be elevated using curved osteotomes and rongeurs. Larger plugs can be removed as above, using ultrasonic devices or drills, taps and screws. Great care should be taken with cement plugs, particularly those that have ‘mushroomed’ beyond their entry point, resulting in a larger diameter than the hole into which the cement was introduced.
Particular care should be taken when removing intra-pelvic cement in these circumstances. Indeed, frequently, in an aseptic case the surgeon might choose to leave these ‘in-situ’, rather than risk significant bone damage/loss and/or haemorrhage. A specific approach for the extraction of intra-pelvic components will be discussed below.

小的骨水泥残渣塞子可以使用弯骨凿或咬骨钳切除。大的塞子可以通过使用超声装置或钻头，丝锥和螺钉。应加倍小心对待这些骨水泥塞子，特别是那些在其入点以下具有幅射状的，可以导致超过洞口更大的直径骨水泥。在这样的情况下，当移除骨盆内的骨水泥应特别的注意。的确，经常的，在无菌的病例里，外科医生可能选择保留这些在原位，而不是冒骨损伤/丢失或出血风险。一个特殊的入路，用以取出骨盆内的组件将在以下章节讨论。

Other techniques have been described to remove well-fixed cemented acetabular components. An acetabular reamer can be used to ‘ream out’ the implant. While this can be successful, it can result in considerable debris. Similarly, this will blunt reamers that should not then be used in primary hip arthroplasty. The technique may, however, allow consideration of a ‘cement in cement’ technique for acetabular reconstruction in the presence of a perfect remaining acetabular bone-cement interface.

其他技术以取出固定良好的骨水泥型髋臼组件也被描述。一个髋臼锉能用以锉出内植物。这样做法可以成功的，也能导致相当可观的碎屑。相似的，这也导致髋臼锉变钝，使它不能再用于初次全髋置换。然而，该技术可能在骨水泥内骨水泥技术时被允许使用，该技术用于髋臼重建，在完美的剩余髋臼侧骨－骨水泥界面存在的情况下。

The use of the ‘Explant’ device (Zimmer, Warsaw, IN), more popular in the removal of well-fixed uncemented components, can be helpful.

In my own practice, the vast majority of cemented acetabular components, both fixed and indeed loose, can be removed using the techniques described above.

取出器（Zimmer，华生，IN）的使用，更常用于取出固定良好的非骨水泥型组件，非常有用。
在我们的实践中，绝大多数的骨水泥型髋臼假体，固定良好的和松动的，能使用以上所描述的技术取出。


Removal of the uncemented acetabular component
The removal of a well-fixed uncemented acetabular component can be a technical challenge. As detailed above, the surgeon needs to have a good understanding of the design of the component, including the extent, location and type of coating. Additional fixation devices, such as screws, fins, spikes and pegs need to be addressed. Manufacturers may provide specific tools that attach to a particular socket design to facilitate removal.

非骨水泥髋臼组件的取出
固定良好的非骨水泥型髋臼组件的取出，是个技术性的挑战。就像以上详细说的，外科医生需要很好的理解组件的设计，包括其范围、位置和涂层类型。附加的固定装置，如螺钉，鳍片，钉脚，和钉夹等需要找出。制造商可能会提供特制工具可以附着于特殊的髋臼杯设计，以方便取出。


Frankly loose uncemented sockets can be removed without difficulty. Many failed uncemented sockets, however, are surrounded by osteopenic bone, frequently with associated lysis. This can occur even in the presence of a relatively secure implant (Figure 3). As can be seen in this example, the socket, while damaged and surrounded by severe lysis, has two or three small areas of residual ‘fixation’ that have prevented the implant from ‘collapsing’ into the surrounding defects. Such implants can be ‘released’, and removed using curved osteotomes, with care to avoid unnecessary additional damage to the grossly deficient surrounding bone, albeit leaving a demanding reconstruction.

直观松动的非骨水泥型髋臼杯可以毫无困难的取出。然而，很多失败的非骨水泥型髋臼杯，周围有骨质减少状态的骨，常常和伴发的溶解相关。这甚至能够发生在相对安全的内植物（图3）。正如在此例中所看到，这髋臼杯，己经损坏，周围有严重的骨溶解，有2或3个小的残留区域固定，因此阻止内植物塌陷进周围的缺损内。如此的内植物可以松动，使用弯骨凿取出，仔细的避免不必要的对周围不足骨量的进一步损伤，因此丢下一个很高要求的重建任务。

图3

The removal of a well-fixed uncemented acetabular component, for infection, mal-orientation and/or wear, remains one of the more challenging procedures in revision hip arthroplasty, though the morbidity associated with this has been significantly reduced by the development and widespread use of devices such as the ‘Explant’.

固定良好的非骨水泥型髋臼组件的取出，感染，位置不良和（或）颗粒，遗留一个或多个挑战性的髋关节翻修操作，尽管和此相关的发病率己经通过发展和普及那些如取出器之类装置的使用而显著的减少。

Removal of a well-fixed uncemented socket starts with a thorough exposure of the entire acetabular rim. Again, care should be taken with retraction to avoid additional bone loss on both the acetabular and femoral sides. There are circumstances in which the surgeon may choose to perform an extended trochanteric osteotomy (ETO) or trochanteric slide, solely to facilitate mobilisation of the femur to allow good acetabular exposure. Similarly, the use of a ‘cement in cement’ femoral revision technique can be useful. This allows a well-fixed cemented component to be removed, albeit temporarily, at the time of acetabular revision, potentially solely to facilitate acetabular exposure.

固定良好的非骨水泥型髋臼杯的取出，首先通过彻底对完整髋臼缘的暴露，一再的，应很小心的缩回以避免髋臼侧和股骨侧额外的骨量丢失。有一些情况下，外科医生可能选择去实行广泛的转子截骨术或转子滑移，单独的推进股骨的移动以允许更好的髋臼暴露。相似的，使用骨水泥内骨水泥技术股骨侧翻修技术是有用的。这允许固定良好的骨水泥组件取出，纵然是暂时的，在髋臼侧翻修的同时，可能的单独的帮助髋臼侧暴露。

Having identified the rim of the socket, the next step is to remove the liner and any screws. Loose liners can be removed easily, however in other cases, and specifically those in which there is no release mechanism, a cortical screw can be used. As the screw is advanced into the polyethylene liner, it contacts the internal shell surface. Further turning of the screw will disengage the locking mechanism (Figure 4). Alternatively, the liner may need to be sectioned to gain access to back surface fixation devices.

完成对髋臼杯边缘的鉴别，下一步是去除衬垫和螺钉，松动的衬垫可以很容易的取出，然而在其他情况下，和特殊的没有解除机制的情况下，可以使用一个皮质骨螺钉。当螺钉拧进聚乙烯衬垫，它接触到内壳的表现。更进一步的旋转螺钉可以解锁衬垫的锁定机制（图4）。可选择的，衬垫可能需要切割以进入表面固定装置的背面（衬垫的背面）。

图4

Removal of hard bearing liners presents a particular problem. Many systems have specific devices with which the surgeon can simultaneously impact against the rim of the intact shell, while a spring-tensioned suction device, attached to the liner, extricates the liner. Essentially, the morse taper is released as the surgeon strikes the rim of the socket. Other systems provide specific instruments that can be introduced through gaps in the periphery of the shell and behind the morse taper, to allow the liner to be levered out of the shell. This particular issue should be discussed with the implant manufacturer or colleagues prior to the case. No attempt should be made to remove the shell without removing screws. This is likely both to be challenging and to result in catastrophic bone loss.

对于硬的承重衬垫的取出是个特殊的问题。很多系统有特殊的器械，使用这个器械，外科医生用弹簧紧张吸引装置，附着于衬垫，同时压紧完整外壳边缘，拔出衬垫。本质上，当外科医生打击髋臼杯的边缘时，morse锥形被释放。其他系统提供特殊的工具，可以通过壳外围的间隙和morse锥形之后，去允许衬垫撬出内壳。在手术之前，应该和假体制造商和同事们讨论这些。不要尝试在移除螺钉之前取出内壳。这样不仅仅是挑战性的，而且能导致灾难性的骨丢失后果。

While the surgeon should try to locate specific screwdrivers for a particular system, many generic implant and broken implant removal sets have various modular heads that can be attached to a driving system. Periodically, screw heads will fail and broken screw removal instrumentation will be required. In addition, a metal cutting burr can be used, with irrigation and soft tissue protection, to remove the head of a damaged screw to allow removal of the socket. The remaining screw shaft can be removed subsequently, using curettes, crown reamers and reverse threaded screw removal systems.

当外科医生尝试对特别的系统放置螺钉起子，许多非通用的假体和断裂的假体取出工具有不同的模块头部，能附加到驱动系统上。周期性的，螺钉头部将失效，将需要断钉取出工具。另外，金属切割钻头可以使用，通过冲洗和软组织保护，以打磨掉损坏螺钉的头部，以使髋臼杯能取出。残留的螺钉干部可以随后取出，使用刮匙，空心钻头和反向螺钉取出系统。

After the rim has been exposed and the screws have been removed, sequential curved osteotomes can be introduced and impacted carefully into the implant-bone interface, gradually releasing the implant, allowing it to be removed. Alternatively, more recently, and perhaps now in the majority of cases, the use of the ‘Explant’ (Zimmer, Warsaw, IN) system has become the standard technique.

The ‘Explant’ device (Figure 5) comprises detachable heads that centralize the device within the socket. Subseqently, short then long blades in 2 mm diameter increments, are used to ‘cut’ the well-fixed implant out of the acetabular bone.

当髋臼边缘暴露好，螺钉己取出，使用连续的弯骨凿，仔细小心的嵌插进假体－骨界面，逐渐松动内植物，并取出。可选择的，最近的，可能现在对于大多数病例，使用取出器系统(Zimmer, Warsaw, IN)（图5） 成为标准技术。

图5

Prior to the ‘Explant’ system being used, the rim of the bone-implant interface should be identified and the surgeon must ensure that the device is satisfactorily centralized within the component. Where there has been gross acetabular polyethylene lysis, either a trial liner or a definitive liner temporarily cemented into the shell can be used. Subsequently, the short Explant blade, corresponding to the diameter of the socket to be removed, is passed around the rim of the implant, using both rotational and longitudinal ‘stabbing’ movements. This steadily deepens disruption of the boneimplant interface. Gentle taps with a mallet can be used in a linear direction to deepen penetration at the interface, though great care should be taken not to fracture the blade. As the interface is developed, the short blade is changed to the longer one. Thus, the implant is functionally ‘cut out’ from the surrounding bone (Figure 6).

在取出器系统使用之前，骨－假体界面的边缘应该鉴别，外科医生必须确保取出器满意的位于髋臼杯的中央。当存在大量的髋臼聚乙烯骨溶解时，用试验的衬垫或最终的衬垫辅以暂时性的骨水泥，堵塞到内壳。随后，短旋的和长纵度的刺穿运动。这稳定的加深破坏了骨－假体界面。使用有手柄的轻柔丝锥直线形的加深穿透界面，尽管应该加倍的小心不使刀头折断。当界面进展了，短刀头更换为长的，因此，内植物功能性的从骨周围切割出来（图6）。

图6

With experience, removal of a well-fixed uncemented socket can become a relatively straightforward procedure and can be achieved in a reasonably short time, with little if any additional bone loss (Figure 7). Indeed, frequently it is possible to remove the implant and subsequently implant a new socket with only a 2 or 4 mm increased diameter. The blades on the ‘Explant’ device should be inspected carefully after each use, to ensure that they have not been damaged.

通过经验，固定良好的非骨水泥假体的取出变成相对直接的操作程序，能完成在适当的短时间内，如果有骨丢失也是很少的（图7）。的确，通常它能够取出假体，随后安装的假体髋臼杯仅增加2－4mm的直径。取出器的刀头装置，应该每次使用后仔细检查，确保他们还没有损坏。

图7

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While hemispherical sockets can be removed relatively easily, peripherally expanded sockets can be more difficult. There remains the potential for removing slightly more bone medially than is necessary. While this is a possibility, with careful use of the ‘Explant’ device and with curved osteotomes, bone loss in this circumstance can be minimized.

当半球型的髋臼杯能相对容易的取出，周围扩展型的髋臼杯要更困难。轻柔取出通过必须多的骨介导，这仍存有可能性。这是一个可能性，通过小心的使用取出器和弯骨凿，在这种情况下骨量丢失能减少到最小。

With the increasing numbers of hip resurfacing implants inserted, removal of a well-fixed uncemented resurfacing acetabular component has become a more common procedure. Where the centre radius of curvature of the socket is not at the centre of the socket internal geometry, there are specific conversion devices that can be introduced into the resurfacing socket, allowing for the altered hip centre, into which the ‘Explant’ device can be introduced (Figure 8). Similarly successful extraction is possible using this technique (Figure 9). The potential use of this system will depend on design of the acetabular component. This should be discussed with the implant manufacturer.

随着越来越多的髋关节表面置换术，取出固定良好的非骨水泥型表面置换髋臼组件成为一个常见操作。当髋臼杯的曲率半径中央，并不在臼窝内几何学的中央，有特殊的转换装置，能够放置进表面臼内，允许可选择的髋关节中央，在这里面，取出器（图8）可以使用。使用这个技术（图9），相似的成功的取出是可能的。使用这个系统的可能依赖于髋臼组件的设计，这应该和假体制造商探讨。

图8

图9

Removal of intra-pelvic components
Intra-pelvic components constitute a challenge in revision hip arthroplasty. Quite apart from access and technical difficulties in retrieving the implants, there is major concern regarding potential intra-pelvic disruption, which could cause major haemorrhage and other complications. As such, the removal of intra-pelvic components needs to be planned carefully. Pre-operative imaging is important. The use of CT scans is helpful, along with the use of CT or MRI arthrography, to identify the proximity of the components to major vessels (Figure 10). The procedures should be discussed pre-operatively with general surgical, vascular or other colleagues who have experience and the ability to provide retroperitoneal access to the pelvic vessels and the internal aspect of the acetabulum.

骨盆内组件的取出
骨盆内组件在髋关节翻修术中是个挑战。离术野较远和技术上显露内植物困难，考虑到可能的骨盆内破裂，这是一个较大的顾虑，这可能会引起大出血和其他并发症。因此，骨盆内组件的取出需要仔细计划。术前影像学图片很重要。CT扫描是有帮助的，使用CT或MRI重建以鉴别组件离大血管的距离（见图10）。手术操作应该术前同普外科，血管外科或其他同行讨论，他们有经验和能力去提供腹膜后有关骨盆血管和髋臼内侧壁的入路。


图10

Where a truly intra-pelvic implant is to be removed, there are a number of options available to the surgeon (Figure 11). It may still be possible to remove the implant via a traditional approach. However, in this circumstance, care must be taken in planning and practice to ensure adequate exposure. As previously detailed, the use of an extended trochanteric osteotomy or trochanteric slide can facilitate mobilization of the femur, improving acetabular access.

当一个真实地骨盆内植物取出时，对外科医生来讲有几个选择（图11）。仍有可能取出内植物通过一个传统手术入路，然而，在此种情况下，应仔细小心计划和实施以确保足够的暴露。如同先前详述的，使用一个扩大范围的转子截骨或转子滑移能方便移动股骨，改善髋臼显露。

图11

If this is to be attempted, it is prudent to have a colleague with vascular experience available. Vascular instruments should be available in case a rapid change of plan is required. If, while removing the implant through a traditional approach, excessive bleeding occurs, a more extensive approach with proximal control of the vessels is likely to be required. Therefore, the patient needs to be prepared and draped to allow patient position to be changed rapidly, intra-operatively, for an additional surgical procedure, frequently a retroperitoneal approach, to be performed to gain urgent control of any bleeding.

如果进行这种尝试，应谨慎的和一个有血管科经验的同行一道。应该备血管工具以防更改计划。如果，内植物取出通过传统手术入路，发生出血过多，可能需要更加扩大范围的暴露以控制邻近的血管。因此，病人需要准备，术中手术铺单可以允许病人体位快速改变，进行一个另外的手术操作，经常为腹膜后入路，以完成紧急止血。

The alternative is to combine the traditional hip approach with a retroperitoneal approach. This technique allows the implant to be mobilized and delivered more safely through either approach. Simultaneously, the surgeon gains primary access and control of potential bleeding prior to the implant being removed. Typically, the retroperitoneal approach is performed and the vessels are identified and mobilized before the traditional hip approach is performed. Frequently, nothing further will be required from the retroperitoneal approach if the surgeon is able to remove the implant via the traditional approach, however, with unexpected bleeding the surgeon has access for rapid control.

可选的方案是联合传统髋关节入路和一个腹膜后入路。该技术允许内植物移动取出在更安全的入路。同时，外科医生得到了最主要的入路，可能可能的出血，这优先于内植物的取出。通常，腹膜后入路的实施和血管的鉴别移动在传统髋入路之前。如果外科医生能够取出内植物通过传统入路，腹膜后入路可能不需要更进一步的工作。然而，如果有意外的出血，外科医生应快速止血。

The approach chosen in this circumstance depends on planning, surgical experience and the availability of colleagues with the required surgical expertise. It is outwith this article to discuss this in detail, however, this complex procedure should be performed by an experienced revision arthroplasty team.

在此种情况下入路选择依赖于术前计划，手术经验和可以同台的具备必要技能的同事。本文讨论这样的细节己经超出范围，然而，如此复杂的操作应该由有经验的关节翻修团队实施。

One other area of concern surrounds intra pelvic-cement, particularly in the presence of infection. Typically, it is essential that all foreign material is removed at the time of revision, or the first stage of a two-stage procedure. Therefore, with truly intrapelvic cement, it is important that the surgeon has other adjunctive techniques available to ensure that all foreign material is removed. Small cement plugs can be removed using gouges. Longer cement plugs can be removed using ultrasonic devices, such as the ‘plug puller’. In other circumstances, particularly with large pieces of intra-pelvic cement, a similar approach to that detailed above will need to be considered. It should be appreciated that the intra-pelvic cement can become adherent to local soft tissues. Great care should be taken to avoid merely pulling on these cement pieces as significant bleeding, which can be difficult to control, can result.

另外一个考虑围绕着骨盆内骨水泥，特别是伴发感染的存在。经典的，必须所有的杂质材料在翻修时取出，或者是两步翻修法中的第一阶段。因此，对于骨盆内骨水泥，外科医生有其他辅助技术以确保所有的杂质材料被取出，这是重要的。小的骨水泥塞子能使用圆凿取出。长的骨水泥塞子能使用超声装置取出，如塞子取出器。在其他情况下，特别是大的骨盆内骨水泥碎片，应当考虑使用一个相似的之前详述的路径。应理解骨盆内骨水泥会粘附在局部的软组织上。应非常小心避免去拽这些碎骨水泥块以免出现难以控制的大出血。

Removal of cemented femoral components
Removal of a cemented femoral component for loosening, wear, component failure, infection, instability or periprosthetic fracture is a common procedure in revision hip arthroplasty surgery. The procedure starts with planning. The surgeon should identify the implant to be removed, both from the point of view of the likely areas and extent of residual fixation, but also to identify any specific aspects of the component that will facilitate removal. The surgeon should discuss the implant with the manufacturer, if necessary, to determine whether any specific instrumentation is available to facilitate removal.