成人发育性髋关节脱位解剖形态变化与全髋关节置换假体选择相关性研究
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摘要
目的:分析成人发育性髋关节脱位继发骨关节炎患者髋臼及股骨髓腔解剖形态和参数变化，为临床合理选择假体类型及假体型号以获得满意初始稳定和良好应力分布提供理论基础;探讨Zweymüller生物型假体治疗成人发育性髋关节脱位继发骨关节炎初期疗效，评价Zweymüller假体在成人发育性髋关节脱位继发骨关节炎中的应用价值。
方法：根据筛选标准收集2003年1月至2008年1月应用Zweymüller假体治疗DDH继发骨关节炎病例。共43例53髋符合纳入标准，其中女31例，男12例。双侧髋关节脱位5例，其中2例为双侧Crowe I型，1例为Crowe II和型，2例为一侧Crowe III型和一侧Crowe IV型；全部为蒙古族。采用Crowe分型，其中Ⅰ型20髋（37.7%）、型19髋（35.8%）、型7髋（13.2%）、型7髋（13.2%）。Ⅰ、Ⅱ、Ⅲ、Ⅳ型分别对应Ⅰ、Ⅱ、Ⅲ、Ⅳ组。收集43例53髋行全髋关节置换的DDH患者髋关节下肢全长DR影像学资料（正侧位）及髋关节CT三维重建资料，图片格式为DICOM格式。分别进行髋臼及股骨解剖形态学测量并与对照组（原发性髋关节骨性关节病组）比较。所有43例53髋患者均应用Zweymüller髋关节假体进行THA手术。术后分别进行临床和影像学评价，并进行Harris评分。
结果：所有DDH患者中女性比例: Crowe I型93%，Crowe II型55%，Crowe III型84%和CroweIV型85%。患者平均年龄52.3±5.7岁(23-70)，平均体重64.7±6.9kg(50-110)，平均身高165.4±4.7cm (158-190)。DDH各组间患者年龄、体重、身高无统计学差异。DDH各组间患者股骨形态相似，股骨峡部平均位于小粗隆下115mm处。DDH组股骨髓腔宽度明显小于对照组。DDH组髓腔张开指数相似,多表现为锥形髓腔，分别为5.2;5.4;5.2;5.1。DDH组股骨头中心高度明显低于对照组，分别为51.3mm和61.5mm。DDH组II型颈干角与Ⅲ型、 Ⅳ型和对照组相比明显增大。所有DDH组与对照组相比前倾角变大； DDH组与对照组在肢体不等长、颈干角和髓腔张开指数方面有差异。43例行全髋关节置换患者全部获得随访，平均随访时间60.2月，最后一次随访Harris评分88.9分，优良率89.7﹪。所有患者2天后扶拐部分负重行走，3月后负重独立行走。DR片显示无假体松动，髋臼覆盖率满意，3例粗隆下短缩旋转截骨全部获得骨性愈合。DDH I型8例、DDHⅡ型5例、 Ⅲ型3例、DDHⅣ型2例出现大腿痛。
结论：发育性髋关节脱位继发骨关节炎患者其髋臼及股骨髓腔形态变异较大，尤其是CroweⅢ、 Ⅳ患者。DDH患者髋周软组织及髋臼和股骨髓腔变异较大,术前假体选择及准备小型号假体是手术取得良好效果的关键。临床随访和影像学检查显示Zweymüller生物型假体初始稳定性好，临床效果满意。
Objective: To analysis the anatomic morphology parameter variation ofacetabulum and the femoral canal of the patient with developmental dislocation of thehip (DDH) secondary to osteoarthritis in adult, provide a theoretical basis for theclinical selection of the type of prosthesis and prosthesis model and get initial stabilityand good stress distribution; to explore the early efficacy of Zweymüller biologicalprosthesis treatment with developmental dislocation of the hip secondary toosteoarthritis in adult.
Methods: According to the screening criteria, the cases of DDH secondary toosteoarthritis treated with Zweymüller prosthesis were collected. All43cases met theinclusion criteria, including31females and12males. All are Mongolian. Using theCrowe classification, Crowe20hips,19hips, III7hips, IV7hips. Collect thelower extremity total length of DR imaging data of the43cases treated with THA andHip3DCT data (image format was DICOM format). Measure the acetabulum and thefemoral canal by anatomic morphology, then compare the result with the controlgroup.43cases were performed operation using Zweymüller hip prosthesis. Clinic andradiograph evaluation were performed after the operation, and then scored by HarrisScore.
Results According to Crowe classification, female: Crowe I93%, II55%, III84%, IV85%. The average ages is52.3±5.7yrs (23-70)，The average weight is64.7±6.9kg(50-110)，the average height is165.4±4.7cm (158-190). There was no statisticaldifferences in4groups with age,weight and height. The anatomical features of proximalfemur were similar among4groups of DDH. The canal flare indexes of DDH weresimilar. The height of femoral head center in DDH group were apparently lower than the control group. The neck-shaft angle in Crowe、II of DDH were apparently greaterthan Crowe III、IV of DDH. The anteversion angles of DDH group were greater.Therewere differences of the leg-length inequality, the neck-shaft angle and the canal flareindex between DDH group and the control group.43patients were followed up average60.2months. The Harris Score for last follow were88.9. The ratio of excellent and goodis89.7﹪.3cases with Sub-trochanter derotation and shortening osteotomy gain boneunion. thigh pain were Crowe I8,Crowe5,Crowe3,Crowe2.
Conclusion There were variation anatomic forms of acetabulum and medullary cavityat the patients with DDH secondary to Osteoarthritis in adults, especially in Crowe III、IV. For the high dislocation of DDH in adults is treated with THA, anatomical variationmust be fully taken into account. The key for THA are the choose of prosthesis andpreparation of the small size prosthesis. Zweymüller cementless hip prosthesis have agood primary stability and a satisfactory outcomes.
方法：根据筛选标准收集2003年1月至2008年1月应用Zweymüller假体治疗DDH继发骨关节炎病例。共43例53髋符合纳入标准，其中女31例，男12例。双侧髋关节脱位5例，其中2例为双侧Crowe I型，1例为Crowe II和型，2例为一侧Crowe III型和一侧Crowe IV型；全部为蒙古族。采用Crowe分型，其中Ⅰ型20髋（37.7%）、型19髋（35.8%）、型7髋（13.2%）、型7髋（13.2%）。Ⅰ、Ⅱ、Ⅲ、Ⅳ型分别对应Ⅰ、Ⅱ、Ⅲ、Ⅳ组。收集43例53髋行全髋关节置换的DDH患者髋关节下肢全长DR影像学资料（正侧位）及髋关节CT三维重建资料，图片格式为DICOM格式。分别进行髋臼及股骨解剖形态学测量并与对照组（原发性髋关节骨性关节病组）比较。所有43例53髋患者均应用Zweymüller髋关节假体进行THA手术。术后分别进行临床和影像学评价，并进行Harris评分。
结果：所有DDH患者中女性比例: Crowe I型93%，Crowe II型55%，Crowe III型84%和CroweIV型85%。患者平均年龄52.3±5.7岁(23-70)，平均体重64.7±6.9kg(50-110)，平均身高165.4±4.7cm (158-190)。DDH各组间患者年龄、体重、身高无统计学差异。DDH各组间患者股骨形态相似，股骨峡部平均位于小粗隆下115mm处。DDH组股骨髓腔宽度明显小于对照组。DDH组髓腔张开指数相似,多表现为锥形髓腔，分别为5.2;5.4;5.2;5.1。DDH组股骨头中心高度明显低于对照组，分别为51.3mm和61.5mm。DDH组II型颈干角与Ⅲ型、 Ⅳ型和对照组相比明显增大。所有DDH组与对照组相比前倾角变大； DDH组与对照组在肢体不等长、颈干角和髓腔张开指数方面有差异。43例行全髋关节置换患者全部获得随访，平均随访时间60.2月，最后一次随访Harris评分88.9分，优良率89.7﹪。所有患者2天后扶拐部分负重行走，3月后负重独立行走。DR片显示无假体松动，髋臼覆盖率满意，3例粗隆下短缩旋转截骨全部获得骨性愈合。DDH I型8例、DDHⅡ型5例、 Ⅲ型3例、DDHⅣ型2例出现大腿痛。
结论：发育性髋关节脱位继发骨关节炎患者其髋臼及股骨髓腔形态变异较大，尤其是CroweⅢ、 Ⅳ患者。DDH患者髋周软组织及髋臼和股骨髓腔变异较大,术前假体选择及准备小型号假体是手术取得良好效果的关键。临床随访和影像学检查显示Zweymüller生物型假体初始稳定性好，临床效果满意。
Objective: To analysis the anatomic morphology parameter variation ofacetabulum and the femoral canal of the patient with developmental dislocation of thehip (DDH) secondary to osteoarthritis in adult, provide a theoretical basis for theclinical selection of the type of prosthesis and prosthesis model and get initial stabilityand good stress distribution; to explore the early efficacy of Zweymüller biologicalprosthesis treatment with developmental dislocation of the hip secondary toosteoarthritis in adult.
Methods: According to the screening criteria, the cases of DDH secondary toosteoarthritis treated with Zweymüller prosthesis were collected. All43cases met theinclusion criteria, including31females and12males. All are Mongolian. Using theCrowe classification, Crowe20hips,19hips, III7hips, IV7hips. Collect thelower extremity total length of DR imaging data of the43cases treated with THA andHip3DCT data (image format was DICOM format). Measure the acetabulum and thefemoral canal by anatomic morphology, then compare the result with the controlgroup.43cases were performed operation using Zweymüller hip prosthesis. Clinic andradiograph evaluation were performed after the operation, and then scored by HarrisScore.
Results According to Crowe classification, female: Crowe I93%, II55%, III84%, IV85%. The average ages is52.3±5.7yrs (23-70)，The average weight is64.7±6.9kg(50-110)，the average height is165.4±4.7cm (158-190). There was no statisticaldifferences in4groups with age,weight and height. The anatomical features of proximalfemur were similar among4groups of DDH. The canal flare indexes of DDH weresimilar. The height of femoral head center in DDH group were apparently lower than the control group. The neck-shaft angle in Crowe、II of DDH were apparently greaterthan Crowe III、IV of DDH. The anteversion angles of DDH group were greater.Therewere differences of the leg-length inequality, the neck-shaft angle and the canal flareindex between DDH group and the control group.43patients were followed up average60.2months. The Harris Score for last follow were88.9. The ratio of excellent and goodis89.7﹪.3cases with Sub-trochanter derotation and shortening osteotomy gain boneunion. thigh pain were Crowe I8,Crowe5,Crowe3,Crowe2.
Conclusion There were variation anatomic forms of acetabulum and medullary cavityat the patients with DDH secondary to Osteoarthritis in adults, especially in Crowe III、IV. For the high dislocation of DDH in adults is treated with THA, anatomical variationmust be fully taken into account. The key for THA are the choose of prosthesis andpreparation of the small size prosthesis. Zweymüller cementless hip prosthesis have agood primary stability and a satisfactory outcomes.
引文
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42.Dorr LD,Tawakkol S,Moorthy M,etal.Medial protrusio technique for placement of aporous-coated， hemispherical acetabular component without cement in total hiparthroplast in patients who have acetabular dysplasia.J Bone Joint Surg(Am)，1999，81(l):83-91.
43.APangehl MJ，Berrg DJ，Trousdale RT，et al.Uncemented acetabular componentswith bulk femoral head autograft for acetabular reconstruction in developmentaldysplasia of the hip，Results at five to twelve years.J Bone Joint Surg(Am)，2001，83(10):1484-1489.
44.Anderson MJ，Harris WH.Total hip arthroplasty with insertion of the acetabularcomponent without cement in hips with total congenital dislocation or markedcongenital dysplasia.J Bone Joint Surg(Am)，1999.81(3):347-354.
45.Sanchez-sotelo J, Trousdale RT,Berry DJ,et al.Surgical Treatment of DevelopmentalDysplasia of the Hip in Adults: I. Nonarthroplasty Options,[J].J Am Acad Orthop Surg2002:10(5):334.
46.Sugano N， Noble PC， Kamaric E， et a1.The morphology of the femur indevelopment dysplasia of the hip.J Bone Joint Surg (Br),1998，80:711—719.
47.Iida H, Matsusue Y, Kawanabe K, Okumura H, Yamamuro T, Nakamura T. Cemented total hip arthroplasty with acetabular bone graft for developmental dysplasia. Long-term results and survivorship analysis. J Bone Joint Surg Br.2000.82(2):176-84.
48.Eskelinen A,Helenius I,Remes V,et al.Cementless total hip arthroplasty in patientswith high congenital hip dislocation,J Bone Joint Surg(Am)，2006(1).
49.Edwards BN.Tullos HS,Nobel PC.Contributory factors and etiology of sciatic nervepalsy in total hip arthroplasia. Clin Orthop,1987,(218):136-141.
50.Lewallen DG. Neurovascular injury associated with hip arthroplasty.Instr CourseLect,1998,47:275-283.
51.孙俊英，郝跃峰，杨沛彦等.股骨转子下叠加缩短截骨在型成人髋脱位全髋置换术中的应用[J].中华骨科杂志，2008，28（1）：9-13
[1] Gillingham B L， Sancbez A A， Wenger D R． Pelvic osteotomies forthe treatmen of hip dysplasia in children and young adults［J］． JAm Acad Ortop Surg，1999，7(5):325－337．
[2] Hema P．Preventive health care，2001update：screening and managementof developmental dysplasia of the hip in newborns[J]．CMAJ，2001，164(12)：1669-1677．
[3] Troel sen A, J acobsen S, Romer L, etal Weight bearing anteroposteriorpelvic radiographs are recommended in DDH assessment [J].ClinOrthopRelat Res,2008,4:813-819
[4] Gunnar W. Shelf operation in congenital dysplasia of the acetabulumand insubluxation and dislocation and dislocation of the hip [J].JBone Joint Surg(Br),1953,35:65-80.
[5]毛宾尧髋关节外科学[M].第一版.北京:人民卫生出版社,1998,75.
[6] Sharp IK.Acetabular dysplasia the acetabular angle[J].J Bone JointSurg(Br),1961,43:268-272.
[7]刘旭林,周承涛,杜玉清,等.成人髋臼发育不良的CT测量评价[J].中华放射学杂志,2000,34:52-54.
[8] Manster BF. Adult chronic hip pain: radiographic evaluation.Radiographic,2000,20(Special Issue):24-225.
[9] Crowe JF，Mani VJ，Ranawat CS．Total hip replacement in congenitaldislocation and dysplasia of the hip．J Bone Joint Surg(Am)，1979，61：15-23．
[10]Hartofilakidis G，Stamos K，Ioannidis TT．Low friction arthroplastyfor old untreated congenital dislocation of the hip．J Bone JointSurg(Br)，1988，70：182-186.
[11]吕厚山，主编．人工关节外科学．北京：科学技术出版社，1998．125。
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[13]段以祥，马进峰.髋臼发育不良的诊断进展[J].中国矫形外科杂志，2003，11:1567-1569。
[14] Frantz Langlais, Jean-Christophe Lambotte, Ronan Lannou, et al. Hippain from impingement and dysplasia in patients aged20-50years.Workup and role for reconstruction［J］. Joint Bone Spine73(2006)614-623.
[15] Ito H，Matsuno T，Minami A．Intertrochanteric varns osteotomy forosteoarthritis in patient s with hip dysplasia：6to28yearsfollowup[J]．ClinOrthop Relat Res．2005，433(4)：124-128．
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[21] Michael Leunig, Reinhold Ganz. Bernese periacetabular osteotomy［J］.Current orthopedics (2007)21,100-108.
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41.吴立东，熊炎，严世贵等.非骨水泥臼杯加自体股骨头植骨全髋关节置换术治疗髋臼发育不良伴骨性关节炎.中华外科杂志，2004，42(16)：1006-1009.
42.Dorr LD,Tawakkol S,Moorthy M,etal.Medial protrusio technique for placement of aporous-coated， hemispherical acetabular component without cement in total hiparthroplast in patients who have acetabular dysplasia.J Bone Joint Surg(Am)，1999，81(l):83-91.
43.APangehl MJ，Berrg DJ，Trousdale RT，et al.Uncemented acetabular componentswith bulk femoral head autograft for acetabular reconstruction in developmentaldysplasia of the hip，Results at five to twelve years.J Bone Joint Surg(Am)，2001，83(10):1484-1489.
44.Anderson MJ，Harris WH.Total hip arthroplasty with insertion of the acetabularcomponent without cement in hips with total congenital dislocation or markedcongenital dysplasia.J Bone Joint Surg(Am)，1999.81(3):347-354.
45.Sanchez-sotelo J, Trousdale RT,Berry DJ,et al.Surgical Treatment of DevelopmentalDysplasia of the Hip in Adults: I. Nonarthroplasty Options,[J].J Am Acad Orthop Surg2002:10(5):334.
46.Sugano N， Noble PC， Kamaric E， et a1.The morphology of the femur indevelopment dysplasia of the hip.J Bone Joint Surg (Br),1998，80:711—719.
47.Iida H, Matsusue Y, Kawanabe K, Okumura H, Yamamuro T, Nakamura T. Cemented total hip arthroplasty with acetabular bone graft for developmental dysplasia. Long-term results and survivorship analysis. J Bone Joint Surg Br.2000.82(2):176-84.
48.Eskelinen A,Helenius I,Remes V,et al.Cementless total hip arthroplasty in patientswith high congenital hip dislocation,J Bone Joint Surg(Am)，2006(1).
49.Edwards BN.Tullos HS,Nobel PC.Contributory factors and etiology of sciatic nervepalsy in total hip arthroplasia. Clin Orthop,1987,(218):136-141.
50.Lewallen DG. Neurovascular injury associated with hip arthroplasty.Instr CourseLect,1998,47:275-283.
51.孙俊英，郝跃峰，杨沛彦等.股骨转子下叠加缩短截骨在型成人髋脱位全髋置换术中的应用[J].中华骨科杂志，2008，28（1）：9-13
[1] Gillingham B L， Sancbez A A， Wenger D R． Pelvic osteotomies forthe treatmen of hip dysplasia in children and young adults［J］． JAm Acad Ortop Surg，1999，7(5):325－337．
[2] Hema P．Preventive health care，2001update：screening and managementof developmental dysplasia of the hip in newborns[J]．CMAJ，2001，164(12)：1669-1677．
[3] Troel sen A, J acobsen S, Romer L, etal Weight bearing anteroposteriorpelvic radiographs are recommended in DDH assessment [J].ClinOrthopRelat Res,2008,4:813-819
[4] Gunnar W. Shelf operation in congenital dysplasia of the acetabulumand insubluxation and dislocation and dislocation of the hip [J].JBone Joint Surg(Br),1953,35:65-80.
[5]毛宾尧髋关节外科学[M].第一版.北京:人民卫生出版社,1998,75.
[6] Sharp IK.Acetabular dysplasia the acetabular angle[J].J Bone JointSurg(Br),1961,43:268-272.
[7]刘旭林,周承涛,杜玉清,等.成人髋臼发育不良的CT测量评价[J].中华放射学杂志,2000,34:52-54.
[8] Manster BF. Adult chronic hip pain: radiographic evaluation.Radiographic,2000,20(Special Issue):24-225.
[9] Crowe JF，Mani VJ，Ranawat CS．Total hip replacement in congenitaldislocation and dysplasia of the hip．J Bone Joint Surg(Am)，1979，61：15-23．
[10]Hartofilakidis G，Stamos K，Ioannidis TT．Low friction arthroplastyfor old untreated congenital dislocation of the hip．J Bone JointSurg(Br)，1988，70：182-186.
[11]吕厚山，主编．人工关节外科学．北京：科学技术出版社，1998．125。
[12]赵云鹤，赵栓柱，邓晓明，等。髋关节发育不良的实用分型与术式选择[J].中国矫形外科志，杂志2002，9:557-559。
[13]段以祥，马进峰.髋臼发育不良的诊断进展[J].中国矫形外科杂志，2003，11:1567-1569。
[14] Frantz Langlais, Jean-Christophe Lambotte, Ronan Lannou, et al. Hippain from impingement and dysplasia in patients aged20-50years.Workup and role for reconstruction［J］. Joint Bone Spine73(2006)614-623.
[15] Ito H，Matsuno T，Minami A．Intertrochanteric varns osteotomy forosteoarthritis in patient s with hip dysplasia：6to28yearsfollowup[J]．ClinOrthop Relat Res．2005，433(4)：124-128．
[16] Michael Leunig MD，Klaus A，Siebenrock MD，et a1．Rationale of periace–tabular osteotomy and background work [J]．J Bone Joint Surg Am，2001，83(3)：438448．
[17] Hailer NP，Soykaner L，Ackermann H，et a1．Triple osteotomy of thepelvis for acetabular dysplasia：age at operation and the incidenceof nonunions and other complications influence outcome [J]．J BoneJoint Surg Br，2005．87(12)：1622-1626．
[18] Trousdale RT. Acetabular osteotomy: indications and results［J］. ClinOrthop Relat Res.2004Dec;(429):182-7. Review.
[19] GazR,Klaue KN,V inh TS,et al.A new periace tabular osteotomy for thetreatment of hip dysplasias technique and preliminary results［J］.ClinOrthop,1988,232:26.
[20] Gillett CA. Bernese periacetabular osteotomy for hip dysplasia inyoung adults［J］. AORN J.2002Apr;75(4):737-42,744-7,749-51; quiz752,754,756-8.
[21] Michael Leunig, Reinhold Ganz. Bernese periacetabular osteotomy［J］.Current orthopedics (2007)21,100-108.