改良转子间截骨术联合全髋关节置换治疗重度髋关节发育不良

发布时间：2017-12-26 22:29

本文关键词：改良转子间截骨术联合全髋关节置换治疗重度髋关节发育不良　出处：《山东大学》2016年硕士论文　论文类型：学位论文

【摘要】：背景对于发育性髋关节发育不良(developmental dysplasia of hip, DDH),人工全髋关节置换术(THA)是行之有效的治疗方法,可以有效改善关节功能并缓解疼痛症状。但是对于重度DDH患者(达到C rowe Ⅳ型标准)进行THA治疗将会是技术上的挑战。为使此类患者在术后获得最为满意的结果,需要保证的一个重要前提是在术中将髋关节旋转中心解剖学复位。髋关节的复位需要对股骨进行短缩截骨,以最大程度地降低由于下肢延长牵拉神经血管而致其损伤的风险。现行的几种常用的股骨短缩方式,包括阶梯形(step-cut)截骨术及chevron截骨术等,疗效确切,但术中操作较为精密复杂,需要外科医生具备精湛技艺,且有创伤大、手术时间过长及伴随而来的高感染风险,术后骨不愈合率较高。因此在对重度DDH患者行THA治疗过程中,寻找一种相对创伤小、预后良好且并发症少的股骨截骨技术,有益于患者术后康复及医疗资源的有效利用。目的本文描述在对Crowe Ⅳ型DDH患者进行全髋关节置换的过程中,正确重建髋臼后,采用Paavilainen提出的转子间截骨技术并将其改良后,进行短缩股骨以协助复位髋关节,同时对这一技术的疗效和预后进行评价。方法回顾性分析2009年1月至2015年12月,由山东大学齐鲁医院骨一科收治的因重度DDH而进行转子间截骨联合THA的患者19例(21髋),其中男性4例,女性15例,男性及女性患者中各有有1例累及双侧髋关节。脱位原因为发育不良者15例,幼年时期髋关节感染者4例。平均年龄48.5(29-66)岁。术前和术后第6、12个月及随访结束时分别记录髋关节功能评分(髋关节Harris评分)。于术前、术后第2天及随访第12个月时拍摄骨盆前后正位、髋关节正侧位X线片进行动态比对,需要进行观察的指标有：骨愈合情况、假体周缘透亮线、股骨假体位置及沉降、髋臼假体位移及角度变化。记录手术前及手术后双下肢长度偏差(leg length discrepancy, LLD)和术后神经血管并发症。结果19名患者均获得随访,平均随访时间31(7-69)个月。在随访期间所有患者诉疼痛明显缓解及关节功能显著提升。髋关节Harris评分从术前的平均55.0(28-61)分,显著提高到术后12个月的88.4(79-94；P0.01)分。末次随访时X线检查没有发现感染、脱位及假体松动的病例,所有患者截骨处骨皮质均显示愈合征象,平均愈合时间为3.3(3-6)个月。17例单侧髋关节脱位患者中,有15例在术后第12个月获得随访,其术前双下肢长度平均偏差53.9(23～76)mm；术后即刻测量的双下肢长度偏差平均9.5(4-23)mm；术后12个月偏差小于10 mm者11例,介于10-20 mm者3例,超过20mm者1例,平均6.9(0-21)mm。在随访期间所有病例没有出现明显的坐骨神经麻痹症状。结论改良后的Paavilainen转子间截骨技术联合THA治疗Crowe Ⅳ 型DDH,能获得满意的短期疗效,长期预后有待进一步的观察。这项截骨技术具有相对创伤小、操作较简便及并发症少等优势,值得在关节领域的外科医生关注和进一步完善。
[Abstract]:Background for developmental dysplasia of hip (DDH), total hip arthroplasty (THA) is an effective treatment method, which can effectively improve joint function and relieve pain symptoms. But for severe DDH patients (reaching the C Rowe IV standard), THA treatment will be a technical challenge. An important prerequisite for ensuring the most satisfactory results of such patients after surgery is the anatomical reduction of the rotation center of the hip joint. The reduction of the hip requires a short osteotomy of the femur to minimize the risk of injury due to prolonged stretch of the lower extremities. Several common femoral shortening current, including ladder shaped (step-cut) effect of osteotomy and chevron osteotomy, exactly, but the operation is more sophisticated, need to have the surgeon virtuosity, and trauma, long operation time and with high risk of infection and postoperative bone nonunion rate. Therefore, in the process of THA treatment for severe DDH patients, we need to find a relatively less invasive, good prognosis and less complications of femoral osteotomy technology, which is beneficial for postoperative rehabilitation and effective utilization of medical resources. The purpose of this paper is described in the process of total hip replacement in Crowe IV DDH patients, the correct acetabular reconstruction, the proposed inter rotor Paavilainen osteotomy technology and its improvement, by shortening the femur to assist in reduction of hip joint, and the curative effect and prognosis of this technique is evaluated. Methods a retrospective analysis from January 2009 to December 2015, from Qilu Hospital of Shandong University Department of orthopaedics were due to severe DDH and 19 cases of intertrochanteric osteotomy combined with THA patients (21 hips), of which 4 were male, 15 cases of female, male and female patients in the 1 patients with bilateral hip joint. The causes of dislocation were 15 dysplasia, and 4 cases of hip joint infection at young age. The average age was 48.5 (29-66) years. The hip joint function score (Harris score) was recorded before and sixth, twelfth months after the operation and at the end of the follow-up. Preoperatively, second days and twelfth months follow-up after shooting pelvic anteroposterior, hip joint X-ray dynamic alignment, require observation indicators are:, peripheral prosthesis and femoral prosthesis radiolucent line position and settlement, displacement and angle of acetabular prosthesis in bone healing. Double leg length deviation (leg length discrepancy, LLD) and postoperative neurovascular complications were recorded before and after operation. Results all the 19 patients were followed up and the average follow-up time was 31 (7-69) months. During the follow-up period, all patients complained of significant pain relief and significantly improved joint function. The Harris score of the hip joint was 55 (28-61) scores from the preoperative, which was significantly increased to 88.4 (79-94; P0.01) scores at 12 months after the operation. No signs of infection, dislocation and prosthesis loosening were found in X-ray examination at the last follow-up. Bone healing in all the osteotomy sites showed an average healing time of 3.3 (3-6) months. 17 cases of patients with unilateral hip dislocation, 15 cases after twelfth months follow-up, the preoperative limb length average deviation 53.9 (23 ~ 76) mm; postoperative limb length deviation immediately measured average 9.5 (4-23) mm; 11 cases 12 months after the operation deviation is less than 10 mm in 3 cases, between 10-20 mm, 1 cases of more than 20mm, an average of 6.9 (0-21) mm. There was no obvious symptom of sciatic nerve paralysis in all cases during the follow-up period. Conclusion modified Paavilainen intertrochanteric osteotomy combined with THA in the treatment of Crowe type IV DDH can achieve satisfactory short-term effect, and long-term prognosis needs further observation. This osteotomy technique has the advantages of small relative trauma, simple operation and less complications, which should be paid attention to and further improved by surgeons in the field of joint.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R687.4

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