【专题文献】之人工髋关节置换——髋关节翻修术中股骨失败的重建和翻修

【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：髋关节翻修术之四

(iv) Reconstruction and revision of femoral failure in revision hip arthroplasty
髋关节翻修术中股骨失败的重建和翻修

Alexander Acornley；Robin Banerjee；Robert Kerry

Abstract
Suitable techniques for femoral reconstruction and revision are dependent on the status of femoral bone stock. The pre-operative planning and operative strategies utilised increase in complexity as the bone stock diminishes. The options range from proximal to distal fixation techniques using cemented or cementless prostheses. Bone stock augmentation in the form of impacted morcellised or structural strut allografts may be required. In the most severe cases bone stock may need to be restored with bulk allograft or restored with a mega-endoprosthesis. A structured reconstruction cascade discussing these options is presented.

Keywords arthroplasty; femur; hip Joint; re-operation

摘要
用于股骨重建和翻修的适用技术，依赖于股骨骨量的状态。术前计划和动用的手术决策，在骨量减少时，增加了复杂性。治疗选择包括使用骨水泥型或非骨水泥型假体的近端到远端固定技术。打压植骨形式的骨量加强，或结构性支撑的同种异体骨移植，可能是必需的。在很多严重案例中，骨量可能需要通过大块骨种异体骨移植或通过大型内用假体而恢复。论述这些选择的结构性重建串联，在本文展示

关键词：关节置换，股骨，髋关节，再手术。




Introduction
The number of patients undergoing total hip arthroplasty (THA) continues to increase, with 66 839 primary and 6757 (10%) revision THA procedures being recorded in the National Joint Registry for the United Kingdom in 2007/8. Femoral revision and/or reconstruction at the time of THA can range from the simple to the extremely technically demanding, but will essentially revolve around the status of the bone stock within the femur. The potential methods employed are summarised in Table 1. If bone stock is acceptable then revision can be performed using either proximal or distal fixation. If bone stock is unacceptable then the main question is whether bone augmentation or replacement is required.

引言
经历全髋置换的病例数量持续增长，在英国，2007/8年，国家关节注册中心登记有66839例初次全髋和6757例全髋翻修手术。在全髋置换时，股骨翻修和（或）重，从很简单到极高的技术要求，这基本上围绕着股骨的骨量状态。需要使用的可能方法总结在表1。如果骨量是可以接受的，那翻修可以使用近端或远端固定。如果骨量不能按受，，那主要的问题是，是否骨量加强，或置换是必需的。


表1

Pre-operative planning
Pre-operative planning starts with a thorough history and examination of the patient. This is vital to ensure that infection has been ruled out as a cause of failure. Investigation should include the measurement of plasma viscosity erythrocyte sedimentation rate (ESR), full blood count (FBC) and C-Reactive protein (CRP). If inflammatory markers are raised a pre-operative aspiration of the joint is a sensitive and specific method to confirm the presence and sensitivities of the infecting organism.1

术前计划
术前计划由一个彻底的病史和物理检查开始。这是极重要的，以确保排除感染非失败原因。化验包括血沉，全血计数和C-反应蛋白。如果炎症标记物升高，术前关节穿刺是敏感和特异性的方法，以证实感染的存在和感染组织的敏感性。


Bone stock is assessed radiographically. This should include an antero-posterior view of the pelvis in conjunction with an antero-posterior and lateral view of the hip to include the full length of any prosthesis and cement tail present. Obtaining previous radiographs where possible is essential to assess progression of any bone stock loss and assessment of subtle but significant changes.15 An attempt to classify residual bone stock should be made, bearing in mind the known inter/intra-observer limitations of all classification systems. Our unit classifies femoral bone stock abnormalities via the Endo-Klinik system2 (Table 2) though other systems such as that of the American Academy of Orthopaedic Surgeons, and Paprosky,8 are commonly used within the literature.

通过放射学评估骨量。应拍摄骨盆前后位和髋关节的前后位和侧位片，包括任何假体和骨水泥尾部全长。尽可能获取旧片，是必要的，以评估任何骨量丢失的进展和微妙但有意义变化的评价。应尝试对残存骨量分类，对己知的所有分类系统的观察者之间（之内）的不足，牢记在心。尽管其他系统如AAOS，Paprosky在文献中更常使用，我们单位使用Endo-Klinik系统（表2）对股骨骨量异常进行分类。

表2

Radiographs should be used for pre-operative templating of components. This gives the surgeon a plan to work towards during the reconstruction and also allows for component selection based on bone size or stock in more difficult cases. If the patient is a tertiary referral then all previous surgical operative notes should be obtained. This will confirm current implant type and size/configuration and may also reveal any technical difficulties encountered during the previous procedures.

应用放射学图片作为术前假体模板。这给了外科医生在重建时一个去努力的计划，同时在特别困难的病例中，允许假体的选择依赖于骨骼大小或骨量。如果患者是三级转诊，那么应该获取所有的以前的手术记录。这将会证实目前的假体类型和直径/构造，同时可能显示在先前手术时遇到的技术难题。

Operative surgery
Surgery should be carried out in a laminar flow theatre, with appropriate prophylactic intravenous antibiotics administered after specimens have been obtained. Impervious, non-woven, disposable drapes should be used.

外科手术
手术应该在层流室进行，在取得切片后使用适当的抗生素静脉给药。应使用不透水的非针织的一次性洞巾。


The use of an extensile approach should be encouraged to facilitate implant and cement removal, as appropriate. Many units perform revision hip arthroplasty with the patient in a lateral decubitus position and utilise a posterior approach. This can then easily be combined with either a trochanteric slide or extended trochanteric osteotomy based on the pre-operative plan and requirements at the time of surgery.

应推荐使用可扩展入路，以方便假体和骨水泥适当的取出。很多单位用侧卧位后侧入路进行髋关节翻修术。依据术前计划和术中需要，这可以很容易的结合转子滑动或扩展的转子截骨术。

Femoral reconstruction is preceded by acetabular reconstruction, if required, aimed at restoring the anatomical hip centre, and choice of an appropriate bearing surface.

Potential fixation strategies and techniques for bone augmentation/replacement will now be discussed in more detail.

股骨重建先于髋臼重建，如果需要，目的在于恢复髋关节解剖中心和一个适当负重面的选择。
用于骨质加强/置换的可能的固定策略和技术将更详细的讨论。


Proximal fixation (Endo-Klinik Grade 1 bone loss)
Femoral reconstruction using proximal fixation can be either cemented or cementless;

Cemented: The situation often arises where there is a loose acetabular component but well fixed femoral cemented component. Complete removal of a well fixed femoral cement mantle in an aseptic revision THA can be avoided using the cement-incement technique. This is advantageous in that it avoids the potential complications of removing a well fixed cement mantle, as well as reducing blood loss and operative time.
This technique involves cementing a new smaller femoral component into a complete or distally intact cement mantle, most commonly using a polished, tapered stem design. The main indications are after;

近端固定（骨丢失Endo-Klinik分级I级）
使用近端固定的股骨重建，可以是骨水泥型或非骨水泥型。
骨水泥型：这种状况通常发生于松动的髋臼假体，但是固定良好的股骨骨水泥型假体。在无菌性全髋翻修中，可以使用“骨水泥内骨水泥”技术以避免完整取出固定良好的股骨骨水泥封套。这是有益的，在于它避免了取出固定良好骨水泥封套时的可能并发症，同时减少出血和手术时间。
该技术包括将一个新的更小点的股骨假体用骨水泥接合放进完整或远端完整的骨水泥封套内，更常用一个抛光的，逐渐变细设计的股骨假体干。主要指征在之后述说。




- removal of a stable stem to aid acetabular exposure,
- removal of a broken stem,
- removal of a monoblock or inadequate offset stem in instability cases to allow increased offset or larger head sizes to be utilised.
The most important technical details of the technique are;
- the distal mantle must be intact and not damaged by extraction of the old implant,
- the shoulder of the implant should be completely clear of cement before extraction is attempted,
- any defects or osteolysis in the proximal mantle, i.e. corresponding to Gruen zones 1 and 7,3 need to be extracted and the bone-cement interface debrided until a surface that would support osseo-integration can be confirmed and
- the old distal cement interface must be kept meticulously clean and dry to avoid debris and blood entering the interface at the time of cementation of the new implant.

－取出稳定的股骨假体干帮助髋臼暴露
－取出坏掉的股骨假体干
－在不稳定案例中取出单块或不足偏距的股骨假体干，以允许增加偏距或应用更大直径的股骨头
该技术最重要的技术细节是：
－远端骨水泥封套应该是完整的，在拔出旧的假体时没有损伤
－在尝试拔出假体前，应该完全清除假体肩部骨水泥
－在近端骨水泥封套内的任何缺损或骨溶解，对应于Gruen分区1和7，需要被拔出，骨-骨水泥界面清创，直到证实能支持骨粘合剂的表面，和，
－在骨水泥粘合新的假体时，旧的远端骨水泥界面应该谨慎地保持清洁和干燥，以避免碎屑和血进入界面。








The technique was first described by Eftekhar in 1978[4] and recent good short-term clinical and radiological results have now been reported.5,6

Removal of a cementless femoral component without a biological ingrowth surface often yields a femur with minimal metaphyseal cancellous bone loss and an intact diaphysis. The use of cemented femoral components can be justified as the proximal bone stock remains supportive.

该技术最早由Eftekhar在1978年描述，最近良好的短期临床和放射结果现已公布。
取出没有生物学骨长入表面的非骨水泥型股骨假体，常常带来最小的干骺端松质骨丢失和一个完整的骨干。近端骨量仍然有支持，使用骨水泥型股骨假体是合理的。


The most important technical point, as in a primary THA, is bone preparation for cementation. Meticulous removal of any fibrous tissue and exploration of osteolytic areas with curettage of granulation tissue must be performed. Often there has been the formation of a neo-cortex, which must also be debrided; a high speed burr is a useful tool in this situation. Care must be taken to remove any pedestal formed distally if it is likely to impede the correct placement of a cement restrictor.

Implantation of a standard cemented femoral component into the cancellous bed can then be performed with the use of third generation cementation techniques.

正如初次全髋置换中，最重要的技术点，是使用骨水泥的骨准备。必须进行细致的取出任何纤维组织以及通过肉芽组织刮除探测骨溶解区域。
常常形成新生皮质，也必须对此进行清创。在如此状况下高速钻头是有用的工具。应仔细小心的取出任何远端形成的基底，如果它有可能阻碍了骨水泥限制器的正确位置。


Cementless: Complete removal of a cemented femoral component would not normally yield enough bone stock proximally to allow for a metaphyseal fit cementless system to be used.

非骨水泥型：完整取出骨水泥型股骨假体一般不会导致足够的近端骨量，去允许一个干骺端匹配的非骨水泥型假体的使用。

Removal of a cementless femoral component without a biological ingrowth surface often yields a femur with minimal metaphyseal cancellous bone loss and an intact diaphysis. The use of cementless metaphyseal fit femoral components is justified as the proximal bone stock remains supportive.

取出没有生物学骨长入表面的非骨水泥型股骨假体，常常带来最小的干骺端松质骨丢失和一个完整的骨干。近端骨量仍然有支持，使用非骨水泥型干骺端匹配股骨假体是合理的。

In revision THA for instability, where malalignment of the primary components is an issue, the use of modular systems that allow metaphyseal fit and fill to be reconstructed as an independent variable to stem version can be an advantage.

If required both mechanical and biological modifications such as proximal internal collars and hydroxyapatite coatings can be used, avoiding the need for distal fixation.

Strict attention to detail in the surgical technique of implantation of the femoral component remains identical to that of cementless primary THA.

不稳的全髋翻修中，其初次假体的排列顺序不良是个问题，使用组块模式的系统，可允许干骺端匹配并满足对股骨假体干的版本进行独立可变的重建，是个优势。
如果生物力学和生物学变型如近近内颈部和能使用羟基磷灰石涂层是必须的，则避免使用远端固定。
严格注意于在股骨假体植入的手术技术中的细节，同非骨水泥型初次全髋置换仍然一样。



Distal fixation (Endo-Klinik group 2 and 3)
Cemented－long stem: In the context of adequate distal but reduced proximal bone stock the use of a long stemmed cemented implant can be considered. Early series using standard length components in combination with first generation cementation techniques did yield relatively poor results but 98% stem survival for aseptic loosening has now been reported with the use of polished long-stemmed, double tapered, collarless prostheses without the addition of any bone augmentation.7 This is certainly an attractive option in the elderly, osteoporotic population with their associated co-morbidities and osteopaenia; risk factors that increase the potential for complications with the use of impaction grafting or cementless implants.

远端固定（Endo-Klinik分级2和3级）
骨水泥型长假体：在适当的远端，但近端骨量减少的情况下，应考虑使用长干骨水泥型假体。早期使用标准长度的假体合并使用第一代骨水泥技术的病例，有相对较差的结果，但己报道的无菌性松动的假体干留存的，其98%的案例，是那些使用抛光的长假体干，双面逐渐变细的（锥形），无领假体，并且没有任何骨加强的附加措施。在老年病人，骨质疏松人群，伴相关基础疾病和骨量减少，骨水泥型长假体这肯定是一个有吸引力的选择。使用打压植骨或非骨水泥型假体，这种危险因素增加了并发症的可能性。


A double taper design allows for the taper slip principle of stem engagement and the slim profile distally allows for a large
cement mantle to aid load transfer (Figure 1). Meticulous removal of all fibrous tissue and exploration of osteolytic areas
with curettage of granulation tissue must be performed. Neocortex must be debrided to provide an acceptable cancellous base for cement osseo-integration. Cementation should proceed with the use of:
- distal cement restriction,
- pulsatile lavage of the cancellous bed,
- retrograde canal filling via a long nozzle cement gun,
- proximal seal and
- cement pressurisation prior to insertion.

双面锥形设计允许干接触的锥形滑动原则，远端变细设计允许大的骨水泥封套以帮助负荷转移（图1）。必须进行细致的取出任何纤维组织以及通过肉芽组织刮除探测骨溶解区域。新生皮质应该被清创，以提供用于骨水泥骨粘附的可接受的松质骨床。骨水泥应该使用如下：
－骨水泥远端限制
－对松质骨床进行脉冲冲洗
－通过长嘴的骨水泥*对髓腔进行逆行填充
－近端封闭，和：
－在插入前对骨水泥挤压






图1

Cementless: The two main types of cementless stems of use in femoral reconstruction are broadly divided into shorter proximal (metaphyseal) fit stems, such as may be used in primary total hip arthroplasty, and longer stems designed for revision purposes to fit distally within the diaphysis. After initial preoperative planning and confirmation of findings at operation, appropriate implant choice can be made. If proximal metaphyseal bone stock is adequate then shorter stems designed to fit and fill the metaphysis can be used, but if the metaphyseal bone stock is inadequate distal fit stems are appropriate. At the preoperative planning stage one must make a decision on the amount of bone available above the isthmus. According to Paprosky, if there is more than 4 cm of bone stock within the diaphysis above the isthmus then a distal fit stem is suitable8 (Figure 2). If there is less than 4 cm then a distal fit stem can still be used but augmentation in the form of graft or interlocking screws across the distal stem must be employed. The adequacy of distal support is ultimately a decision based on experience and the design characteristics of the particular implant.

非骨水泥型：在股骨重建中使用的两种主要类型的非骨水泥型假体干，划分为较短的近端（干骺端）匹配干，如可能在初次全髋转换中使用的，和为翻修目的设计的较长的干，可以在骨干内远端匹配。在最初的术前计划和术中所见证实之后，能做出适合的假体选择。如果近端干骺端骨量是足够的，能使用匹配和填充干骺端设计的短干，但是如果干骺端骨量不足，远端匹配的假体是适当的。在术前计划阶段，医生应当对股骨峡部以上可得到的骨量进行判断。根据Paprosky，如果在股骨峡部以上在干骺端有超过4cm以上的骨量，远端匹配的假体是适合的（图2）。如果少于4cm，远端匹配假体仍能使用，但是必须使用骨移植加强或通过假体远端的锁定螺钉。远端支持的足够性，最终是一个依据经验和特定假体设计特点的决定。

图2

On-table axial and rotational stability are mandatory. A number of stem designs and surface finishes are available in order to help ensure this. The length of the stem is also of vital importance as one must assure that the stem progresses at least two full cortical diameters below any significant defect. This can be difficult as after removal of a cemented stem, distal cement and cement restrictor the distance to the isthmus may be greatly reduced. As the length of the stem increases one must also be aware of the natural bow of the distal femur and if possible use a stem that matches this to avoid a stress riser on the anterior cortex of the femur or even perforation.

术中，轴向和旋转稳定性是强制性的。许多假体设计和表面磨光可用的，以帮助确保此目的。假体长度也是极重要的，医生必须保证，假体前进至少在任何显著缺损之下两个完整皮质直径。这将是困难的，因为在取出骨水泥型假体、远端骨水泥和骨水泥限制器后，到股骨峡部的距离可能显著减少。由于假体的长度增加，医生必须当心远端股骨的弓状特点，如果可能，使用可匹配此弓状特点的假体以避免股骨前皮质应力升高或甚至穿孔。

During the approach in such cases, an extended trochanteric osteotomy offers many advantages for the following reasons:
- ease of exposure,
- ease of removal of cement along with products of osteolysis,
- with larger and bulkier stems it still allows secure abductor reattachment and
- proper placement of the level of the abductor mechanism, especially when the limb has been shortened for some time.

在此类病例的入路中，扩展的转子截骨术提供了很多优点：
－容易暴露
－容易取出骨水泥和骨溶解产物
－使用更大的和更加庞大的假体，它仍允许确保外展肌附丽，和：
－妥善的安置了外展肌力水平，特别是在某些时候当肢体短缩时





Even when care is taken, there is still the risk of a distal fracture of the diaphysis below the stem and appropriate clamps/cerclage wiring around the femur distally at the time of prosthesis insertion may be required.

甚至己经做到小心仔细，仍然有假体之下股骨远端骨折风险，在假体置入时适当扎股骨远端环扎可能是必需的。

When attention is turned to the proximal portion of these longer modular stems, both offset and version must be addressed. With more modern prostheses there is a range of bodies available and care must be taken to restore optimal offset and version so as to leave the surgeon with a full set of available head lengths to fully balance the hip (Figure 3).

当注意力转向到这些加长组块模式假体的近端部分，偏距和假体类型都必须定位。通过更现代的假体，有很多可用的主体范围，应小心恢复最佳的偏距和假体类型，以便使外科医生有一整套可用的头长度以完全平衡髋关节（图3）。

图3

If appropriate care is taken with all of these points then a full set of plus and minus heads is still available to the surgeon to finely balance the tension of the reduced hip and ensure adequate stability without excessive lengthening.

如果采取适当的照顾是所有的这些问题，外科医生仍然可用一全套正或负的股骨头来细微的平衡短缩髋关节的张力，没有过度延长的情况下确保足够的稳定性。

Bone augmentation
In the presence of significant bone stock loss it may be advisable to augment the revision THA with bone. This can take the form of either impaction grafting of morcellised allograft bone chips or extramedullary bypass support in the form of allograft cortical strut fixation.

骨加强
在显著骨量丢失存在时，用骨加强翻修全髋，可能是明智的。这可以使用morcellised同种异体骨碎片打压植骨或用同种异体骨支柱固定形式的髓外旁路支持。


It is important to highlight that avoiding unnecessary compromise of bone stock in the distal femur through appropriate choice of primary or revision implant leaves more options for future revision THA surgery. This is especially important in the young patient where multiple revision procedures can be anticipated in a lifetime.

Regardless of the reconstruction chosen, the end result must be a stable implant.

重要的是，需强调，通过适当的初次和翻修假体选择以避免不必要的在股骨远端损害骨量，为今后的全髋翻修手术保留了更多的选择。这对于年轻病人特别重要，因为在其生命中可以预见多次翻修手术。

Impaction grafting: Impaction grafting of the femoral canal as a technique for revision THA was first described by the Exeter group in 1991.9 Morcellised allograft bone chips created by milling donated bone are impacted into the proximal femur to replace deficient bone stock. Any uncontained defects require prior containment. This is achieved with the application of fine stainless steel mesh or occasionally plates or cortical strut allografts, which are secured with the use of wires.

打压植骨：作为全髋翻修的一个技术，股骨的打压植骨最初由Exeter团队描述于1991年。由磨碎的捐赠骨产生的Morcellised骨种异体骨碎片，被打压植入股骨近端以代替骨量缺损。任何非包裹的缺损需要优先防漏。通过使用钢板固定的，细微的不钢钢网孔或临时钢板或皮质支撑同种异体骨，以达到目标。

Once impacted, the canal is retrograde filled with low viscosity bone cement, proximally sealed, pressurised and the new standard or long-stemmed polished, tapered, collarless component is implanted (Figure 4).

一旦打压植骨后，髓腔使用逆行注入低粘度的骨水泥，近端密封，增压，新的标准或加长的、抛光的、锥形的、无领假体被植入(图4）

图4

。

Concerns about subsidence and ultimately failure of the reconstruction have been raised with this method. The technique has now evolved to include dedicated instrumentation for impaction and certain technical considerations are now recommended to lower the risk of subsidence10:

- use of larger bone chips (5 mm) within the femur if the canal is capacious,
- good distribution of particle size,
- washing of the bone chips,
- tight impaction within the femur to the point where the impaction device cannot be removed or rotated from the femur unless it is physically disimpacted with the backslapping hammer and
- the use of long stems in severe cases to reduce the risk of fracture.

对下沉的忧虑和重建的最终失败，因而提出了这个方法。目前该技术进展了，包括用于打压的精细的工具，和，目前推荐使用某些技术方面的考虑以降低沉降的风险。

－如果髓腔更大，则在股骨内使用更大的骨碎片
－骨碎片的洗涤
－在股骨内密封打压到打压装置不能移动或从股骨旋转的那处，除非是使用倒打锤打压不到
－在严重病例中使用长假体以减少骨折风险






It must be remembered that due to the very nature of tight impaction of the allograft, femoral fracture either intra- or postoperatively is a potential complication and a low threshold for investigation of this possibility should be employed.

必须记住，由于同种异体骨密闭打压的自然特性，术中或术后的股骨骨折是一个可能的并发症，为调查这种可能性应采用低门槛.

Cortical strut allograft: These can be used as an adjunct to fixation in several scenarios:
- to restore uncontained non-circumferential defects in the diaphysis,
- to bypass stress risers or
- to stabilise a proximal femoral allograft at the junction of host bone.
The struts are cut from diaphyseal bone. They are placed over the required area and should be wired in place rather than held with stronger cables to avoid damaging the periosteal supply to the host bone. To promote healing to the host bone supplementary autograft bone may be used. In a study of 52 patients over 4 years the average time to union was 10 months, with a 4% rate of non-union and graft resorption.11

皮质骨支持的骨种异体骨移植：在几种情况下这些可以被用来作为辅助固定
－恢复非包容的非圆周的骨干缺损
－应力集中的分流
－稳定近端股骨在宿主骨交界处的同种异体骨移植
支持骨从骨干切害而来，他们被放置在需要的区域，应在合适的地方捆扎，而不是使用更强的缆绳以避免损伤供应宿主骨的骨膜。为刺激愈合到宿主骨，可能需补充使用自体骨移植。在一项52例病例超过4年随访的研究中，平均愈合时间为10个月，4%的骨不连和移植物吸收率。





Bone replacement
There will come a point in the reconstructive cascade that bone loss has become so severe that its total replacement becomes the only remaining option. This is most commonly the case in the young patient who has had multiple revision procedures and in cases of severe infection where the radical debridement required has resulted in massive bone stock loss.

骨替换
在重建过程中可能会出现，骨丢失变得如此严重，而骨的整体置换变成仅有的选择。这常见于那些经历多次翻修手术的年轻病人，和需要彻底清创的严重感染，导致大量骨量丢失。


The options for replacement are either bulk allograft or megaendoprosthetic replacement.

Bulk allograft:12,13 The use of bulk proximal femoral allografts (BPFA), harvested from cadaveric donors gained popularity in the late 20th century both within the United States, Canada and the United Kingdom. The main indication is a circumfrential defect that is more than five centimetres in length. The use of BPFA has several theoretical advantages:
- restoration of proximal femoral bone stock,
- good soft tissue reattachment around the hip aiding muscle function and stability, and
- dry virgin surface for cementation proximally and distal press-fit, with limited compromise of the remaining distal femur.

置换的选择是，大块同种慢体骨移植，或巨大内用假体置换
大块同种异体骨移植：近端股骨同种异体骨（BPFA）的使用，在在美国、加拿大和英国，20世纪后期流行的采集于尸体器官供者。主要指征是圆周形的缺损，超过5cm的长度。使用BPFA有几种理论优点：
－恢复近端股骨骨量
－好的髋周软组织再附丽，帮助肌肉功能和稳定，
－干燥纯净的表面，用于骨水泥近端和远端匹配，剩余股骨远端有限的影响。





All donors are screened for known transmissible diseases. The grafts are usually harvested under sterile conditions and then processed so as to decrease their immunogenicity and ensure sterility. The most common methods used are freezing (－70 0C) or freeze drying, which can be combined with irradiation. Minus seventy degree Celsius stored samples have a storage life of five years.

所有捐献者进行己知传染性疾病的筛选。移植物通常在消毒环境下采集，然后处理以减少免疫原性，确保无菌。最常见的方法是冷冻于－70度或冻干，联合使用照射。－70度储存的样本有五年的保存期。

The surgical approach is usually dictated by remaining host bone, which is often kept to allow it to be wrapped around the BPFA at the end of the procedure. This allows good restoration of the soft tissue envelope and can aid stability. The host junction is sectioned as a step-cut osteotomy to allow initial rotational stability and this can be further augmented with cerclage wires.

手术入路通常由剩余宿主骨所决定，在手术最后，宿主骨常常保持以允许它被BPFA包绕。这允许很好的恢复软组织外膜，能帮助稳定。主连接被切成片，逐步切割截骨术以允许最初的旋转稳定性，且可以使用环扎术进一步加强。

Bone ingrowth cannot occur within the BPFA, therefore the prosthesis should be secured to it with cement proximally. The stem protrudes distally out of the composite to allow insertion and a press-fit into the host. The BFPA, can be held in a vice on a sterile trolley within the operating theatre and prepared as for a standard cemented stem. The cement should be pressurised. This can be achieved by thumb occlusion of the distal end, retrograde cement insertion with a gun and the use of a proximal seal. The prosthesis is then inserted in a standard fashion into the BFPA, allowing further pressurisation. It is essential to ensure that no cement enters the interface between the graft and host.

在BPFA内，骨长入不能发生，因此应该在近端使用骨水泥将假体固定到BPFA。假体突出于远端超过复合物，以允许插入和匹配进入宿主。BPFA，在手术室内可以放置在无菌的推车上，使用老虎钳抓住，作为一个标准的骨水泥型假体进行准备。骨水泥应该加压。这可以用拇指闭塞其远端，用骨水泥*将骨水泥逆行注入，并使用近端封闭。然后将假体以标准作法插入到BPFA，允许进一步的加压。必须确保没有骨水泥进行移植物和宿主骨的界面。

The stem/BFPA composite, is then placed into the host and the step cuts matched, conferring initial stability. This can then be further secured with cerclage wires (Figure 5). The remaining host bone can then be folded back over the BPFA, and held with cerclage wires. Post-operatively patients can weight-bear protected until radiological evidence of trochanteric and graft-host union is present.

假体/BPFA的复合物，然后置入到宿主，逐步切割配对，给予初始稳定性。这也可以进一步通过环扎术固定（图5）。然后将剩余的宿主骨折叠靠向BPFA，再通过环扎术加固。术后病人能保护下负重，直到放射学证据显示出转子部和移植物－宿主骨愈合。

图5

Unsurprisingly significant though very variable complication rates have been reported for this major procedure:
- infection (4e13%)
- instability (0e35%)
- non-union of graft-host (4e23%)
- non-union of trochanter (usually not an issue if distal soft tissue attachment has been preserved and trochanteric escape has been avoided)
- resorption (8e34%) and
- fracture.

对于这主要程序，毫不意外的显著的，尽管非常不定的并发症发生率己经报道。
－感染，4－13%
－不稳，0－35%
－移植物－宿主骨骨不连，4－23%
－转子骨不连，通常并不是一个问题，如果己保存远端软组织附丽，且避免了转子的逃逸（移位）





Failure of such a construct, or bone stock loss which is not suitable for reconstruction with BPFA, may be salvaged with a mega-endoprosthesis.

如此构造的失败，或不适合使用BPFA进行重建的骨量丢失，可以使用一个巨大内用假体挽救。

Mega-endoprostheses: Replacement of the proximal femur with a large endoprosthesis has been used in neoplastic cases for many years. The long term outcome of these procedures can be limited by the poor life expectancy of the patients. In the case of revision hip arthroplasty in non-neoplastic scenarios, proximal femoral endoprosthetic replacement has a high morbidity rate, with such complications as dislocation in 10% of patients and eventual revision in up to 30% of patients at an average follow up of 11 years.14 To this end, endoprosthetic replacement must be viewed as the last option in the reconstructive surgeon’s armamentarium.

巨大内用假体：使用一个大的内用假体进行股骨近端置换，己经在肿瘤病例中应用很多年。这种手术的长期效果，被预期寿命较短的病例所限制。在非肿瘤的髋关节翻修病例中，股骨近端内用假体置换有较高的发病率，并发症如脱位在10%，在11年的随访中，最终的翻修率上升到30%。为此，在重建外科医生的所有武器中，内用假体置换应该被看成最后的选择。

When there is gross destruction of the proximal third of the femur with concomitant destruction of the isthmus then insertion of any stemmed prosthesis is precluded and endoprosthetic replacement must be considered. Numerous different systems are available but the basic principles of insertion are the same. Most systems offer cemented and uncemented fixation but the majority of cases require cement fixation distally, as the isthmus has been passed.

当总体破坏达到股骨近端1/3,伴股骨峡部的破坏，排除了插入其他任何类型的假体，应当考虑内用假体置换。很多不同的系统可用，但是插入的基本原则是相同的。多数系统提供了骨水泥型和非骨水泥型固定，但是由于己经超过股骨峡部，多数病例需要远端骨水泥固定。

One of the main problems is dislocation due to the lack of abductor function and soft tissue attachment. The proximal bone is not supportive of the implant but can be left in the sterile case and wired around the prosthesis to offer some soft tissue attachment. When there is no proximal bone whatsoever, great care is required to ensure the correct tension and ensure stability. Some implants offer the option of trabecular metal at the shoulder of the implant to allow any remnant of greater trochanter the potential to fix to the replacement, but in our experience this seldom occurs.

主要问题之一是由于外展肌功能和软组织附着的缺陷而导致脱位。近端骨不能支持假体，在无菌性病病例中，可以舍弃，以钢丝环绕假体以提供一些软组织附丽。一些假体在其肩部提供金属梁选择以允许任何大转子的剩余固定到假体的可能性，但是根据我们的经验，这很少发生。

All other opportunities to reduce the high risk of dislocation should be considered, such as increasing the head size and captive acetabular components, despite the inevitable associated disadvantages. In cases where the patient has an ipsilateral knee replacement then the use of long endoprosthetic proximal femoral replacement carries a very high risk of periprosthetic fracture between the knee and the hip. In these cases total femoral replacement should be considered (Figure 6).

应当考虑所有减少高脱位风险的其他因素，如增加股骨头直径，髋臼假体的容积，尽管这不可避免的带来缺点。在那些有同侧膝关节置换的病例中，使用内用假体股骨近端置换，在膝和髋之间带来很高的假体周围骨折风险。在这些病例中，应当考虑全股骨置换（如图6）。

图6

Summary
In summary, cases higher up the reconstruction ladder will require more complex reconstructions and have greater potential for complications. A surgeon and unit with adequate experience of that type of case are essential if an optimal outcome is to be achieved.

总结
总的来讲，更高重建阶梯的案例，将需要更复杂的重建，且有更大可能的并发症。如果要获得一个最佳结果，具备对那一类型病例足够经验的外科医生和单位是必须的。


REFERENCES
1 Ali F, Wilkinson JM, Cooper JR, et al. Accuracy of joint aspiration for the preoperative diagnosis of infection in total hip arthroplasty. J Arthroplasty 2006; Feb; 21(2): 221e6.
2 Engelbrecht E, Heinert K. Klassifikation und behandlungsrichtlinien von knochensubstanzverlusten bei revisionsoperationen am hu¨ftgelenk. Hrsg Endo-Klinik Hamburg. [[Classification and guidelines for treatment of loss of bone stock during revision surgery on the hipdmedium-term results]]. In: Endo-Klinik, editor. Prima¨rund revisionsalloarthroplastik. Hamburg, Berlin: Springer; 1987. p. 189e201. German.
3 Gruen TA, McNiece GM, Amstutz HC. ‘‘Modes of failure’’ of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop 1979; 141: 17e27.
4 Eftekhar NS. Principles of total hip arthroplasty. St Louis:Mo***; 1978.
5 Quinlan JF, O’Shea K, Doyle F, Brady OH. In-cement technique for revision hip arthroplasty. J Bone Joint Surg Br 2006; 88-B: 730e3.
6 Goto K, Kawanabe K, Akiyama H, Morimoto T, Nakamura T. Clinical and radiological evaluation of revision hip arthroplasty using the cement-in-cement technique. J Bone Joint Surg Br August 1, 2008; 90-B( 8): 1013e8.
7 Howie DW, Wimhurst JA, McGee MA, et al. Revision total hip replacement using cemented collarless double-taper femoral components. J Bone Joint Surg Br 2007; 89-B: 879e86.
8 Valle CJ, Paprosky WG. Classification and an algorithmic approach to the reconstruction of femoral deficiency in revision total hip arthroplasty. J Bone Joint Surg Am 2003; 85-A(Suppl 4): 1e6.
9 Simon JP, Fowler JL, Gie GA, et al. Impaction cancellous grafting of the femur in cemented total hip revision arthroplasty. In: Proceedings of the British Orthopaedic Association. J Bone Joint Surg Br 1991; 73(Suppl 1): 73.
10 Halliday BR, EnglishHW, Timperley AJ, et al. Femoral impaction grafting with cement in revision total hip replacement. Evolution of the technique and results. J Bone Joint Surg Br 2003 Aug; 85( 6): 809e17.
11 Gross AE, Wong PK, Hutchison CR, King AE. Onlay cortical strut grafting in revision arthroplasty of the hip. J Arthroplasty 2003 Apr; 18(3 Suppl. 1): 104e6.
12 Haddad FS, Garbuz DS, Masri BA, et al. Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Femoral bone loss in patients managed with revision hip replacement: results of circumferential allograft replacement. J Bone Joint Surg Am Mar 1999; 81: 420e36.
13 Graham NM, Stockley I. The use of structural proximal femoral allografts in complex revision hip arthroplasty. J Bone Joint Surg Br 2004 Apr; 86(3): 337e43.
14 Malkani AL, Settecerri JJ, Sim FH, Chao EY, Wallrichs SL. Long-term results of proximal femoral replacement for non-neoplastic disorders. J Bone Joint Surg Br 1995; 77(3): 351e6.
15 Andoni P Toms, Rajesh Botchu, John F Nolan. Diagnostic plain film radiology of the failing hip replacement. Ortho & Trauma 2009; 23(2): 88e100.