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      股骨頸量化截骨在初次人工髖關(guān)節(jié)置換術(shù)中的應(yīng)用

      2016-12-27 16:20:51湯世斌胡耀華何小明
      關(guān)鍵詞:人工髖關(guān)節(jié)置換術(shù)股骨頸

      湯世斌 胡耀華 何小明

      [摘要] 目的 探索一種在初次髖關(guān)節(jié)置換術(shù)中控制雙下肢不等長(zhǎng)的新方法。 方法 對(duì)2010年1~5月100例正常成年人的髖關(guān)節(jié)正位DR片進(jìn)行相關(guān)數(shù)據(jù)測(cè)量,依據(jù)等長(zhǎng)原理,得出股骨頸截骨公式:L=H+M-h。從2010年6月~2015年12月中山市南朗醫(yī)院骨科收治的76例股骨頸骨折中選取符合入選標(biāo)準(zhǔn)需施行人工髖關(guān)節(jié)置換患者45例(45側(cè)),采用隨機(jī)數(shù)字表法將其分為實(shí)驗(yàn)組(23例23側(cè),采用量化截骨)和對(duì)照組(22例22側(cè),采用傳統(tǒng)方法截骨)。術(shù)后測(cè)量術(shù)側(cè)(h+L)值和健側(cè)(H+M)值,比較兩者間的差異;術(shù)后髖關(guān)節(jié)功能按髖關(guān)節(jié)Harris評(píng)分評(píng)定;術(shù)后12個(gè)月通過(guò)問(wèn)卷調(diào)查的形式比較兩組雙下肢長(zhǎng)度差異感。 結(jié)果 45例中41例獲得12~48個(gè)月的隨訪,實(shí)驗(yàn)組術(shù)側(cè)和健側(cè)的下肢長(zhǎng)度比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P > 0.05),對(duì)照組術(shù)側(cè)和健側(cè)的下肢長(zhǎng)度比較差異有統(tǒng)計(jì)學(xué)意義(P < 0.05);術(shù)后12個(gè)月實(shí)驗(yàn)組和對(duì)照組髖關(guān)節(jié)Harris評(píng)分分別為(95.30±1.74)、(94.24±1.83)分,差異無(wú)統(tǒng)計(jì)學(xué)意義(P > 0.05);問(wèn)卷調(diào)查顯示,實(shí)驗(yàn)組20例均無(wú)長(zhǎng)度差異感,對(duì)照組3例有輕微長(zhǎng)度差異感;本組病例術(shù)后無(wú)感染、脫位和假體下沉等并發(fā)癥發(fā)生。 結(jié)論 股骨頸量化截骨在初次人工髖關(guān)節(jié)置換術(shù)中能精確控制股骨矩截骨平面,從而確保術(shù)后雙下肢真正等長(zhǎng)。股骨頸截骨公式使截骨得以量化,不因手術(shù)者不同而出現(xiàn)較大誤差,且影響數(shù)據(jù)的可變因素少,確保了科學(xué)性、可重復(fù)性和可行性,是一種準(zhǔn)確性高、可重復(fù)性強(qiáng)、操作簡(jiǎn)易的控制髖關(guān)節(jié)置換術(shù)中雙下肢不等長(zhǎng)的新方法,值得臨床推廣應(yīng)用。

      [關(guān)鍵詞] 股骨頸;量化截骨;初次;人工髖關(guān)節(jié)置換術(shù)

      [中圖分類號(hào)] R687.4 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1673-7210(2016)10(b)-0107-04

      [Abstract] Objective To explore a new method of controlling unequal length of both lower extremities in primary artificial hip replacement. Methods The relevant data of anteroposterior direct radiography (DR) of hip joint in 100 normal adults from January to May 2010 was measured. According to the principle of equal length, the formula for osteotomy of neck of femur: L=H+M-h, was obtained. 45 cases (45 sides) of patients scheduled for artificial hip replacement accorded with the inclusion criteria were selected from 76 patents with fracture of neck of femur admitted to Nanlang Hospital of Zhongshan City from June 2010 to December 2015, and they were randomly divided into experimental group (23 cases, 23 sides, treated by quantizing osteotomy) and control group (22 cases, 22 sides, treated by traditional osteotomy). The values of (h+L) of the surgical sides and those of (H+M) of the healthy sides were measured after surgery, the difference of the two sides was compared. The postoperative function of the hip joint was assessed according to Harris score. The different feelings of the length of both lower extremities after operation between the two groups were compared through questionnaire survey. Results Among 45 cases, 41 cases of patients were followed-up for 12 to 48 months. There was no statistically significant difference of the length of lower extremities between the surgical side and the healthy side in the experimental group (P > 0.05), while there was a statitically significant difference of the length of lower extremities between the surgical side and the healthy side in the control group (P < 0.05). After 12 months of surgery, the Harris scores of hip joint in the experimental group and control group were (95.31±1.74), (94.24±1.83) points respectively, the differences between the two groups were not statistically significant (P > 0.05). Questionnaire survey revealed that there were no obvious different feelings of the length of lower extremities in 20 cases of experimental group and there were slight different feelings of the length of lower extremities in 3 cases of control group. None of all cases had such complications as infection of incision, dislocation and sinking of prosthesis after surgery. Conclusion Application of quantizing osteotomy of neck of femur in primary artificial hip replacement can precisely adjust the femoral neck osteotomy plan to ensure the really equal length of both lower extremities. The formula for osteotomy of neck of femur makes osteotomy be quantizing, so as to avoid big error because of different operators, and the variable factors those can influence data are less, which make sure the scientificity, repeatability and feasibility of the method. It is a new method of controlling unequal length of both lower extremities with high veracity, strong repeatability and simple operation and worthy of clinical promotion and application.

      [Key words] Neck of femur; Quantizing osteotomy; Primary; Artificial hip replacement

      雙下肢不等長(zhǎng)是髖關(guān)節(jié)置換術(shù)后的常見(jiàn)并發(fā)癥,常導(dǎo)致術(shù)后患者滿意度降低,重者可出現(xiàn)跛行,加速假體磨損,縮短假體壽命,甚至導(dǎo)致假體松動(dòng)、關(guān)節(jié)脫位等并發(fā)癥,嚴(yán)重影響患者生活質(zhì)量。雖然國(guó)內(nèi)外有關(guān)預(yù)防雙下肢不等長(zhǎng)的方法多種多樣,但仍缺乏一種精確性高和可重復(fù)性強(qiáng)的預(yù)防方法。為此,從2010年1~5月,本研究小組對(duì)100例正常成人的髖關(guān)節(jié)正位DR片(急診科一般創(chuàng)傷患者給予常規(guī)攝髖關(guān)節(jié)正位DR片)進(jìn)行相關(guān)數(shù)據(jù)測(cè)量,得出股骨頸截骨公式:L=H+M-h。按此截骨方法,從2010年6月~2015年12月收治的76例股骨頸骨折中選取符合入選標(biāo)準(zhǔn)的45例(45側(cè)髖)施行初次人工髖關(guān)節(jié)置換術(shù),41例獲得平均22.5個(gè)月(12~48個(gè)月)隨訪,臨床效果非常滿意,現(xiàn)報(bào)道如下:

      1 資料與方法

      1.1 一般資料

      2010年6月~2015年12月廣東省中山市南朗醫(yī)院骨科收治股骨頸骨折76例,選取需行人工髖關(guān)節(jié)置換符合入選標(biāo)準(zhǔn)的患者45例(45側(cè)),其中,男28例,女17例;年齡65~95歲,平均(73.5±11.2)歲;入選病例均為≥65歲股骨頸骨折;全髖置換20例20側(cè),半髖置換25例25側(cè)。采用隨機(jī)數(shù)字表法將全部病例隨機(jī)分成實(shí)驗(yàn)組(23例)按股骨頸量化截骨方法施行,對(duì)照組(22例)按傳統(tǒng)方法截骨施行,所有病例為同一個(gè)手術(shù)主刀醫(yī)師完成。本研究無(wú)附加損傷,未違反醫(yī)學(xué)倫理規(guī)范。

      公式L=H+M-h中各個(gè)字母的含義表述如下:小粗隆向股骨矩移行點(diǎn),稱為a點(diǎn);股骨干軸線,稱為C線;經(jīng)過(guò)a點(diǎn)作C線之垂直線,稱為A線;作一條平行于A線的股骨頭最高點(diǎn)之切線,稱為B線;A線和B線間的垂直距離稱為H值,股骨頭-臼間隙距離稱為M值,如圖1左所示;L為患側(cè)a點(diǎn)到股骨矩截骨平面的垂直距離,如圖1右所示。

      1.2 治療方法

      實(shí)驗(yàn)組按股骨頸量化截骨,對(duì)照組按傳統(tǒng)方法截骨。

      本組病例全部使用北京春立正達(dá)科技開(kāi)發(fā)有限公司生產(chǎn)的人工假體,生物型假體柄選用“微槽面135型股骨柄”,骨水泥型假體柄選用“BC型股骨柄”。

      術(shù)前測(cè)量健側(cè)H值和M值;腰硬聯(lián)合或氣管插管麻醉下,作患髖后外側(cè)入路,顯露小粗隆并確定a點(diǎn)(股骨矩和小粗隆相互移行處,電刀標(biāo)記);若為全髖置換,為便于操作,先部分切除股骨頸,銼磨髖臼,確定髖臼假體大小,用游標(biāo)卡尺測(cè)量金屬臼杯和內(nèi)襯壁厚度,安裝臼假體。用股骨近端擴(kuò)髓器擴(kuò)至髓腔內(nèi)層皮質(zhì)骨為止,確定假體柄大小,用此型號(hào)假體柄試模匹配中頸球頭試模并測(cè)量h1值(在器械臺(tái)上測(cè)量,和測(cè)量h值方法相同,測(cè)量a1點(diǎn)至球頭的切線距離),見(jiàn)圖2。

      對(duì)于雙側(cè)髖關(guān)節(jié)置換,術(shù)前不需測(cè)量H和M值,先按傳統(tǒng)方法進(jìn)行一側(cè)置換,測(cè)量L值,記錄假體尺寸、型號(hào);另一側(cè)按L值行股骨矩截骨,安裝同樣尺寸、型號(hào)假體即可。

      1.3 觀察指標(biāo)及評(píng)價(jià)標(biāo)準(zhǔn)

      術(shù)后髖關(guān)節(jié)功能(疼痛、功能、活動(dòng)范圍)按Harris[1]評(píng)分評(píng)定,功能評(píng)價(jià):≥90分為優(yōu),80~<90分為良,70~<80分為可,<70分為差。比較兩組功能優(yōu)良率。通過(guò)調(diào)查問(wèn)卷形式比較術(shù)后兩組雙下肢長(zhǎng)度差異感。比較兩組組內(nèi)健側(cè)(H+M)值和術(shù)側(cè)(h+L)值之間的差異。

      1.4 統(tǒng)計(jì)學(xué)方法

      采用SPSS 19.0統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)分析,計(jì)數(shù)資料采用四格表χ2檢驗(yàn),計(jì)量資料采用均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,組間比較采用兩獨(dú)立樣本t檢驗(yàn)。以P < 0.05為差異有統(tǒng)計(jì)學(xué)意義。

      2 結(jié)果

      2.1 兩組術(shù)后髖關(guān)節(jié)Harris評(píng)分比較

      實(shí)驗(yàn)組和對(duì)照組術(shù)后髖關(guān)節(jié)Harris評(píng)分分別為(95.30±1.74)、(94.24±1.83)分,差異無(wú)統(tǒng)計(jì)學(xué)意義(t = 0.851,P = 0.40)。髖關(guān)節(jié)功能評(píng)價(jià):實(shí)驗(yàn)組優(yōu)19例,良1例,優(yōu)良率為100%(20/20);對(duì)照組優(yōu)18例,良3例,優(yōu)良率為100%(21/21),兩組功能評(píng)價(jià)差異無(wú)統(tǒng)計(jì)學(xué)意義(P > 0.05)。

      2.2 兩組術(shù)后雙下肢長(zhǎng)度差異感比較

      術(shù)后12個(gè)月實(shí)驗(yàn)組20例雙下肢長(zhǎng)度無(wú)差異感,對(duì)照組21例中有3例慢步平地行走自覺(jué)術(shù)側(cè)腿比健側(cè)偏長(zhǎng),雙下肢長(zhǎng)度有輕微差異感,兩組術(shù)后雙下肢長(zhǎng)度差異感比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(χ2=3.06,P > 0.05)。見(jiàn)表1。

      2.3 兩組術(shù)后組內(nèi)健側(cè)(H+M)值和術(shù)側(cè)(h+L)值比較

      實(shí)驗(yàn)組健側(cè)(H+M)值和術(shù)側(cè)(h+L)值比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P > 0.05),說(shuō)明實(shí)驗(yàn)組髖關(guān)節(jié)置換術(shù)后雙下肢長(zhǎng)度無(wú)差異。對(duì)照組健側(cè)(H+M)值和術(shù)側(cè)(h+L)值比較,差異有統(tǒng)計(jì)學(xué)意義(P < 0.05),說(shuō)明對(duì)照組髖關(guān)節(jié)置換術(shù)后雙下肢不等長(zhǎng)。見(jiàn)表2。

      2.4 并發(fā)癥發(fā)生情況

      本組病例術(shù)后無(wú)感染、脫位和假體下沉等并發(fā)癥發(fā)生。

      3 討論

      3.1 國(guó)內(nèi)外現(xiàn)狀

      雙下肢不等長(zhǎng)是髖關(guān)節(jié)置換術(shù)后最受關(guān)注的并發(fā)癥,可引起患髖力學(xué)改變,導(dǎo)致假體磨損、松動(dòng)、脫位甚至出現(xiàn)神經(jīng)損傷[2]。邵世坤等[3]和曹知貧[4]為探討全髖關(guān)節(jié)置換術(shù)中下肢不等長(zhǎng)處理的方法及可行性,對(duì)行單側(cè)人工全髖置換術(shù)患者48例的臨床資料進(jìn)行回顧性分析,術(shù)中通過(guò)多種手段綜合評(píng)估,以獲得術(shù)后雙下肢基本等長(zhǎng),結(jié)果滿意。鄭之和等[5]通過(guò)術(shù)前雙下肢長(zhǎng)度測(cè)量和X線模板測(cè)量,確定髖臼中心,術(shù)中應(yīng)用克氏針?lè)y(cè)量及綜合調(diào)整來(lái)平衡下肢長(zhǎng)度。周才勝等[6]回顧性分析行單側(cè)全髖關(guān)節(jié)置換術(shù)患者48例,采用綜合手段,以均衡雙下肢長(zhǎng)度。廣東醫(yī)學(xué)院第二附屬醫(yī)院楊磊[7]通過(guò)術(shù)前X線測(cè)量、模板測(cè)量,標(biāo)記出需切除股骨矩位置,術(shù)中比較雙側(cè)膝關(guān)節(jié)是否等長(zhǎng)來(lái)調(diào)節(jié)股骨頸的截骨距離和選取人工股骨頭的頸長(zhǎng)來(lái)避免下肢的不等長(zhǎng)。北京大學(xué)深圳醫(yī)院韋良臣等[8]術(shù)中依據(jù)大轉(zhuǎn)子Bryant三角頂點(diǎn)標(biāo)記點(diǎn)之間的距離變化平衡下肢長(zhǎng)度。Cech等[9]利用克氏針術(shù)中定點(diǎn)法,測(cè)量?jī)舍橀g距為術(shù)中調(diào)節(jié)肢體長(zhǎng)度的主要依據(jù)。尚宏喜等[10]用L形測(cè)徑器在術(shù)中測(cè)量,認(rèn)為可有效控制雙下肢長(zhǎng)度。嚴(yán)建鋒等[11]認(rèn)為采用綜合措施進(jìn)行雙下肢長(zhǎng)度控制能獲得較好效果。黃奎等[12]以大轉(zhuǎn)子為參考點(diǎn),通過(guò)術(shù)前、術(shù)中測(cè)量大轉(zhuǎn)子頂點(diǎn)與股骨頭中心、股骨柄球頭中心的距離來(lái)恢復(fù)雙下肢等長(zhǎng)。應(yīng)錦河等[13]通過(guò)術(shù)前數(shù)字影像精確測(cè)量及術(shù)中C形臂X光機(jī)透視調(diào)整置入髖臼假體可有效控制全髖置換術(shù)后下肢不等長(zhǎng)。曹林虎等[14]通過(guò)改良髖臼中心化技術(shù)可有效糾正全髖關(guān)節(jié)置換術(shù)中雙下肢不等長(zhǎng)。李宏斌等[15]介紹一種自行設(shè)計(jì)的下肢等長(zhǎng)測(cè)量裝置來(lái)調(diào)控雙下肢長(zhǎng)度。

      3.2 傳統(tǒng)方法存在的不足

      術(shù)前依據(jù)X片來(lái)測(cè)量和模板比對(duì)來(lái)確定股骨頸截骨位置和假體柄大小以及測(cè)量雙下肢長(zhǎng)度(通常采用測(cè)量髂前上嵴至內(nèi)踝尖的長(zhǎng)度)來(lái)評(píng)估長(zhǎng)度差。這些方法測(cè)量出來(lái)的數(shù)據(jù)可變因素多,可造成測(cè)量數(shù)據(jù)失真。Sairn等[16]認(rèn)為5°股骨內(nèi)收或外展將導(dǎo)致8.0 mm的下肢長(zhǎng)度測(cè)量誤差。

      3.3 股骨頸量化截骨的優(yōu)點(diǎn)

      ①只需術(shù)前和術(shù)后攝標(biāo)準(zhǔn)前后位髖關(guān)節(jié)DR片,術(shù)中不攝片。②公式L=H+M-h中數(shù)據(jù)的測(cè)量相對(duì)精確、可重復(fù)性強(qiáng)。③統(tǒng)一用中頸球頭和股骨假體柄匹配,肢體長(zhǎng)度完全靠股骨矩截骨平面來(lái)決定。于建華等[17]認(rèn)為患肢長(zhǎng)度的控制主要應(yīng)通過(guò)股骨頸截骨位置的高低來(lái)達(dá)到。羅正亮等[18]提出股骨距截骨保留不當(dāng)也是造成雙下肢不等長(zhǎng)的原因。④術(shù)后攝髖關(guān)節(jié)正位DR片可精確測(cè)量健側(cè)(H+M)值和術(shù)側(cè)(h+L)值,能客觀、科學(xué)評(píng)估雙下肢長(zhǎng)度差。Douglas等[19]報(bào)道全髖關(guān)節(jié)置換術(shù)后肢體不等長(zhǎng)2.8~11.6 mm。Woolson等[20]報(bào)道,髖關(guān)節(jié)術(shù)后肢體不等長(zhǎng)多為患肢術(shù)后延長(zhǎng),并認(rèn)為較合適的長(zhǎng)度差在7 mm以內(nèi)。研究小組前期對(duì)100例正常成人相關(guān)測(cè)量證明,正常成人的雙下肢其實(shí)并不等長(zhǎng),仍有5.0 mm以內(nèi)的長(zhǎng)度差,因此,我們認(rèn)為髖關(guān)節(jié)置換術(shù)后雙下肢長(zhǎng)度差小于5.0 mm可以認(rèn)為等長(zhǎng),和Woolson等[20]觀點(diǎn)基本吻合。

      [參考文獻(xiàn)]

      [1] Nilsdotter A,Bremander A. Measures of hip function and symptoms [J]. Arthritis Care & Research,2011,63(11):200-207.

      [2] Plaass C,Clauss M,Ochsner PE,et al. Influence of leg length discrepancy on clinical results after total hip arthroplasty-a prospectively clinical trial [J]. Hip Int,2011,21(4):441-449.

      [3] 邵世坤,符孔龍,陳煜東,等.人工全髖關(guān)節(jié)置換術(shù)中下肢不等長(zhǎng)處理方法的臨床研究[J].中國(guó)修復(fù)重建雜志,2010,24(5):541-543.

      [4] 曹知貧.人工全髖關(guān)節(jié)置換術(shù)后雙下肢不等長(zhǎng)的原因分析及對(duì)策[J].中醫(yī)藥導(dǎo)報(bào),2008,14(9):38-40.

      [5] 鄭之和,董軍峰,李新志,等.全髖關(guān)節(jié)置換術(shù)后雙下肢不等長(zhǎng)的預(yù)防和處理[J].中國(guó)修復(fù)重建外科雜志,2008, 22(6):662-664.

      [6] 周才勝,杜遠(yuǎn)立,許維亞,等.全髖關(guān)節(jié)置換術(shù)均衡雙下肢長(zhǎng)度的探討[J].中國(guó)修復(fù)重建外科雜志,2006,20(6):643-646.

      [7] 楊磊.全髖關(guān)節(jié)置換術(shù)肢體不等長(zhǎng)的原因和預(yù)防[J].中國(guó)臨床解剖學(xué)雜志,2006,24(2):221-223.

      [8] 韋良臣,謝笑宸,張晟,等.利用Bryant三角標(biāo)志術(shù)中均衡下肢長(zhǎng)度預(yù)防全髖關(guān)節(jié)置換術(shù)下肢不等長(zhǎng)[J].中國(guó)骨與關(guān)節(jié)外科,2010,3(1):59-61.

      [9] Cech O,F(xiàn)assbender M,Kirschner P,et al. Preoperative planning and surgical technic in achieving stability and leg lenth equality in total hip joint arthroplasty [J]. Acta Chir Orthop Traumatol Cech,2002,69(6):362-368.

      [10] 尚宏喜,劉安慶,郝敏,等.預(yù)防人工全髖關(guān)節(jié)置換術(shù)后雙下肢不等長(zhǎng)的臨床療效分析[J].中國(guó)藥物與臨床,2012,12(5):562-564.

      [11] 嚴(yán)建鋒,符培亮,李強(qiáng),等.人工髖關(guān)節(jié)置換術(shù)后的雙下肢不等長(zhǎng)[J].中國(guó)組織工程研究,2012,16(52):9844-9851.

      [12] 黃奎,彭松明,張記恩,等.全髖關(guān)節(jié)術(shù)中恢復(fù)雙下肢等長(zhǎng)和外展偏心距的處理[J].生物骨科材料與臨床研究,2013,10(2):11-13.

      [13] 應(yīng)錦河,鄭榮宗,吳偉東.術(shù)前精確測(cè)量及術(shù)中透視調(diào)整在預(yù)防全髖關(guān)節(jié)置換術(shù)雙下肢不等長(zhǎng)中的應(yīng)用[J].中國(guó)骨與關(guān)節(jié)損傷雜志,2012,10(27):914-915.

      [14] 曹林虎,譚倫,吳超,等.人工全髖關(guān)節(jié)置換術(shù)中改良髖臼中心化技術(shù)對(duì)雙下肢不等長(zhǎng)的影響[J].中國(guó)修復(fù)重建外科雜志,2014,28(2):213-217.

      [15] 李宏斌,朱振安,陳雪榮,等.髖關(guān)節(jié)置換術(shù)中下肢不等長(zhǎng)的預(yù)防[J].臨床骨科雜志,2011,14(5):499-501.

      [16] Sairn VK,Pratt WR,Bradley GW. Accurate femur repositioning is critical during intraoperative total hip arthropplasty leith and offset assessment [J]. Arthroplasty,2005, 20(7):887-891.

      [17] 于建華,張鐵良.全髖關(guān)節(jié)置換術(shù)下肢不等長(zhǎng)的處理[J].中華骨科雜志,2001,21(5):261-264.

      [18] 羅正亮,尚希福,胡飛,等.全髖關(guān)節(jié)置換術(shù)治療創(chuàng)傷性股骨頭缺血性壞死的療效分析[J].中華醫(yī)學(xué)雜志,2014, 94(23):1773-1776.

      [19] Douglas EP,Slephen LH,Timothy SM,et al. Effectiveness of an acetabular positioning device in primary total hip arthroplasty [J]. Hospital Special Surgery,2005,1(8):64-67.

      [20] Woolson ST,Rahimtoola ZO. Risk factors for dislocation during the first 3 months after primary total hip replacement [J]. Arthroplasty,1999,14(6):662-668.

      (收稿日期:2016-07-05 本文編輯:張瑜杰)

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