虞連奎,于騰波,趙夏,孟慶陽(yáng),戚超

(青島大學(xué)醫(yī)學(xué)院附屬醫(yī)院關(guān)節(jié)外科,山東青島 266003)

骨水泥全髖關(guān)節(jié)置換對(duì)腎移植后股骨頭壞死短期效果

虞連奎,于騰波,趙夏,孟慶陽(yáng),戚超

(青島大學(xué)醫(yī)學(xué)院附屬醫(yī)院關(guān)節(jié)外科,山東青島 266003)

目的評(píng)價(jià)骨水泥全髖關(guān)節(jié)置換術(shù)(THR)治療腎移植術(shù)后股骨頭壞死(ONFH)的短期效果。方法回顧性分析初次THR治療腎移植術(shù)后ONFH病人12例14髖(腎移植組)臨床資料,隨機(jī)挑選年齡和性別與其無(wú)明顯差異且未服用糖皮質(zhì)激素、未行器官移植的THR病人25例29髖作為對(duì)照組。比較兩組術(shù)前及術(shù)后髖關(guān)節(jié)Harris評(píng)分、術(shù)后假體翻修率及其并發(fā)癥的發(fā)生情況,X線隨訪評(píng)估假體位置及有無(wú)松動(dòng)。結(jié)果術(shù)后病人全部獲得隨訪,平均隨訪37個(gè)月(4～64個(gè)月),隨訪期間病人無(wú)死亡。腎移植組術(shù)后髖關(guān)節(jié)Harris評(píng)分較術(shù)前提高(t＝11.35,P＜0.05),其中優(yōu)10髖,良3髖,可1髖,優(yōu)良率92.8%;對(duì)照組術(shù)后髖關(guān)節(jié)Harris評(píng)分較術(shù)前亦提高(t＝16.75,P＜0.05),其中優(yōu)27髖,良2髖,優(yōu)良率100.0%。腎移植組有3例翻修,1例因?yàn)榧袤w感染,2例因?yàn)榧袤w松動(dòng),翻修率21.4%;而對(duì)照組1例翻修(因假體松動(dòng)),翻修率為3.4%,兩組之間比較差異有顯著性(χ2＝6.93, P＜0.05)。腎移植組術(shù)后并發(fā)髖關(guān)節(jié)脫位、感染各1例,假體松動(dòng)2例;對(duì)照組假體松動(dòng)1例,兩組并發(fā)癥發(fā)生率比較差異有顯著性(χ2＝5.80,P＜0.05)。結(jié)論隨訪期內(nèi)骨水泥型THR治療腎移植術(shù)后股骨頭壞死的短期臨床效果可,但與普通病人相比有較高的并發(fā)癥發(fā)生率及翻修率,術(shù)后應(yīng)加強(qiáng)隨訪。

關(guān)節(jié)成形術(shù),置換,髖;腎移植;股骨頭壞死

股骨頭壞死(ONFH)是腎移植術(shù)后一種嚴(yán)重的并發(fā)癥,嚴(yán)重影響病人的生活質(zhì)量。近年來(lái),隨著新型免疫抑制劑如環(huán)孢素A在臨床的廣泛應(yīng)用,腎移植術(shù)后病人糖皮質(zhì)激素(簡(jiǎn)稱激素)使用量減少,盡管ONFH的發(fā)生率有所降低,但仍高達(dá)4.5%,其中85%為雙側(cè)[1]。腎移植術(shù)后ONFH的保守治療效果較差,全髖關(guān)節(jié)置換術(shù)(THR)是目前最佳的治療方法[2]。因腎移植病人往往伴有腎性骨病及激素誘發(fā)代謝性骨病,多選用骨水泥型THR,但其臨床療效和假體生存率國(guó)內(nèi)文獻(xiàn)未見(jiàn)報(bào)道。因此,本文對(duì)初次THR治療腎移植術(shù)后ONFH病人12例的臨床療效、X線隨訪及并發(fā)癥等進(jìn)行分析?，F(xiàn)將結(jié)果報(bào)告如下。

1 資料和方法

1.1 一般資料

2007年2月—2012年6月,我科收治行骨水泥THR治療的腎移植術(shù)后ONFH病人12例14髖(腎移植組),男8例9髖,女4例5髖;年齡25～57歲,平均41.2歲。病人腎移植術(shù)前均無(wú)ONFH表現(xiàn),術(shù)后腎功能均恢復(fù)可,術(shù)后至接受THR的平均時(shí)間為30個(gè)月(18～50個(gè)月)。導(dǎo)致腎衰竭的原發(fā)病包括慢性腎小球腎炎8例,腎病綜合征2例,糖尿病腎病1例,梗阻性腎病1例。ONFH按ARCO標(biāo)準(zhǔn)分期,ⅡC期1例1髖,ⅢB期1例1髖,ⅢC期2例3髖,Ⅳ期8例9髖。所用假體由Link或Zimmer公司提供。隨機(jī)挑選年齡和性別與其無(wú)明顯差異,且未服用激素、未行器官移植的THR病人25例29髖作為對(duì)照組,ⅢB期1例1髖,ⅢC期4例5髖,Ⅳ期20例23髖。

1.2 治療方法

1.2.1 腎移植組 ①免疫抑制治療:圍手術(shù)期與術(shù)后均按原免疫抑制劑方案維持治療。術(shù)晨給予少量開水吞服既往劑量免疫抑制劑,或者換算成相同劑量藥物靜脈注入;術(shù)后進(jìn)食后即給予日常免疫抑制劑治療。常規(guī)三聯(lián)免疫抑制治療:環(huán)孢素A(Cs A)或他克莫斯FK506＋嗎替麥考酚酯(MMF)＋潑尼松(Pred),并且嚴(yán)密監(jiān)測(cè)圍手術(shù)期的血藥濃度,確保血藥濃度的穩(wěn)定性。Cs A的治療窗濃度為150～200μg/L,FK506為5～10μg/L,MMF用量1.0～2.0 g/d,Pred用量5～10 mg/d。②手術(shù)方法:術(shù)前常規(guī)對(duì)病人進(jìn)行腎功能、心肺功能評(píng)估,積極控制并發(fā)癥?？刂蒲獕涸谡７秶⒕S持穩(wěn)定,血糖＜8.0 mmol/L,谷丙轉(zhuǎn)氨酶＜80 U/L,輸注清蛋白或血漿糾正低蛋白血癥。如無(wú)嚴(yán)重呼吸系統(tǒng)疾病,一般采用硬膜外麻醉。手術(shù)均由我科同一治療組醫(yī)師完成,常規(guī)取前外側(cè)入路行THR[3]。③術(shù)后處理:術(shù)后常歸監(jiān)測(cè)腎功能,包括尿素氮和肌酐。術(shù)中及術(shù)后常規(guī)用腎毒性較小的廣譜抗生素3～7 d預(yù)防感染,術(shù)后第2天開始口服利伐沙班抗凝35 d,術(shù)后1周在助步器輔助下下床活動(dòng)。

1.2.2 對(duì)照組 對(duì)照組病人均未接受免疫抑制治療,未服用激素,未進(jìn)行器官移植,余治療方法與腎移植組相同。

1.3 療效評(píng)價(jià)

評(píng)價(jià)內(nèi)容包括臨床療效、并發(fā)癥及X線隨訪。①臨床療效:采用Harris髖關(guān)節(jié)評(píng)分系統(tǒng)[4]。②并發(fā)癥:觀察髖關(guān)節(jié)脫位、深靜脈血栓、假體無(wú)菌性松動(dòng)、異位骨化和假體感染的發(fā)生情況。③X線隨訪:分別于術(shù)后第2天、1個(gè)月、3個(gè)月、6個(gè)月和12個(gè)月及以后每年復(fù)查X線片,了解假體情況。術(shù)后初始假體位置的評(píng)價(jià):股骨側(cè)根據(jù)KIM等[5]的方法;髖臼根據(jù)Ranawat三角、外展角和前傾角評(píng)價(jià)。假體松動(dòng)評(píng)價(jià):股骨柄假體評(píng)價(jià)根據(jù)ENGH等[6]方法,髖臼側(cè)則根據(jù)KAWAMURA等[7]方法。異位骨化按Brooker標(biāo)準(zhǔn)。

1.4 統(tǒng)計(jì)學(xué)方法

2 結(jié) 果

2.1 兩組臨床療效比較

所有病人均獲得了完整隨訪,平均隨訪37個(gè)月(4～64個(gè)月),術(shù)后切口均愈合良好。腎移植組髖關(guān)節(jié)Harris評(píng)分術(shù)前(28.4±4.3)分(23～45分),末次隨訪(92.1±5.2)分(78～98分),手術(shù)前后相比較差異均有顯著意義(t＝11.35,P＜0.05),其中優(yōu)10髖(71.4%),良3髖(21.4%),可1髖(7.2%),優(yōu)良率92.8%;對(duì)照組術(shù)前Harris評(píng)分(34.2±3.9)分,術(shù)后(96.7±3.3)分,差異有顯著意義(t＝16.75,P＜0.05),其中優(yōu)27髖(93.1%),良2髖(6.9%),優(yōu)良率100.0%。

2.2 兩組并發(fā)癥比較

末次隨訪時(shí)腎移植組病人有3例翻修(1例因?yàn)榧袤w感染,2例因?yàn)榧袤w松動(dòng)),翻修率21.4%;而對(duì)照組1例病人翻修(3.4%,為假體松動(dòng)),兩組之間差異有顯著意義(χ2＝6.93,P＜0.05)。腎移植組病人術(shù)后并發(fā)髖關(guān)節(jié)脫位1例(復(fù)位后保守治療),感染1例(抗感染治療失敗,先行曠置術(shù),后行翻修術(shù)),假體松動(dòng)2例(14.3%),并發(fā)癥發(fā)生率28.6%;而對(duì)照組僅出現(xiàn)假體松動(dòng)1例(3.4%,行翻修術(shù)),兩組之間并發(fā)癥發(fā)生率比較差異有顯著性(χ2＝5.80,P＜0.05)。

2.3 兩組X線隨訪結(jié)果比較

骨盆正位X線片顯示,術(shù)后兩組病人股骨側(cè)假體及髖臼側(cè)假體初始位置均滿意(圖1)。末次隨訪,腎移植組股骨假體骨性固定9髖,纖維固定3髖,不穩(wěn)定1髖,股骨假體及髖臼側(cè)均松動(dòng)1髖,髖松動(dòng)病人均行翻修術(shù);對(duì)照組股骨假體骨性固定28髖,不穩(wěn)定1髖行翻修術(shù),髖臼側(cè)均穩(wěn)定固定。兩組病人無(wú)異位骨化的發(fā)生。

病人,男,48歲,因梗阻性腎病行腎移植術(shù)后34個(gè)月出現(xiàn)左側(cè)ONFH,行骨水泥THR術(shù)前及術(shù)后隨訪X線片。a:術(shù)前骨盆正位X線片; b:術(shù)后2 d骨盆正位X線片;c:術(shù)后54個(gè)月骨盆正位X線片;d:術(shù)后54個(gè)月骨盆蛙式位X線片。

3 討 論

隨著腎移植技術(shù)的全面開展,我國(guó)腎衰竭病人的壽命得到明顯延長(zhǎng),生活質(zhì)量也明顯提高。然而腎移植并發(fā)癥也日益突出,這些病人由于長(zhǎng)期服用激素,往往繼發(fā)缺血性骨壞死,其中又以O(shè)NFH最多[8]。由于對(duì)移植腎、免疫抑制和骨質(zhì)疏松等并發(fā)癥的擔(dān)心,多數(shù)骨科醫(yī)生對(duì)腎移植病人的ONFH采取保守治療。早期措施包括休息、理療、減輕體質(zhì)量,口服雙磷酸鹽、他汀類藥物及止痛藥,然而失敗率高達(dá)97%[2,8]。部分骨科醫(yī)生采用一些創(chuàng)傷較小的手術(shù)如股骨頭髓芯減壓、髖臼成形、粗隆間截骨、帶血管腓骨移植、骨小梁金屬棒植入等[9-12],但長(zhǎng)期隨訪結(jié)果顯示療效較差。目前,THR技術(shù)成熟、療效確切,多數(shù)學(xué)者傾向于選擇THR作為這類病人最佳手術(shù)方式。

腎移植病人一般需長(zhǎng)期服用激素及免疫抑制劑,然而激素可使病人在術(shù)后6～18個(gè)月內(nèi)血鈣增高,血磷降低,抑制骨形成及礦化,促進(jìn)骨質(zhì)脫鈣及骨吸收,病人往往伴隨不同程度的骨質(zhì)疏松及骨量丟失。骨科醫(yī)師多選用骨水泥型THR,因?yàn)檫@種術(shù)式對(duì)骨質(zhì)要求較低,骨水泥固化時(shí)間短,且固化后即可達(dá)到穩(wěn)定,滿足病人早期下地進(jìn)行康復(fù)訓(xùn)練的要求,并且大大減少圍手術(shù)期并發(fā)癥。國(guó)外文獻(xiàn)對(duì)骨水泥型THR治療腎移植術(shù)后ONFH病人近期療效報(bào)道不一,有學(xué)者認(rèn)為腎移植病人骨水泥THR并發(fā)癥的發(fā)生率和普通人群沒(méi)有明顯差異,但也有學(xué)者報(bào)道腎移植病人骨水泥THR并發(fā)癥發(fā)生率較高。DEBARGR等[13]報(bào)道了36例腎移植病人行骨水泥THR后10年的隨訪結(jié)果,Harris評(píng)分術(shù)前平均為61分,術(shù)后為85分,優(yōu)良率為81%。GOFFIN等[8]報(bào)道了93例腎移植病人行骨水泥THR后10年隨訪結(jié)果,假體生存率高達(dá)98%,證實(shí)在10年內(nèi)腎移植病人的骨水泥全髖關(guān)節(jié)假體生存率和相同年齡階段正常人群的結(jié)果相近。本文結(jié)果顯示,腎移植術(shù)后骨水泥型THR近期療效可,與上述報(bào)道相符;但術(shù)后翻修率及并發(fā)癥發(fā)生率高于非腎移植及激素應(yīng)用者,與上述報(bào)道不符?？赡茉蛉缦?。①腎移植病人大部分具有高血壓、糖尿病、動(dòng)脈硬化及出凝血功能異常等高危因素,加之長(zhǎng)期使用Cs A等免疫抑制劑使病人感染等并發(fā)癥風(fēng)險(xiǎn)大大增加。②雖然骨水泥型THR可使假體得到即刻穩(wěn)定,然而病人大多較年輕、生存期較長(zhǎng)、活動(dòng)量大、主動(dòng)活動(dòng)要求高,并且腎移植病人多并發(fā)腎性骨營(yíng)養(yǎng)不良癥及繼發(fā)性甲狀旁腺功能亢進(jìn)癥,使后期穩(wěn)定性受到影響,脫位及假體松動(dòng)風(fēng)險(xiǎn)大大增加。本文研究結(jié)果顯示,腎移植組假體松動(dòng)率為14.3%,高于對(duì)照組的3.4%。③研究樣本數(shù)量偏低,術(shù)者的手術(shù)經(jīng)驗(yàn),評(píng)分標(biāo)準(zhǔn),骨水泥技術(shù)和假體的選擇不同,缺乏統(tǒng)一的標(biāo)準(zhǔn)也會(huì)使研究結(jié)果有偏差。GOFFIN等[8]還認(rèn)為,腎移植THR并發(fā)癥與病人腎移植前透析的方式、腎移植后是否有甲狀旁腺功能亢進(jìn)、腎移植后是否有急性排斥反應(yīng)等有關(guān)。DEVLIN等[14]報(bào)道,腎移植術(shù)后THR病人骨組織出現(xiàn)激素導(dǎo)致的骨質(zhì)疏松,骨水泥和骨組織界面出現(xiàn)骨轉(zhuǎn)化率增高的表現(xiàn)。以上這些因素都可能與腎移植病人骨水泥THR的失敗率明顯高于普通病人有關(guān)。

以往的觀點(diǎn)認(rèn)為,非骨水泥THR在腎移植病人應(yīng)用是禁忌。然而ENGH等[14]指出,假體的穩(wěn)定與骨質(zhì)量無(wú)明顯關(guān)系,生物型髖關(guān)節(jié)置換后假體位移在28μm內(nèi)可以滿足即刻穩(wěn)定性要求,通過(guò)骨長(zhǎng)入從而達(dá)到二次穩(wěn)定,髖關(guān)節(jié)置換假體的選擇應(yīng)主要參考股骨假體的髓腔形態(tài)。目前,隨著假體設(shè)計(jì)的進(jìn)步、手術(shù)經(jīng)驗(yàn)的增長(zhǎng)和骨質(zhì)疏松治療藥物的發(fā)展,越來(lái)越多的學(xué)者開始重視非骨水泥THR治療腎移植病人的ONFH,并且有文獻(xiàn)報(bào)道取得良好近期療效[15],讓人看到可喜的前景,也是不錯(cuò)的嘗試。但是選擇非骨水泥全髖假體仍要謹(jǐn)慎,由于腎移植病人非骨水泥THR的病例數(shù)較少,隨訪時(shí)間較短,所以對(duì)其療效和并發(fā)癥還需要進(jìn)一步觀察。

綜上所述,骨水泥型THR術(shù)治療腎移植術(shù)后ONFH的短期臨床療效可,但總體并發(fā)癥發(fā)生率及翻修率高于普通人群,治療過(guò)程中要加強(qiáng)隨訪,盡量避免并發(fā)癥的出現(xiàn)。同時(shí),未來(lái)需要大樣本、長(zhǎng)期隨訪研究,進(jìn)一步明確這種手術(shù)方式的臨床療效。

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(本文編輯 黃建鄉(xiāng))

SHORT-TERM OUTCOMES OF CEMENTED TOTAL HIP REPLACEMENT FOR FEMUR HEAD NECROSIS AFTER RENAL TRANSPLANTATION

YU Liankui,YU Tengbo,ZHAO Xia,MENG Qingyang,QI Chao (Department of Joint Surgery, The Affiliated Hospital of Qingdao University Medical College,Qingdao 266003,China)

ObjectiveTo evaluate the short-term outcomes of cemented total hip replacement(THR)for femur head necrosis(FHN)after renal transplantation.MethodsA retrospective analysis was done in 12 patients(14 hips)after cemented THR for FHN after renal transplantation(RT),and 25 cases of sex and age-matched THR with no history of steroid therapy or organ transplantation were served as controls.A comparison was done between the two groups(before and after surgery)in regard to Harris score,postoperative prosthesis revision rate and complications including dislocation of hip joint,deep vein thrombosis, aseptic loosening,heterotopic ossification and prosthesis infections.A follow-up X-ray film was used for assessing the prosthesis.ResultsAll the patients survived during a follow-up for 37 months(4－64 months),Harris score of hip joint after surgery was higher than before surgery(t＝11.35,P＜0.05),of which,10 hips were classified as excellent,three as good,and one as general, the excellent and good rate being 92.8%;the score in the control group also increased(t＝16.75,P＜0.05),27 hips were rated as excellent,two were good,excellent and good rate being 100.0%.In RT group,prothesis revision was done in three cases,one due to infection and two due to loosing of the prothesis;in the control,one prothesis was revised because of loosing,the difference between the two groups being significant(χ2＝6.93,P＜0.05).Postoperative complications:in RT group,one with dislocation,one with infection and two with loosing of the prothesis;in the control,one with loosing of the prothesis.No deep vein thrombosis and heterotopic ossification were found in both groups.The differences of complications between the two groups were significant(χ2＝5.80,P＜0.05).ConclusionDuring follow-up period,the short-term outcomes of cemented THR for FHN after renal transplantation are acceptable,but,it has a higher complications and revision rate of prothesis as compared with ordinary patients.A postoperative follow-up should be emphasized.

arthroplasty,replacement,hip;kidney transplantation;femur head necrosis

R681.8;R687.4

A

1008-0341(2013)04-0361-04

10.11712/qlyx201304027

2012-12-03;

2013-04-23

虞連奎(1987-),男,在讀碩士研究生。

戚超(1977-),男,博士,主治醫(yī)師。