人工全髋关节置换术后脱位的原因分析和防治对策(一)

1、人工全髋关节置换术后脱位的原因分析和防治对策(一)    作者：黄炎，孔荣，方诗元，禹德万，李守民，张彪【摘要】 目的探讨人工全髋关节置换术后脱位的原因分析和防治对策。方法本科自2001年1月2006年12月行全髋置换术311例，对术后脱位15例患者进行回顾性分析，评价术后脱位的危险因素及防治对策。结果所有病例中术后6个月发生脱位15例(脱位率4.82%)，首次全髋置换术后脱位11例，脱位率4.00%，而全髋翻修术后脱位4例，翻修手术脱位率11.11%，两者有显著差异(P0.01)。首次全髋置换手术患者中，骨折组、侧卧外展试验阳性组、后外侧入路组、髋臼假

2、体置于安全区外组，患者术后脱位率分别为6.04%、10.29%、4.52%、9.93%，均明显高于对照组(P0.05)，而不同性别、年龄以及使用不同直径股骨头的患者中术后脱位率无明显差异(P>0.05)。15例脱位中14例经保守治疗后未再发生脱位。1例患者发生习惯性脱位，行全髋翻修后未再发生脱位。结论全髋关节置换术后脱位与是否翻修，术前疾病状态，组织的肌力平衡，手术入路，假体位置的安放等因素有关，与患者性别、年龄以及假体设计无关。大多数脱位患者通过保守治疗未再发生脱位。通过改进手术方式，正确安放假体位置，及在医师指导下康复训练等会降低人工全髋关节置换术后脱位率。 【关键词】 全髋关节置换

3、术; 人工假体; 术后脱位; 原因Abstract: ObjectiveTo analyze and prevent postoperative dislocation after total hip replacement (THR). MethodAmong 311 cases of THR treated from Jan 2001 to Dec 2006, 15 developed dislocation. These cases were retrospectively reviewed and their risk factors were investigated.ResultS

4、ix months after THR, 15 patients (4.82%) had postoperative dislocation. Among them 11 had primary procedure and 4 had revision procedure. The dislocation rates were 4.00% and 11.11%,respectively. This difference was statistically significant (P0.01). Among patients with primary procedure, the disloc

5、ation rates of bone fracture subgroup, side-lying-abduction-test-positive subgroup, posterolateral-approach subgroup and prosthesis-malposition subgroup were 6.04%, 10.29%, 4.52% and 9.93%, respectively. These differences were statistically significant (P0.05) compared with the control groups. But t

6、here was no difference between the variables of gender, age and prosthesis's diameter. No redislocation was found in 14 patients after conservation treatment. Habitual dislocation was operatively revised in one patient.ConclusionThe causes of postoperative dislocation after THR are related with

7、primary or revision arthroplasty, disease status, the balance of soft tissue, the operative approach and the position of prostheses, but not related with gender, age and prosthesiss diameter. Most patients with dislocation may be cured by manipulative reduction.Dislocation rate can be significantly

8、decreased by improvement of operative approach, proper placement of prostheses and rehabilitation training under the guide of specialist doctor.Key words：total hip replacement; dislocation人工全髋关节置换(total hip replacement，THR)术后髋关节脱位是仅次于假体松动的第2大并发症，目前报道THR后首次脱位率3.2%6.5%，翻修后的脱位率可高达7.4%11.4%1。本文对311例THR进

9、行总结分析THR后髋关节脱位的危险因素和防治对策。1 材料与方法1.1 临床资料自2001年1月2006年12月行首次全髋置换术275例，男性103例，女性172例;平均年龄61岁(3883岁)，平均体重65 kg(4580 kg)。术前诊断股骨颈骨折149髋，股骨头缺血性坏死51髋，髋关节骨关节炎43髋，其他疾病(髋臼发育不良，股骨头术后翻修，强直性脊柱炎等)32髋。其中221例经后外侧入路(Gibson入路)，54例经前外侧入路(Harding入路)。采用直径28 mm的股骨头假体212例，直径大于或小于28 mm的股骨头假体63例。另外进行全髋翻修术36例。1.2 检查方法1.3 疗效标

10、准据Harris髋关节百分制评分标准，从包括疼痛、功能、畸形和关节活动度4方面对髋关节进行评价，90100分为优，8089分为良，7079分为中，小于70分为差。1.4 统计学处理采用SPSS统计软件(11.0版)，组内比较采用x2检验，P0.05为差异有统计学意义。所有百分数保留两位小数。2 结果本组病例术后随访时间：最短1.5年，最长7.5年，平均4.2年。2.1 术后脱位发生情况及相关危险因素分析本组病例术后6个月发生脱位15例，总脱位率4.82%。首次全髋置换术后脱位11例，脱位率4.0%，全髋翻修术后脱位4例，脱位率11.1%，两者有显著差异(P0.01)。其中，首次全髋置换术后脱位

11、的发生与患者的疾病状态，手术入路，外展肌力大小，髋臼假体的位置等因素有关，而与患者年龄，性别，股骨头假体直径无明显关系。图1、2表1。2.2 术后脱位的治疗及疗效15例脱位患者均在腰麻下手法复位后患侧髋“人字形”石膏固定6周，其中14例未再发生脱位。1例患者因假体位置不良发生习惯性脱位，后行全髋翻修术后未再发生脱位。所有患者随访6个月后，按Harris评分标准优10例，良5例，未见80分以下病例。3 讨论3.1 THR术后髋关节脱位的原因3.2 THR术后脱位的治疗对策3.3 THR术后脱位的预防方法【参考文献】1 Demos HA,Rorabeck CH,Bourne RB，et al.In

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14、vivorship of cemented all-polyethylene acetabular components in patients > 75 years of ageJ.J Arthroplasty,2000,15:461-467.6 Hedlundh U,Ahnfelt L,Hybbinette CH,et al.Surgical experience related to dislocations after total hip arthroplastyJ.J Bone Joint Surg Br,1996,78:206-209.7 Ritter MA,Harty LD,Keating ME,et al.A clinical comparison of the anterolateral and posterolateral approaches to the hipJ. Clin Orthop Relat