股骨柄假體的設(shè)計和臨床應用選擇

髖關(guān)節(jié)假體的設(shè)計

和

臨床應用選擇應明MD,

PhD

12024/8/4股骨柄臨床成功的重要因素設(shè)計理念表面處理假體材料22024/8/4非骨水泥股骨柄材料

鈦合金(鈦鋁釩,鈦鋁鈮)鈷鉻鉬合金不銹鋼32024/8/4非骨水泥股骨柄經(jīng)典設(shè)計方型柄圓形柄錐形柄解剖柄組配柄42024/8/4方形柄52024/8/4圓形柄62024/8/4錐形柄72024/8/4解剖柄82024/8/4組配柄92024/8/4非骨水泥股骨柄植入后的穩(wěn)定初期穩(wěn)定柄局部與髓腔的緊密匹配和卡壓遠期穩(wěn)定骨長上或骨長入102024/8/4非骨水泥股骨柄初期穩(wěn)定的部位112024/8/4非骨水泥股骨柄遠期穩(wěn)定的實現(xiàn)骨長上粗糙表面骨長入多孔表面122024/8/4粗糙表面上的骨長上132024/8/4多孔表面上的骨長入采用多種不同的工藝，在非骨水泥柄表面形成具有一定厚度的多孔涂層，以利骨長入多孔內(nèi)而獲得柄遠期穩(wěn)定142024/8/4152024/8/4對表面多孔涂層的要求162024/8/4孔隙率對骨長入的影響172024/8/4孔隙大小對骨長入的影響孔隙大小(um)骨長入情況50結(jié)締組織形成，無骨長入100有礦化骨組織侵入，有可能血管化200骨組織生長明顯300明確加速骨組織的生長400骨組織進入孔隙深部仍有可能500骨組織生長速度受限，進入深部受限182024/8/4孔隙大小對術(shù)后抗剪力強度的影響192024/8/4各種不同多孔表面的骨接觸百分比鈦多孔表面植入后1個月植入后6個月鈦絲21.8±2.5%43.2±4.5%鈦珠34.0±4.2%33.3±2.9%等離子噴涂32.5±3.8%41.9±5.2%202024/8/4多孔涂層比較212024/8/4VPS222024/8/4VPS232024/8/4VPS原理242024/8/4涂層形成過程252024/8/4多孔表面上的骨長入262024/8/4非骨水泥柄的選擇中的其他考慮假體選擇的正確——髓腔評價型號選擇的準確——術(shù)前計劃并發(fā)癥的預見（應力遮擋、大腿疼痛）頸干角/頸距/頸長/頸高/肢體長度272024/8/4股骨柄的發(fā)展195019601970198019902000骨水泥柄非骨水泥柄對非骨水泥柄熱情下降骨水泥柄回潮非骨水泥柄回潮282024/8/4骨水泥柄的兩種基本設(shè)計理念承載錐型主要關(guān)注載荷分散組合柱型主要關(guān)注柄的形狀292024/8/4骨水泥柄的兩種基本設(shè)計302024/8/4骨水泥柄的兩種基本設(shè)計承載錐型組合柱型柄體材料CoCr，SSCoCr,

SS,

Ti合金柄體形狀錐形為主截面方、橢圓頸領(lǐng)通常無通常有表面處理高拋光毛糙、粗糙骨水泥層的要求較低較高植入后下沉顯著(0.9-1.4mm)甚小(0.1-0.5mm)312024/8/4骨水泥柄設(shè)計的兩種思想承載錐型組合柱型骨水泥層是不可能完美的，股骨柄與骨水泥層之間的綁定也無法完美。因此通過允許柄的下沉達到二次穩(wěn)定，使骨水泥在柄與骨骼之間形成良好的充填，使應力更好地從柄傳遞到骨水泥層再到骨骼應盡一切可能獲得骨水泥層的完美，增加骨水泥層與柄之間的邦定，這是植入柄遠期穩(wěn)定的基礎(chǔ)。因此應盡量限制柄的任何下沉或微動。增加頸領(lǐng)、表面粗糙化處理等均是出于這一目的。322024/8/4骨水泥柄中的“法國悖論”髓腔銼與植入柄同號盡可能植入較大號柄可去除較多的松質(zhì)骨無需均勻的骨水泥層柄可直接與骨質(zhì)接觸332024/8/4342024/8/4352024/8/4A,Neck-stemangleisreduced.B,Neckisattachedatmoremedialpositiononstem.362024/8/4372024/8/4382024/8/4Large-diameterheadwithtrapezoidalneck(A)hasgreaterrangeofmotionandlessimpingementthansmallerdiameterheadandskirtedmodularneck(B).392024/8/4DefinitionPMstem.Proximallongitudinalgroovesandsurfacetexturingpromotemechanicalinterlockwithcement.Integralproximalanddistalpolymethylmethacrylatespacersensureneutralpositioningincanalandadequatethicknessofcementmantle.

(CourtesyofStrykerOrthopaedics,Kalamazoo,Mich.)

402024/8/4OmnifitEONstem(StrykerOrthopaedics,Kalamazoo,Mich).Normalizedproximaltexturingconvertsshearforcestocompressiveforces.A,Standardoffset.B,Enhancedoffset.412024/8/4SpectronEFstem.Rounded,rectangularshapeandlongitudinalgrooveimproverotationalstability.A,Highoffset.B,Standardoffset.

(CourtesyofSmith&Nephew,Memphis,Tenn.)

422024/8/4CPThipstem(Zimmer,Warsaw,Ind).Collarless,polished,tapereddesignallowscontrolledsubsidenceandmaintainscompressivestresseswithincementmantle.432024/8/4Basiccementlessstemshapes(StrykerOrthopaedics,Kalamazoo,Mich).A,MeridianTMZFstraightstemissymmetricalandfitseitherfemur.B,CitationTMZFanatomicalstemdesignincorporatesproximalposteriorbowandantevertedfemoralneck.442024/8/4Synergyporousstem(Smith&Nephew,Memphis,Tenn).Taperedstraightstemdesign.Proximalflutesprovideadditionalrotationalstability.A,Standardoffset.B,Highoffset.Shownwithoxidizedzirconiaheads.452024/8/4APRstem(Zimmer,Warsaw,Ind).Collaredanatomicaldesign.Standard(A)andlargebody(B)componentsprovidevariableproximalfitforgivendistalstemsize.462024/8/4Taperlocstem.Plasma-sprayedtitaniumporoussurface.Collarless,flat,wedge-shapedgeometryisavailablewithtwofemoraloffsets.

(CourtesyofBiomet,Warsaw,Ind.)

472024/8/4VerSysstem.Collaredtitaniumalloystemwithtitaniumfibermetalcircumferentialporoussurface.Trapezoidalproximalgeometryanddistalflutespromoterotationalstability.

(CourtesyofZimmer,Warsaw,Ind.)

482024/8/4S-ROMmodularstem.A,Multipleproximalsleevesizescanbecombinedwithgivendiameterstem.Stemcanberotatedinrelationtosleevetocorrectrotationaldeformityoffemur.Distalflutesimproverotationalstability.B,Long,curvedstem.Distalpartofstemisslottedincoronalplanetodiminishbendingstiffness.

(CourtesyofJohnson&Johnson,DePuy,Warsaw,Ind.)

492024/8/4Extensivelyporous-coatedstems.A,AMLstemforprimaryandrevisionarthroplastieswhenisthmusisintact.B,ExtensivelycoatedSolutionlongstemusedforrevisionswhenproximalbonelossissevere.C,Calcarreplacementlongstem.

(CourtesyofJohnson&Johnson,DePuy,Warsaw,Ind.)

502024/8/4Noncircumferentialporouscoating.Despiteexcellentingrowthintoporouspad,debrismaymigratetodistalaspectofstemthroughadjacentsmoothchannels(arrow).512024/8/4Alloclassicstem(Zimmer,Warsaw,Ind).Conicalstraightstemwithrectangularcrosssection.Titaniumalloywithgrit-blast,nonporoussurface.522024/8/4Corailstem(Johnson&Johnson,DePuy,Warsaw,Ind).Titaniumalloystemwithextensivehydroxyapatitecoating.Proximalridgesanddistalgroovesprovideadditionalstability.532024/8/4Specializedfemoralcomponentsforreplacementofvariablelengthofproximalfemur.OrthogenesisLimbPreservationSystem.Modularsegmentalreplacementstemforreplacementoflargesegmentofproximalfemur.Stemcanbecombinedwithtotalkneereplacementtoreplaceentirefemur.

(CourtesyofJohnson&Johnson,DePuy,Warsaw,Ind.)

542024/8/4EnduranceCDHstem.Straightsmall-diameterstemdesignisidealforuseinpatientswithdevelopmental(congenital)hipdysplasiaorsmallstature.

(CourtesyofJohnson&Johnson,DePuy,Warsaw,Ind.)

552024/8/4Acetabularcomponentdesignedforcementfixation.Texturedsurfaceandpolymethylmethacrylatespacersoptimizecementmantleandcement-prosthesisinterface.

(CourtesyofSmith&Nephew,Memphis,Tenn.)

562024/8/4Contourantiprotrusiocage(Smith&Nephew,Memphis,Tenn)hastitaniumsupportringfixedtoiliumandischiumwithscrews.Alternatively,inferiorfincanbeimpactedintoischiumwithoutscrews.572024/8/4Universalacetabularcomponent(Biomet,Warsaw,Ind).Titaniumplasmaspraycoatingwithdomeandrimscrewfixationoptions.582024/8/4592024/8/4Interfitacetabularcomponent.Hemisphericaldesignwithgradualtransitiontoenlargementinperipheralrimforimprovedinitialstabilityandperipheralstresstransfer.

(CourtesyofSmith&Nephew,Memphis,Tenn.)

602024/8/4Arrayoflineroptionsavailablewithcontemporarymodularacetabularsystem:standardflatliner(A);posteriorlipwithoutanteversion(B);4-mmlateralizedflat(C);anteverted20degrees(D