本文選題：全髖關(guān)節(jié)置換術(shù)　切入點：偏心距重建　出處：《鄭州大學(xué)》2014年碩士論文

【摘要】：背景及目的 人工全髖關(guān)節(jié)置換術(shù)(total hip arthroplasty,THA)是一種常見的髖關(guān)節(jié)成形術(shù)，THA首先解決了髖關(guān)節(jié)疾患所帶來的疼痛癥狀，，同時也改進(jìn)了受累髖關(guān)節(jié)的功能。THA提高髖關(guān)節(jié)疾病患者們的生活質(zhì)量的同時也帶來了一些令患者和醫(yī)生都非�？鄲赖男g(shù)后并發(fā)癥，如感染、假體周圍骨折、假體松動、雙下肢不等長等，其中THA術(shù)后出現(xiàn)的雙下肢不等長（leg length discrepancy，LLD），是較常見的患者對手術(shù)效果不滿意的部分，術(shù)側(cè)肢體的延長較短縮更為常見，而且肢體延長更難以被患者接受。肢體延長超過2.5cm，可引起坐骨神經(jīng)的麻痹和跛行。雙下肢不等長是髖關(guān)節(jié)置換后常見的并發(fā)癥，嚴(yán)重的雙下肢不等長可導(dǎo)致患者跛行、腰痛、關(guān)節(jié)假體磨損加劇、需要穿戴鞋墊甚至最終接受髖關(guān)節(jié)翻修術(shù)。雙下肢不等長常常由以下原因造成：1）患者年齡較大，軟組織張力下降，THA術(shù)中麻醉影響下張力進(jìn)一步下降，使軟組織更加松弛；2）術(shù)前使用模板不當(dāng)，未能選取合適假體；3）術(shù)中糾正患肢屈曲內(nèi)收畸形，使患肢延長；4）股骨頸截骨不夠；5）髖臼旋轉(zhuǎn)中心的下移。因此進(jìn)行THA后雙下肢的長度差與術(shù)中的手術(shù)方式密切相關(guān),而術(shù)中股骨偏心距的重建對于THA的手術(shù)效果有著十分重要的意義。 股骨偏心距（femoral offset，F(xiàn)O）的定義是：股骨頭中心距股骨解剖軸線的垂直距離。以往的研究表明偏心距的重建與術(shù)后髖關(guān)節(jié)的軟組織平衡關(guān)系密切,特別是與外展肌組織張力的關(guān)系較大,偏心距重建較好的髖關(guān)節(jié)術(shù)后外展肌力較偏心距重建不足者優(yōu)。而外展肌張力的大小又和術(shù)后一系列并發(fā)癥如：脫位、跛行、關(guān)節(jié)磨損等相關(guān)聯(lián)。 股骨偏心距的重建與術(shù)后雙下肢的等長都是THA所追求的效果，它們都和術(shù)后髖關(guān)節(jié)周圍軟組織的張力與平衡息息相關(guān)，在THA術(shù)中為了保證髖關(guān)節(jié)能有足夠的軟組織張力及穩(wěn)定性，選擇了某種型號的假體改變股骨偏心距后有時卻出現(xiàn)了術(shù)肢延長的情況。目前關(guān)于THA中股骨偏心距重建的研究多是關(guān)于股骨偏心距與術(shù)后髖關(guān)節(jié)外展肌力的恢復(fù)、假體的無菌性松動、以及假體磨損率之間的研究，對股骨偏心距重建與術(shù)后雙下肢長度差之間的研究較少涉及。 該研究屬于回顧性研究，探討THA術(shù)中股骨偏心距的重建與術(shù)后雙下肢等長率、雙下肢長度差之間的關(guān)系，判斷股骨偏心距的重建是否能降低THA術(shù)后雙下肢不等長的發(fā)生率或減少雙下肢的長度差。本研究的研究目的為：1）探討股骨偏心距重建病例與未重建病例之間雙下肢不等長率之間的差別。2）研究THA術(shù)后雙側(cè)股骨偏心距之間的差值與雙下肢長度差之間的相關(guān)性。3）回顧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別組與雙下肢的等長率之間的關(guān)系。在股骨偏心距重建的范圍內(nèi)，進(jìn)一步縮小偏心距差值能否提高雙下肢的等長率。 方法 1.研究對象選取2009年7月至2013年7月在河南省人民醫(yī)院骨科接受單側(cè)人工全髖關(guān)節(jié)置換術(shù)的患者115例115髖，其中男性61例61髖，女性54例54髖。其中左髖60例，右髖55例。年齡22~80歲，平均51.78歲，其中股骨頭無菌性壞死67例，先天性髖關(guān)節(jié)發(fā)育不良13例，股骨頸骨折35例，平均隨訪時間23.2月（3個月~4年）。 2. X線片拍攝：研究中術(shù)前和隨訪時均為患者拍攝標(biāo)準(zhǔn)的骨盆正位X線片，具體拍攝方法為：患者仰臥于拍攝床，雙側(cè)足尖相對，雙足內(nèi)旋20°，盡量使股骨頸置于冠狀位。X線垂直投射，距離為1m，統(tǒng)一放大率為1.15:1，每張X線片包括股骨中上2/3段[3]。X線拍攝設(shè)備使用的是GE Difinium6000DR。 3.數(shù)據(jù)的測量方法術(shù)前及術(shù)后均在骨盆正位X線片上進(jìn)行測量。確定雙側(cè)的股骨頭中心及股骨解剖軸，測量雙側(cè)股骨偏心距的大小。經(jīng)雙側(cè)淚滴畫出水平參考線，通過測量小轉(zhuǎn)子頂點至水平參考線的距離判斷雙下肢的長度差。股骨偏心距的重建標(biāo)準(zhǔn)和術(shù)后雙下肢的等長標(biāo)準(zhǔn)分別為術(shù)后雙側(cè)股骨偏心距的差值在4mm以內(nèi)，術(shù)后雙下肢長度差在5mm以內(nèi)。 4.在骨盆正位片上使用廠家提供的假體模板，選擇能夠最大程度的減小雙側(cè)股骨偏心距差值的假體。本組病例均由同一組醫(yī)師進(jìn)行髖關(guān)節(jié)后外側(cè)入路THA,使用模板測量下所確定的假體規(guī)格。 5.統(tǒng)計學(xué)處理 統(tǒng)計學(xué)分析使用用SPSS17.0統(tǒng)計學(xué)分析軟件，計量資料使用均數(shù)±標(biāo)準(zhǔn)差。計量資料比較采用兩樣本配對t檢驗。按照股骨偏心距重建的標(biāo)準(zhǔn)將術(shù)后的病例分為重建組與未重建組，將重建組的術(shù)后雙下肢等長率與未重建組進(jìn)行對比，P＜0.05差異具有統(tǒng)計學(xué)意義。按術(shù)后不同的股骨偏心距差值將病例進(jìn)行分組，在不同偏心距差值組間對雙下肢的等長率進(jìn)行X2檢驗，P＜0.05有統(tǒng)計學(xué)意義。 結(jié)果 1. THA術(shù)后股骨偏心距差值與雙下肢長度差之間存在明顯相關(guān)關(guān)系。股骨偏心距差值與術(shù)后雙下肢長度差呈正相關(guān)關(guān)系（r=0.632,P＜0.05）。 2. THA術(shù)后股骨偏心距重建組92例中有71例雙下肢等長，未重建組23例中有5例雙下肢等長，經(jīng)卡方檢驗，股骨偏心距重建組與未重建組的術(shù)后雙下肢等長率之間存在顯著性差異(2=25.229., P＜0.05）。 3. THA術(shù)后股骨偏心距重建范圍內(nèi)，大部分雙側(cè)股骨偏心距差值較小組和差值較大組的雙下等長率之間有顯著性差異。 結(jié)論 在THA術(shù)中應(yīng)盡可能的重建股骨偏心距，以更好的恢復(fù)患肢的長度，降低術(shù)后雙下肢不等長的發(fā)生率，從而提高患者的生活質(zhì)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.
璇ョ爺絀跺睘浜庡洖欏炬

本文編號：1679284