髋臼骨缺损的Paprosky分型_全髋关节置换翻修的植骨原则：髋臼技术(1994)

髋臼骨缺损的Paprosky分型_全髋关节置换翻修的植骨原则：髋臼技术(1994)Principles of bone grafting in revision total hip arthroplasty. Acetabular technique

Paprosky WG, Magnus RE. Principles of bone grafting in revision total hip arthroplasty. Acetabular technique. Clin Orthop Relat Res. 1994 Jan;(298):147-55. PMID: 8118969.

Loyola University, Stritch School of Medicine, Maywood, Illinois.

转载文章的原链接：

https://pubmed.ncbi.nlm.nih.gov/8118969/

Abstract

Multiple revisions of the acetabulum ultimately lead to severe loss of bone stock. Each bone loss type requires a specific method of allograft reconstruction to achieve acetabular component stability. A series of 316 acetabular revisions in which 69 required support allograft were followed for a mean of 5.1 years (range, two to ten years). Support allograft was required when radiographs showed superior component migration greater than 2cm. Severe ischial lysis was indicative of posterior column insufficiency. Distal femurs were used instead of femoral heads as support for porous-coated cups. If in addition to the radiographic findings, Kohler‘s line also was violated (which was indicative of anterior column deficiency as well), then whole acetabular allografts were used with cemented polyethylene cups. Biologic fixation of a porous-coated cup and support allograft were not possible in these cases. All of the distal femoral allografts united to host bone, and there was no migration of porous-coated components at a mean of 5.1 years when Kohler‘s line was intact. When Kohler‘s line was not intact, 70% of the porous cups had migrated more than 4mm and were considered failures. Conversely, when whole acetabular allografts with cemented polyethylene cups were used in these cases, all 14 showed graft union and no change in the cement-graft interface at a minimum follow-up period of 24 months. The postoperative clinical results using the D‘Aubigne and Postel rating scales were 10.1 of 12, with 76% good to excellent results. This study indicates that better results with support allografts can be achieved at similar periods than has previously been reported.

Paprosky分类法根据前后骨盆、髋关节X线片中髋关节中心上移、坐骨支骨溶解、髋关节中心内移和泪滴骨溶解的程度作为衡量的依据，强调髋臼缘、髋臼顶和前后壁以及髋臼前后柱的稳定性。 根据这些信息，可以在术前较为准确地评估缺损的程度，对拟订髋臼重建方案具有重要意义。

髋臼骨缺损 Paprosky分型由美国医生Paprosky等于1994年提出。此分型法对髋臼骨缺失程度、部位进行评估，有利于指导治疗、选择骨重建方式及髋臼假体（图1，表1）。Paprosky 分型的主要标志是旋转中心位移程度、坐骨骨溶解、泪滴骨溶解及髋臼相对于 Kohler 线的位置变化。髋臼旋转中心上移提示骨缺损累及髋臼顶及前、后柱，坐骨骨溶解提示髋臼后柱骨缺损同时有髋臼后壁骨缺损，泪滴骨溶解和假体越过 Kohler 线提示髋臼内侧骨缺失。

图1 髋臼骨缺损的Paprosky分型示意图

Ⅰ型，髋臼环完整；

Ⅱ型，髋臼环部分破坏，但髋臼锉磨后有足够的骨量保证非骨水泥髋臼假体能够获得稳定的初始稳定；

Ⅲ型，髋臼环支撑结构破坏。

表2 Paprosky分类法

注：

髋关节中心上移程度：“不明显”指上移在闭孔横线上方3cm以内；“明显”指在该线3cm以上。

坐骨支骨溶解程度：“轻度”指 距离闭孔横线下方0～7 mm内有骨溶解；“中度”指在该 线以下8～14 mm内有骨溶解；“重度”指在该线下15mm或更远部位有骨溶解。

髋关节中心内移程度: “Ⅰ度”指在 Kohler线外侧；“Ⅱ度”指移至Kohler线处；“Ⅱ⁺度”指在Kohler线内侧，扩展至盆腔内；“Ⅲ度”指移至盆腔内；“Ⅲ⁺度”指明显移至盆腔内。

泪滴骨溶解程度: “轻度”指外侧缘少量骨缺失；“中度”指外侧缘完全缺失；“重度”指外侧缘与内侧缘都有骨缺失。

Paprosky分类法：

Ⅰ型：髋臼壁无重要的骨缺损，未侵犯到内侧壁，前后柱仍保持完整。

Ⅱ型：髋臼有缺损，但仍能发挥支撑假体的作用，前后柱得以维持，但松质骨几乎 完全消失。

Ⅲ型：髋臼的前后柱、顶部以及底部出现大的缺损（见表2）。缺点是分类方法较复杂。

Paprosky分型将髋臼骨缺损分为三型：

Ⅰ型，髋臼环完整；

Ⅱ型，髋臼环部分破坏，但髋臼锉磨后有足够的骨量保证非骨水泥髋臼假体能够获得稳定的初始稳定；

Ⅲ型，髋臼环支撑结构破坏。其中Ⅱ型、Ⅲ型又根据骨缺损部位及程度分为不同的亚型。在指导治疗方面，PaproskyⅢ型骨缺损通常需要大块结构植骨和（或）金属垫块、髋臼加强环或定制髋臼假体提供支撑以重建髋臼。此分型方法不仅可以预测髋臼骨缺损，对重建髋臼同样具有指导意义，因此 Paprosky 髋臼骨缺损分型同样被广泛应用。

AAOS和Papmsky髋臼骨缺损分型各有优缺点。AAOS 分型只能判断骨缺损的模式，无法体现骨缺损的量及骨缺损部位；Paprosky 分型可以对髋臼骨缺损的程度及部位进行判断。临床可根据具体情况选择分型方法，便于进行治疗效果的比较。髋臼骨缺损 Paprosky分型近年来逐渐被越来越多的关节外科医生所接受，故本文根据 Paprosky分型来探讨髋关节翻修术中髋臼骨缺损的评估与重建。

FIG. 1. Type I acetabulum: intact supportive rim and absence of significant osteolysis of ischium and inferior teardrop.

TABLE 1.

FIG. 2. Type 2 acetabulum: Superior bone loss and moderate osteolysis of ischium and inferior teardrop. Rim is still supportive.

FIG. 3. Type 3A acetabulum: severe superior bone loss caused by component migration of

greater than 2 cm. Severe inferior ischial lysis. Rim will not support an implant.

FIG. 4. Type 38 acetabulum: Severe superior and inferior bone destruction. Rim will not support an implant and is inadequate to allow for porous ingrowth to occur.

FIGS. 5A AND 5B. (A) A proximal femur is shown cut in the shape of a No. 7. The graft is placed over the superior acetabular defect, and the placed cup portion of No. 7 is buttressed against the ilium. (B) The graft is reamed after it has been securely fixed to the ilium with 6.5-mm cancellous screws. Note the oblique orientation of the screws that are away from the reamed graft surface. Adequate inferior host bone remains to enable biologic fixation of the cup to occur. A component 2 to 3 cm larger than the reamed cavity is press-fit larger cavity and buttressed superiorly by the strong, thick allograft.

FIG.6. A whole acetabular transplant fixed to the ilium and supported by pubis and ischium infe-

Riorly

FIGS.7A AND 7B: Type 3A defect shows moderate ischial and inferior teardrop osteolysis and superior migration greater than 2 cm. Kohler’s line is intact. Six-year follow-up radiograph of support allograft with distal femoral condyle. No graft collapse or migration of porous-coated acetabular component. Lateral graft resorption noted

FIGS.8A AND 8B. (A) Type 3B defect with superior component migration greater than 2 cm. component Kohler’s line has been violated. There is nor enough bone available for biologic fixation of a porous cup to occur even if it is supported by a superior allograft. (B) Three-year follow-up radiograph of the whole acetabular allograft with cemented polyethylene cup. No graft or component migration has occurred.