摘要
背景:有研究表明全髋关节置换术有较高的假体松动率,大大地影响了假体的远期疗效。无柄解剖人工全髋关节假体能否依靠股骨假体的生物固定作用减少假体松动率的发生?目的:观察无柄解剖型人工全髋关节置换术的生物力学特征对年轻患者髋关节置换后的效果,并以5年随访客观数据评价。设计:病例分析。单位:广西医科大学第一附属医院脊柱骨病科。对象:选择2001-01/05在广西医科大学第一附属医院脊柱骨病科收治的15例髋关节疾患患者(17髋),男8例,女7例,患者手术时年龄21～49岁,平均(37.8±9.8)岁。手术适应症包括:股骨头缺血性坏死(7髋)、创伤性关节炎(4髋)、骨性关节炎(3髋)、发育不良引起的骨性关节炎(3髋)。所有患者术前均对手术项目知情同意,新型无柄解剖人工全髋关节为钻铬钥合金铸件,由上海复升医疗器械有限公司提供,国药管械(试)字2002第3040397号,国食药监械(准)字2005第3460799号。方法:对15例(17髋)髋关节疾患患者进行无柄解剖人工全髋关节置换术,患者于术后第1年间隔6个月随访,以后每年随访1次,共5年,随访包括功能评价及X线评价。①功能评价:采用Harris关节功能评价标准,满分为100分,总分≥80分为优,≥60分为良,≥40分为可,差<40分;记录疼痛缓解情况、侧卧于手术侧的能力、附加手术、止痛药物的使用情况、术后髋关节的脱位情况等。疼痛评估采用视觉模拟疼痛评分法(0-10分,0分代表无痛,10分代表剧痛)。②X射线评价:手术前后拍摄标准的骨盆平片,记录按Busse分类的术前骨性关节炎的分级、按Ficat分类的术前的股骨头缺血性坏死的分级、假体的插入角度以及对侧的颈干角、按Buergi分类的X线透亮带、按Brooker分类的异位骨化分级。③对术后不良事件和并发症进行观察,必要时给予翻修手术。主要观察指标:5年随访患者相关情况分析:①假体的插入角度、对侧的颈干角。②X线透亮带及异位骨化分级结果。③术前骨性关节炎的分级、术前股骨头缺血性坏死分级。④翻修手术情况、不良事件及并发症。⑤术后综合功能效果:疼痛缓解情况(Harris关节功能评分)、侧卧于手术侧的能力、附加手术、止痛药物的使用情况、术后髋关节的脱位情况及视觉模拟疼痛评分结果。结果:纳入15例患者,1例患者治疗3个月后失访,14例均获得5年随访。①患者术后功能评价结果:术后随访第5年,13例(15髋)患者髋关节仍在原位,其中11例患者(84.6%,11/13)疼痛减轻或消失,12例(92.3%,12/13)患者愿意再次手术,10例(76.9%,10/13)患者可以侧卧于手术侧;Harris平均分为(72±19.6)分,不同的疾病之间的Harris记分无明显差别(P>0.05);术后的视觉模拟疼痛评分平均(2.6±2.2)分,不同的疾病组之间的髋关节疼痛没有明显差别(P>0.05);9例(69.2%,9/13)不需要疼痛治疗,2例(15.4%,2/13)偶尔需要非甾体类消炎止痛药止痛,2例(15.4%,2/13)长期需要非类固醇类消炎止痛药止痛。②患者X射线评价结果:术前骨性关节炎的分级情况:1髋有1度的退行性改变,3髋有2度的退行性改变,6髋有3度的退行性改变。术前股骨头缺血性坏死的分级情况:7个股骨头缺血性坏死中4个处于3期,3个处于4期。术后随访第5年,1例患者有X射线透亮区,由于透亮区范围较小,进展不迅速,临床症状不严重,没有进行翻修;术后6个月非手术侧的颈干角是(135.2±6.8)°,手术侧的插入角是(132.2±6.5)°。1例患者先天性髋关节发育不良进行了内翻去旋转截骨本次手术后的插入角是120°。假体插入角在125°-140°之间的患者髋关节疼痛较其他患者减轻。异位骨化分级情况是:3髋有异位骨化,其中1髋有1度的异位骨化,1髋有2度的异位骨化,1髋有3度的异位骨化。③翻修手术情况:1例(5.9%,1/17)患者因术后的疼痛没有缓解而进行了翻修全髋人工关节置换术,术中发现股骨近断骨质保存完好,翻修时使用有柄的假体比较容易。患者术后的顺利康复。④不良事件及并发症:有1例患者(5.9%,1/17)出现了髋关节脱位,其他并发症有大转子滑囊炎1例、伤口瘘管1例、血肿1例。结论:①无柄解剖人工全髋关节提供了股骨假体的生物固定,从而可以有效地固定假体和延长假体的使用寿命。②由于近段股骨干未受干扰,方便了翻修手术。③年轻患者置换术后近、中期疗效满意。
BACKGROUND： The standardized treatment for patients who require total hip replacement is the implantation of an intramedullary diaphyseal anchored hip prosthesis. A bone-sparing non-stemmed hip prosthesis （NSHP） can be used as an alternative device for young patients. The NSHP relies on proximal femoral metaphyseal and neck fixation. The theoretic advahtage of leaving diaphyseal bone intact is easier conversion to a stemmed prosthesis. On the other hand, clinical investigations published reported THR had high loosening rate of the prosthesis, which greatly limits its long-term clinical results; the aim of NSHP is to give the femoral prothesis a kind of biological fixation to decrease the loosening rate of the prosthesis. This retrospective study evaluated the medium- and short-term results after total joint replacement using NSHP.
OBJECTIVE ： To evaluate the outcome of NSHP for the treatment of young patients with hip disorders.
DESIGN ： Case analysis.
SETTING ： Department of Orthopaedics, the First Affiliated Hospital of Guangxi Medical University.
PARTICIPANTS： Fifteen patients （17 hips） with hip disorders, who were treated at the Department of Orthopaedics, First Affiliated Hospital of Guangxi Medical University between 2001 and 2005, were retrieved. The involved patients included 8 males and 7 females. They were aged （37.8±9.8） years ranging from 21 to 49 years when they underwent operation. Indications for implantation included avascular necrosis （7 hips）, posttraumatic osteoarthritis（4 hips）, primary osteoarthritis（3 hips）, osteoarthritis secondary to dysplasia（3 hips）. Informed consents were obtained from all the patients before operation. The neotype of non-stemmed hip prosthesis （NSHP） was made of Co-Cr-Mo casting alloy with good biocompatibility by Shanghai Fusheng Medical Equipment Co., Ltd （Guoyao guanxie （shi） No. 2002-3040397; Guoshi Yaojianxie（zhun） No. 2005-3460799）.
METHODS： Fifteen patients （17 hips） with hip diseases subjected to the replacement of total hip with NSHP. Patients were followed-up once every other 6 months in the postoperative first year, then once every year, 5 years in total. The follow-up visit included functional evaluation and X-ray evaluation. （1） Functional evaluation： Evaluative criteria of Harris joint function scale were adopted： full marks （point） =100, ≥ 80 excellent, ≥ 60 good, ≥ 40 fair and 〈 40 poor; The following clinical data were documented： relief of pain, ability to lie on the operated side, additional procedures, use of pain medication, postoperative hip dislocations and so on. Pain was evaluated by using visual analogue scale （VAS）, which ranged from 0 （no pain） to 10 （worst possible pain）. （2） X-ray evaluation： A standardized radiographic assessment was performed using an anteroposterior view of the pelvis. The following radiological data were recorded： preoperative grade of osteoarthritis as classified according to the method from Busse et al, preoperative grade of femoral head necrosis as classified according to the method from Ficat et al, inclination angle of the operated and the untreated side, radiolucencies according to the method of Buergi et al, heterotopic ossifications, as classified according to the method of Brooker et al. Postoperative adverse events and complications ware observed and revision operation was needed if necessary.
MAIN OUTCOME MEASURES ： Correlative conditions of patients who were followed up for 5 years： （1） Inserting angle of prothesis and the collodiaphyseal angle in the opposite side. （2）Radiolucency and heterotopic ossification classification. （3）preoperative osteoarthritis classification, preoperative avascular necrosis of femoral head classification. （4） Revision operation, adverse events and complications. （5） Postoperative functional evaluation： Relief of pain （Harris joint function score）, ability to lie on the operated side, additional procedures, use of pain medication, postoperative hip dislocations and VAS results.
RESULTS： Fifteen patients were involved. One patient was lost after 3-month treatment and the other patients were followed up for 5 years. （1） Postoperative functional evaluation results of patients. In the postoperative 5-year follow-up visit, hip joints of 13 patients （15 hips） were still in situ, pain lessened or disappeared in 11 patients （84.6% ,11/13）,12 patients（92.3%, 12/13） would undergo the procedure again, 10 patients （76.9%, 10/13） were able to lie on the operated side; The average of Harris hip score was （72±19.6）. The average Harris hip score did not vary significantly between the different diagnosis groups （P 〉 0.05）. Postoperative VAS was 2.6±2.2 on average. There was no significant difference in the hip joint pain among different diagnosis groups （P 〉 0.05）; Nine patients required no pain medication （69.2% ,9/13）. Two patients （15.4% ,2/13） occasionally took nonsteroidal anti-inflammatory drugs and two patients （15.4% ,2/13） took nonsteroidal anti-inflammatory drugs on a regular basis. （2） X-ray evaluation results of patients： Preoperative osteoarthristis classification： One hip had grade 1 joint degeneration, 3 hips had grade 2 joint degeneration and 6 hips had grade 3 degeneration. Preoperative avascular necrosis of femoral head classification： Out of 7 patients with avascular necrosis of femoral head, 4 patients had stage 3 femoral head necrosis, and 3 patients had stage 4 femoral head necrosis. In the postoperative 5-year follow up, 1 patient had radiolucency. Because the range of radiolucency was very small, progression was not quick and clinical symptoms were not severe, so revision operation was not conducted;In the postoperative 6^th month, the inclination angle averaged （135.2±6.8）° on the untreated side and （132.2±6.5）° on the treat side. One patient with congenital hip dysplasia and a previous varus derotational osteotomy had a postoperative inclination angle below 120°. Patients with postoperative inclination angles between 125° and 140° had significantly less hip pain than the rest of the series. Heterotopic ossifications classification： Three patients had postoperative heterotopic ossifications, one hip had grade 1 heterotopic ossification, 1 hip had grade 2 heterotopic ossification, and 1 hip had grade 3 heterotopic ossification.（3） Revision operation： one patient （5.9% ,1/17）required a revision total hip arthroplasty due to pain. Good bone stock of the proximal femur was found in the patient which allowed implantation of a conventional medullary anchored prosthesis. This revision surgery and postoperative rehabilitation were uncomplicated. （4） Adverse events and complications： Hip dislocation occurred postoperatively in one patient （5.9%, 1/17）. Other complications included trochanter bursitis （n =1 ）, fistula （n =1）, and seroma （n =1）.
CONCLUSION ： （1） NSHP provides biological fixation for femoral prothesis by bone proliferation through the windows with connective tissues surrounding the prothesis and has the characteristics of low stress and deformation, high intensity and rigidity, and antHoosening, thus, may prolong its live lime. （2）Revision surgeries are facilitated by the good bone stock remaining in the proximal femur. （3） The short- and medium-term therapeutic effects of total hip arthroplasty are satisfying in young patients.
出处
《中国组织工程研究与临床康复》
CAS
CSCD
北大核心
2007年第16期3176-3180,共5页
Journal of Clinical Rehabilitative Tissue Engineering Research
作者简介
詹新立☆，男，1968年生，汉族，2004年中南大学湘雅医学院毕业，博士，副教授，主要从事骨科疾病的研究。
