股骨偏心距重建与人工全髋关节置换术后下肢长度差的相关性研究

发布时间：2018-03-29 03:11

  本文选题：全髋关节置换术　切入点：偏心距重建　出处：《郑州大学》2014年硕士论文

【摘要】：背景及目的 人工全髋关节置换术(total hip arthroplasty,THA)是一种常见的髋关节成形术，THA首先解决了髋关节疾患所带来的疼痛症状，，同时也改进了受累髋关节的功能。THA提高髋关节疾病患者们的生活质量的同时也带来了一些令患者和医生都非常苦恼的术后并发症，如感染、假体周围骨折、假体松动、双下肢不等长等，其中THA术后出现的双下肢不等长（leg length discrepancy，LLD），是较常见的患者对手术效果不满意的部分，术侧肢体的延长较短缩更为常见，而且肢体延长更难以被患者接受。肢体延长超过2.5cm，可引起坐骨神经的麻痹和跛行。双下肢不等长是髋关节置换后常见的并发症，严重的双下肢不等长可导致患者跛行、腰痛、关节假体磨损加剧、需要穿戴鞋垫甚至最终接受髋关节翻修术。双下肢不等长常常由以下原因造成：1）患者年龄较大，软组织张力下降，THA术中麻醉影响下张力进一步下降，使软组织更加松弛；2）术前使用模板不当，未能选取合适假体；3）术中纠正患肢屈曲内收畸形，使患肢延长；4）股骨颈截骨不够；5）髋臼旋转中心的下移。因此进行THA后双下肢的长度差与术中的手术方式密切相关,而术中股骨偏心距的重建对于THA的手术效果有着十分重要的意义。 股骨偏心距（femoral offset，FO）的定义是：股骨头中心距股骨解剖轴线的垂直距离。以往的研究表明偏心距的重建与术后髋关节的软组织平衡关系密切,特别是与外展肌组织张力的关系较大,偏心距重建较好的髋关节术后外展肌力较偏心距重建不足者优。而外展肌张力的大小又和术后一系列并发症如：脱位、跛行、关节磨损等相关联。 股骨偏心距的重建与术后双下肢的等长都是THA所追求的效果，它们都和术后髋关节周围软组织的张力与平衡息息相关，在THA术中为了保证髋关节能有足够的软组织张力及稳定性，选择了某种型号的假体改变股骨偏心距后有时却出现了术肢延长的情况。目前关于THA中股骨偏心距重建的研究多是关于股骨偏心距与术后髋关节外展肌力的恢复、假体的无菌性松动、以及假体磨损率之间的研究，对股骨偏心距重建与术后双下肢长度差之间的研究较少涉及。 该研究属于回顾性研究，探讨THA术中股骨偏心距的重建与术后双下肢等长率、双下肢长度差之间的关系，判断股骨偏心距的重建是否能降低THA术后双下肢不等长的发生率或减少双下肢的长度差。本研究的研究目的为：1）探讨股骨偏心距重建病例与未重建病例之间双下肢不等长率之间的差别。2）研究THA术后双侧股骨偏心距之间的差值与双下肢长度差之间的相关性。3）回顾性分析股骨偏心距得到重建的病例,研究不同股骨偏心距差别组与双下肢的等长率之间的关系。在股骨偏心距重建的范围内，进一步缩小偏心距差值能否提高双下肢的等长率。 方法 1.研究对象选取2009年7月至2013年7月在河南省人民医院骨科接受单侧人工全髋关节置换术的患者115例115髋，其中男性61例61髋，女性54例54髋。其中左髋60例，右髋55例。年龄22~80岁，平均51.78岁，其中股骨头无菌性坏死67例，先天性髋关节发育不良13例，股骨颈骨折35例，平均随访时间23.2月（3个月~4年）。 2. X线片拍摄：研究中术前和随访时均为患者拍摄标准的骨盆正位X线片，具体拍摄方法为：患者仰卧于拍摄床，双侧足尖相对，双足内旋20°，尽量使股骨颈置于冠状位。X线垂直投射，距离为1m，统一放大率为1.15:1，每张X线片包括股骨中上2/3段[3]。X线拍摄设备使用的是GE Difinium6000DR。 3.数据的测量方法术前及术后均在骨盆正位X线片上进行测量。确定双侧的股骨头中心及股骨解剖轴，测量双侧股骨偏心距的大小。经双侧泪滴画出水平参考线，通过测量小转子顶点至水平参考线的距离判断双下肢的长度差。股骨偏心距的重建标准和术后双下肢的等长标准分别为术后双侧股骨偏心距的差值在4mm以内，术后双下肢长度差在5mm以内。 4.在骨盆正位片上使用厂家提供的假体模板，选择能够最大程度的减小双侧股骨偏心距差值的假体。本组病例均由同一组医师进行髋关节后外侧入路THA,使用模板测量下所确定的假体规格。 5.统计学处理 统计学分析使用用SPSS17.0统计学分析软件，计量资料使用均数±标准差。计量资料比较采用两样本配对t检验。按照股骨偏心距重建的标准将术后的病例分为重建组与未重建组，将重建组的术后双下肢等长率与未重建组进行对比，P＜0.05差异具有统计学意义。按术后不同的股骨偏心距差值将病例进行分组，在不同偏心距差值组间对双下肢的等长率进行X2检验，P＜0.05有统计学意义。 结果 1. THA术后股骨偏心距差值与双下肢长度差之间存在明显相关关系。股骨偏心距差值与术后双下肢长度差呈正相关关系（r=0.632,P＜0.05）。 2. THA术后股骨偏心距重建组92例中有71例双下肢等长，未重建组23例中有5例双下肢等长，经卡方检验，股骨偏心距重建组与未重建组的术后双下肢等长率之间存在显著性差异(2=25.229., P＜0.05）。 3. THA术后股骨偏心距重建范围内，大部分双侧股骨偏心距差值较小组和差值较大组的双下等长率之间有显著性差异。 结论 在THA术中应尽可能的重建股骨偏心距，以更好的恢复患肢的长度，降低术后双下肢不等长的发生率，从而提高患者的生活质量。
[Abstract]:Background and purpose
Total hip arthroplasty (total hip, arthroplasty, THA) is a common hip arthroplasty, THA first solve the pain of hip joint disease caused by.THA also improved the function of hip joint involvement to improve hip joint disease patients' quality of life has also brought some patients and doctors are very the distress of postoperative complications, such as infection, periprosthetic fracture, prosthesis loosening, double limb length, the lower limbs appear after THA (leg length discrepancy, length LLD), is more common in patients are not satisfied with the effect of the operation part, prolonged operative limb shortening is more common moreover, limb lengthening is more difficult to be accepted by patients. Limb lengthening is more than 2.5cm, can cause the sciatic nerve paralysis and claudication. The leg length discrepancy is a common complication after hip replacement, limb length discrepancy can serious In patients with claudication, pain, joint prosthesis wear, wear insoles and eventually accept revision hip arthroplasty. Double limb length is often caused by the following reasons: 1) the patients were older, soft tissue tension decreased, anesthesia during the operation of THA under the influence of tension decline further, make more soft tissue relaxation; 2) before operation to select the appropriate template improper prosthesis; 3) intraoperative correction of limb flexion adduction deformity, the limb lengthening; 4) femoral neck osteotomy is not enough; 5) acetabular rotation center of gravity. So THA leg length discrepancy is closely related with the operation mode of the operation in the reconstruction of femoral offset operation is very important for the operation effect of THA.
The femoral offset (femoral offset, FO) is defined as the vertical distance from the center of the femoral head femoral anatomic axis. Previous studies showed that the soft tissue balance between hip joint reconstruction and operation after the eccentric distance close, especially the larger relationship with abductor muscle tissue tension, eccentricity of hip arthroplasty is better after reconstruction abductor offset reconstruction is preferred. But lack of muscle tension and the size and development of a series of postoperative complications such as dislocation, limp, joint wear is associated.
The femoral offset reconstruction and operation from the lower limbs after the length is THA the pursuit of the effect, all of them and after hip joint surrounding soft tissue tension and balance are closely related, in THA operation in order to ensure the hip can have soft tissue tension and sufficient stability, choose some type of prosthesis of femoral offset change after sometimes appeared limb extended. The current research on THA in the restoration of femoral offset is about femoral eccentricity and recovery of hip abductor after surgery, prosthesis aseptic loosening, prosthesis wear rate between the study and research, the difference between the lower limb length of femoral offset reconstruction and operation after the less involved.
璇ョ爺绌跺睘浜庡洖椤炬

本文编号：1679284