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北京大学学报（医学版） ›› 2021, Vol. 53 ›› Issue (1): 175-182. doi: 10.19723/j.issn.1671-167X.2021.01.026

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全髋关节置换术治疗脊柱骨骺发育不良患者Tönnis 3级髋关节骨关节炎的早期疗效

柯岩1,张蔷2,马云青2,李儒军1,陶可1,Δ(),桂先革3,李克鹏4,张洪2,林剑浩1   

  1. 1.北京大学人民医院骨关节科,北京 100044
    2.解放军总医院第四医学中心骨一科,北京 100037
    3.浙江医院骨一科,杭州 310013
    4.保定市第二中心医院骨科,河北保定 072750
  • 收稿日期:2019-08-19 出版日期:2021-02-18 发布日期:2021-02-07
  • 通讯作者: 陶可 E-mail:keryee@163.com
  • 基金资助:
    国家自然科学基金(81672183);北京市自然科学基金(7182172);北京大学人民医院院内发展基金(RDY2018-04);北京大学人民医院院内发展基金(RDY2016-15)

Short-term outcomes of total hip arthroplasty in the treatment of Tönnis grade 3 hip osteoarthritis in patients with spondyloepiphyseal dysplasia

KE Yan1,ZHANG Qiang2,MA Yun-qing2,LI Ru-jun1,TAO Ke1,Δ(),GUI Xian-ge3,LI Ke-peng4,ZHANG Hong2,LIN Jian-hao1   

  1. 1. Institute of Arthritis, Peking University People’s Hospital, Beijing 100044, China
    2. First Section of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100037, China
    3. First Section of Orthopaedics, Zhejiang Hospital, Hangzhou 310013, China
    4. Department of Orthopaedics, Baoding Second Central Hospital, Baoding 072750, Hebei, China
  • Received:2019-08-19 Online:2021-02-18 Published:2021-02-07
  • Contact: Ke TAO E-mail:keryee@163.com
  • Supported by:
    National Natural Science Foundation of China(81672183);Beijing Natural Science Foundation(7182172);Research and Development Funds of Peking University People’s Hospital(RDY2018-04);Research and Development Funds of Peking University People’s Hospital(RDY2016-15)

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摘要：

目的: 脊柱骨骺发育不良(spondyloepiphyseal dysplasia,SED)患者因骨骼、关节发育异常,生物力学改变和早年手术干预等往往导致严重的髋关节骨关节炎。本研究探讨人工全髋关节置换术治疗SED患者Tönnis 3级髋关节骨关节炎的早期疗效及可能的影响。方法: 2017年1月至2019年6月,将由高年资医生完成人工全髋关节置换术治疗的374例髋关节骨关节炎患者作为研究对象,其中因SED行人工全髋关节置换术的患者9例(男6例,女3例,12髋)符合纳入排除标准,观察人工全髋关节置换术对该类患者的早期疗效。结果: 所有患者均选用强生陶瓷内衬-陶瓷股骨头,均获得随访,平均随访时间20个月,除1例出现肌间静脉血栓外,其余患者均未出现无菌性松动、脱位、骨折、血管神经损伤、深静脉血栓和感染等并发症。术前髋关节Harris评分平均35.55分,美国西部Ontario和McMaster大学骨关节炎指数评分(the Western Ontario and McMaster Universities osteoarthritis index,WOMAC)平均56.56分,SF-12生活质量量表评分平均41.56分,视觉模拟评分(visual analogue scale, VAS)平均7.44分;末次随访时Harris评分平均89.56分,WOMAC骨关节炎指数评分平均41.11分,SF-12评分平均56.33分,VAS评分平均2.67分。与全髋关节置换术术前相比,SED患者术后骨盆入射角、骨盆倾斜角和骶骨倾斜角等骨盆相关参数均有所增加,术前平均骨盆入射角为68.95°±4.60°、平均骨盆倾斜角为52.75°±1.06°、平均骶骨倾斜角为17.45°±1.77°,而术后则相应变为76.98°±5.12°、60.51°±4.35°和18.10°±2.02°。患者术后双下肢均基本等长。结论: 人工全髋关节置换是治疗SED患者Tönnis 3级髋关节骨关节炎的一种有效手术方式,且早期疗效满意。

关键词: 全髋关节置换术, Tönnis 分级, 脊柱骨骺发育不良, 髋骨关节炎

Abstract:

Objective: Severe hip osteoarthritis, caused by bone or joint maldevelopment, biomechanical transformation and previous surgical intervention, is inclusively existed in spondyloepiphyseal dysplasia (SED). To investigate and discuss the short-term efficacy and possible effects of total hip arthroplasty in the treatment of Tönnis grade 3 hip osteoarthritis in patients with SED.Methods: From January 2017 to June 2019, 374 patients with hip osteoarthritis were involved for total hip arthroplasty conducted by senior professional surgeons, of whom 9 patients (6 males and 3 females) with 12 hip osteoarthritis secondary to the SED met the inclusive and exclusive criteria and received the above-mentioned hip operation. The short-term outcomes were observed.Results: All the patients were implanted with Johnson & Johnson ceramic on ceramic cementless hip prostheses within the arthroplasty. They were followed up for an average period of 20 months. Except for one muscular calf vein thrombosis case, no complications, such as aseptic loosening, joint dislocation, fracture, neurovascular injury, deep vein thrombosis and infection were observed in all the 9 patients. Before the surgery, the average Harris hip score was 35.55, while the average of the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) was 56.56. The level of quality of life indicated by SF-12 score was 41.56 on average. The mean pre-operation visual analogue scale (VAS) was 7.44. At the last follow-up, the average Harris hip score increased to 89.56, whereas the average WOMAC declined to 41.11. Compared with the baseline point, the average SF-12 score went up to 56.33. Dramatic drop of the mean VAS value to 2.67 was also observed at the last follow-up. In addition, post-operative increase of several pelvic-related parameters including pelvic incidence, pelvic tilt and sacral slope could be observed in the SED patients. The average measured pelvic incidence, pelvic tilt and sacral slope were 68.95°±4.60°, 52.75°±1.06° and 17.45°±1.77° before operation, respectively; whilst the mean value of these specific parameters increased to 76.98°±5.12°, 60.51°±4.35° and 18.10°±2.02°, respectively. The even leg lengths of the lower extremities were obtained after total hip arthroplasty.Conclusion: Total hip arthroplasty is satisfactory in the short-term pain relieve and function recovery for the management of Tönnis grade 3 hip osteoarthritis secondary to the SED.

Key words: Total hip arthroplasty, Tönnis classification, Spondyloepiphyseal dysplasia, Hip osteoarthritis

中图分类号: 

  • R687.4

图1

SED患者脊柱正侧位及骨盆侧位X线片显示,下胸椎和腰椎的椎体增宽、扁平(A),呈典型的阶梯状改变,椎间隙明显狭窄,同时合并脊柱生理曲度消失,轻度后凸畸形(B),腰5骶1椎体存在明显滑脱征象(C),脊柱-骨盆矢状位失平衡(D)"

图2

SED患者骨盆CT平扫+三维重建检查显示,前后位双髋关节退变明显,形成大量骨赘,存在半脱位(A),为Tönnis 3级;右侧面骨盆可对右髋关节进行细致观察,见右髋退变严重、骨赘增生明显(B);左侧面骨盆可对左髋关节进行细致观察,可见左髋退变严重、骨赘增生明显(C);以左侧股骨头中心为观察点,冠状位可见髋臼与股骨头颈大量骨赘增生,髋关节存在半脱位,股骨头内骨囊性变(D);轴位观察见双侧髋关节退变严重,前后方骨赘增生明显,甚至形成假关节囊包绕股骨头(E);以右侧股骨头中心为观察点,矢状位可见右髋关节退变严重,前后方骨赘增生明显,甚至形成假关节囊包绕股骨头,同时右髋关节股骨头与髋臼侧负重区骨囊性变明显(F)"

图3

1例小于40岁的SED患者使用陶瓷对陶瓷假体成功进行同期双侧THA,术前双髋关节正侧位片显示典型的脊柱骨骺发育不良,髋骨关节炎Tönnis 3级,双髋退变严重,骨赘增生与囊性变明显(A~C),术后12个月随访时的前后位骨盆正位X线片显示,患者双侧THA固定良好且位置正常(D)"

图4

1例大于50岁的SED患者使用陶瓷对陶瓷假体成功进行单侧THA,术前骨盆正位片+右髋关节侧位片显示典型的脊柱骨骺发育不良,双髋骨关节炎Tönnis 3级,右髋退变严重,骨赘增生与囊性变明显(A、B),偏心距为(32.34±0.88) mm,术后24个月随访时的前后位骨盆正位X线片显示,患者右侧THA假体位置良好,无透亮线等早期骨溶解、假体松动或感染等征象(C),偏心距为(36.15±0.54) mm"

表1

SED髋关节骨关节炎行THA患者的特点分析"

Gerder Age/
years		 Height/cm BMI Course of
disease/month		 Left or right Operation
duration/min		 Operative
blood loss/mL		 Time of standing
after operation/d		 Peri-operative
complication		 Follow-up/
month
M 28 165 27.92 7 Right 135 350 2 0 10
M 35 164 24.54 31 Right 120 280 2 0 13
M 44 173 27.73 70 Left 106 195 2 0 19
M 50 172 24.00 8 Right 120 240 3 0 13
M 47 158 23.63 9 Left 107 410 2 0 25
M 38 163 29.73 29 Both 189 530 3 0 37
F 36 144 30.38 44 Both 178 720 7 1 25
F 29 153 33.32 25 Both 223 550 3 0 13
F 37 147 31.47 33 Both 110 270 2 0 7

图5

SED患者骨盆入射角、骨盆倾斜角和骶骨倾斜角等骨盆相关参数的THA术前和术后变化"

表2

SED患者髋关节骨关节炎行THA的早期疗效评价(x-±s)"

Observation
time point		 Harris hip scores WOMAC SF-12 VAS
Pain Function Deformity Range of
motion		 Pain Stiffness Physical
function
Pre-operation 14.22±4.18 19.44±3.84 0.78±0.83 1.11±0.33 12.22±1.86 4.56±1.13 39.78±5.52 41.56±4.22 5.89±1.27
Last follow-up 38.78±5.12 42.89±3.89 3.56±0.73 4.33±0.71 7.44±2.96 3.11±0.93 30.56±5.32 56.33±3.291 2.67±1.58
t value 124.36 165.51 56.82 152.91 16.81 8.78 13.04 59.51 22.73
P value <0.001 <0.001 <0.001 <0.001 0.001 0.009 0.002 <0.001 <0.001
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