股骨偏心距和髋臼旋转中心对人工全髋置换术后关节功能影响的回顾性研究.doc

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1、 股骨偏心距和髋臼旋转中心对人工全髋置换术后关节功能影响的回顾性研究【摘要】  目的通过股骨偏心距及髋臼旋转中心手术后测量，探讨其变化对人工全髋置换术后关节功能的影响。方法临床随访本院人工全髋置换术后患者87例（92髋），均为首次行全髋关节置换术患者，平均随访时间2年1个月，测量手术后双髋关节X线片，比较术后假体股骨偏心距、旋转中心与解剖股骨偏心距、旋转中心符合率，对患者术后髋关节功能进行Harris评分并分组进行统计学分析。结果股骨偏心距及髋臼旋转中心均恢复（A组）27例（29.35%），（B组）仅FO恢复23例（25.00%），（C组）仅HJC恢复31例（33.70%），（D组）

2、FO及HJC均未恢复11例（11.96%），Harris评分优良率A组96.30%，B组为73.19%，C组为74.19%，D组为27.27%，Harris评分优良率A组与B组（P=0.039），A组与C组（P=0.029），A组与D组（P=0.000）差异均有统计学意义。结论股骨偏心距及旋转中心的恢复对人工全髋置换术后关节功能有直接影响。 【关键词】  全髋关节置换； 股骨偏心距； 髋臼旋转中心全髋关节置换术后股骨偏心距（femoral offset,FO）及髋臼旋转中心（hip joint center,HJC）的恢复和重建对髋关节软组织张力的平衡非常重要，直接影响术后关节功能引

3、起人们的关注。在全髋关节置换术中精确恢复股骨偏心距的长度，可增加外展肌张力，提高关节的稳定性。而髋臼旋转中心恢复至解剖旋转中心，可使术后假体与骨质、骨水泥以及髋关节周围软组织内应力分布更趋于生理状态，从而提高临床疗效12。通过随访本院收治87例92髋，测量术后髋关节X线正位片，分析股骨偏心距及髋臼旋转中心解剖恢复率，并验证分析其与临床疗效的关系。    1  资料和方法    1.1  一般资料   随访本院近年来收治人工全髋置换87例92髋，其中男49髋，女43髋；年龄4275岁，平均（61.

4、355.8）岁。其中诊断为股骨头缺血坏死47例51髋，股骨颈骨折21例21髋，髋关节骨性关节炎9例9髋，髋关节发育不良7例8髋，股骨颈骨肿瘤3例3髋。均采用髋关节后外侧手术入路，由同一手术医师完成，假体类型均为骨水泥固定型人工髋关节。    1.2  影像学检查方法    所有患者术前术后均使用数字化摄片机拍摄双髋关节正位X线片。标准的拍摄方法为：患者仰卧，下肢伸直，足尖内旋约15角，使两足趾内侧接触，以耻骨联合上缘为投照中心，X线垂直投影，投照距离1 m。由于股骨的旋转直接地影响了股骨颈干角及股骨偏心距的测量结果，拍摄正位

5、X线片时应使两侧的脚尖相对，双下肢内旋20，这样可以将股骨颈置于冠状位。    1.3  测量步骤    （1）分别测量每例患者术后双髋关节正位X线片患侧股骨偏心距，与健侧股骨偏心距比较。（2）通过健侧髋臼臼旋转中心确定患髋解剖旋转中心，与术后假体旋转中心相比较，统计髋臼假体旋转中心与解剖旋转中心的符合率。    1.4  测量方法（图1）图1术后FO及HJC与解剖FO及HJC测量方法（略）    （1）所有X线片经数字化摄片机（CR）处理，后期行数字化测

6、量，使用CR机操作平台测量软件对患者术后双髋X线片进行测量，使用“两弦法”，即在髋臼的圆弧内任选2条弦，做中垂，2条垂线的交点即为圆心，也就是旋转中心O，确定健侧股骨头及患侧假体头中心（O及O2）。测量两侧的股骨偏心距（femoral offset)，即股骨头中心至股骨干中线的垂直距离，将术后股骨偏心距与正常侧（非手术侧）相比较，差别小于4 mm之内的视为股骨偏心距得到了重建，如为双侧THA置换术者，差别大于4 mm时，股骨偏心距较大侧视为重建，另一侧为未重建。（2）股骨偏心距测量完毕后，于同一X线片上做双侧坐骨结节连线（A）及闭孔下缘连级（A1），通过耻骨联合作A及A1垂线（B）；通过已定健

7、侧旋转中心O作B的垂线并延长到对侧等长处，即为对侧的解剖旋转中心O1，与髋臼假体旋转中心O2比较，计算出二者符合率，甚至可以量化地测出二者的位移差及两者的二维空间相对位置关系。双侧THA置换术者，以髋臼模板确定髋臼解剖旋转中心，并与假体旋转中心相比较。    1.5  疗效评价    每例患者术后临床疗效采用髋关节Harris评分标准，分为优（90分以上）、良（8089分）、中（7079分）、差（70分以下）。    1.6  统计学分析    采用SPS

8、S 10.0统计软件，以Fisher确切概率法检验进行差异性分析，检验水准=0.05。    2  结果2.1  87例92髋股骨偏心距（FO）及髋臼旋转中心（HJC）术后恢复情况（表1）。    表1  股骨偏心距及髋臼旋转中心术后恢复情况（略）2.2  将人工全髋置换92髋临床随访资料分为4组，即股骨偏心距（FO）及髋臼旋转中心（HJC）均恢复（A组）、仅FO恢复（B组）、仅HJC恢复（C组）、FO及HJC均未恢复（D组）。对每例患髋术后功能进行Harris评分，统计优良率并进行分组统计学分

9、析（表2）。     表2  92髋随访疗效比较（略）*A组与B组；*A组与C组；*A组与D组3  讨论    人工全髋关节置换术后关节功能的影响因素是多方面的，其中股骨偏心距及髋臼旋转中心的恢复近年来逐渐引起人们的重视。髋关节是身体重力和外展肌共同的作用支点，它们之间的动力平衡对维持骨盆水平位置及正常的行走步态起着关键的作用。股骨偏心距是股骨头的旋转中心至股骨长轴的垂直距离，全髋人工关节置换术中股骨偏心距的重1建可以恢复髋外展肌的力矩，继而增加髋关节的稳定性。髋臼假体旋转中心恢复至解剖旋转中心可使双侧髋关节负担身

10、体重力得到平衡，双髋肌群及股骨假体受力均衡3。因此，股骨偏心距及髋臼假体旋转中心恢复对髋关节功能产生直接影响。    全髋置换术中，如果股骨偏心距减小，使股骨靠近骨盆，易引起髋关节的活动范围受限及周围的软组织松弛，从而导致髋关节的不稳定及术后髋关节脱位。重建或增大股骨偏心距，使股骨外移，减少了其与骨盆的撞击，改善了周围软组织张力，使髋关节更加稳定，适宜的股骨偏心距可以使髋关节获得最大的外展功能，最小的关节面间的应力，对股骨柄假体及其与骨交界面间产生最小的轴向力矩和内翻应力，使用较小的外展肌肌力即可平衡骨盆，改善行走时的步态，减少跛行的可能性46。髋臼旋转中心与股骨

11、偏心距的恢复在THA中具有统一协调的关系。术中将髋臼杯内移、下移有助于间接重建股骨偏心距。而单纯的内移则可致髋外展肌松弛，则应增加股骨偏心距，单纯髋臼杯外移则不利于恢复股骨偏心距，对术后髋关节功能产生直接影响79。本研究中FO及HJC都恢复组髋关节功能评分优良率显著高于单纯FO及HJC恢复组，统计分析表明对比组具有显著差异。Kuen报道的术后旋转中心符合率达到58%10，随访病例中髋臼旋转中心恢复率为63.04%，髋臼旋转中心未恢复者随访后髋关节功能评分优良率显著低于旋转中心恢复组。    股骨偏心距及髋臼旋转中心的恢复要求术前对双髋正位片进行模板测量。评价股骨假

12、体大小，股骨柄长度，肢体长度，股骨截骨合适的平面、髋臼假体等11、12。总体上要确定髋关节新的旋转中心、股骨偏心距大小、恢复下肢等长。术中髋臼锉磨削髋臼程度、髋臼假体的位置、骨水泥的厚度等因素要充分考虑。因此该手术要求操作医师有一定的该专业领域临床经验，术中安装试模后牵引下肢，感觉髋关节周围软组织张力；反弹试验（髋关节伸直，屈膝90，如果伸膝肌力牵张过高，松手后膝关节有自动伸直的趋势）可以帮助确定软组织的张力。    综上所述，尽可能地重建髋关节的生理结构和功能，恢复股骨偏心距及髋臼假体旋转中心的位置至解剖旋转中心，是影响髋关节置换术后效果的重要因素。通过本组资料

13、的分析，本研究认为要充分重视股骨偏心距及髋臼旋转中心的问题，术前认真分析双髋关节正位X线片，进行模板测量，制定周密手术操作方案，与术后疗效之间关系密切。   【参考文献】  1 Charles MN,Softtissue balancing of the hip:the role of femoral offset restorationJ.Instructional Course Lectures,2005,54:131141.2 张翀，郭开今，辛兵，等.全髋关节置换术髋臼旋转中心的回顾性研究J.中国矫形外科杂志,2006,14(18):1391139

14、2.3 Asayama I,Naito M,Fujisawa M,et al.Relationship between radiographic measurements of reconstructed hip joint postition and the Trendelenburg signJ.Arthroplasty,2002,17:74727511.4 史振才，李子荣.全髋人工关节置换术中股骨偏心距的重建J.中华外科杂志,2004,42（16):9971000.5 李晓华，周维江，吴海山.全髋关节置换术后脱位原因和处理J.中国矫形外科杂志,2001,8(8):771773.6 Yam

15、aguchi T,Total hip arthroplasty:the relationship between posterolateral reconstruction,abductor muscle strength,and femoral offsetJ.Journal of Orthopaedic Surgery,2004,12(2):164167.7 Piazza Sj,Assessment of the functional method of hip joint center location subject to reduced range of hip motionJ.Jo

16、urnal Of Biomechanics,2004,37(3):349356.8 Kirkwood RN,Radiographic and noninvasive determination of the hip joint center location:effect on hip joint monentsJ.Clinical Biomechanics,1999,14(4):227235.9 Hirakawa K,Mitsugi N,Koshino T,et al.Effect of acetabular cup postition and orientation in cemented

17、 total hip arthroplastyJ.Clin Orthop Relat Res,2001,(388):135142.10 Kuen TS,Sang JC,Dae Wk.Comparison of preoperative templating with postoperative assessment in cementless total hip arthroplastyJ.Acta Orthop Scand,2004,75:4044.11 金今，陈宾，徐宏光，等.人工全髋关节置换术术前的模板测量与术后评估J.实用骨科杂志,2005,11:398401.12 Robert L,

18、Barrack MD,R Stephen J,et al.Preoperative planning for revision total hip arthroplastyJ.The Journal of Bone & Joint Surgery,2005,87(12):28002811./Porganization system and working mode, the selection of a number of municipal strengthening group to build innovation and strengthen the organization

19、of the basic level organizations advanced model.(seven) the manual work of the Communist Youth League Organization published and League branch of manual work, to promote the use of two manuals in the citys organizations at various levels. The county committee, directly under the group (work) is unde

20、r the jurisdiction of grassroots League and group (total) using branch ratio shall not be less than 70%.Three, to further strengthen the groups leadership and team building(a) to strengthen the leagues leadership at all levels of construction. Continue to do a good job of municipal Party Committee O

21、rganization Department on the strengthening of the Communist Youth League cadres management opinions implementation. To promote the group counties (autonomous counties, cities) Commission and city directly under the group (workers) appointed to carry out the Five team building activities. Improve th

22、e League Association Department working mechanism. Conscientiously fulfill the duties of CO, combined with the city group directly under (the) Committee of the general election and the adjustment, actively jointly with the unit where the party organization department good group leadership selection

23、with the work. Do a good job in municipal Party committee assistant committee leadership and leading cadres of the annual assessment work, adhere to and improve the assistant secretary of the Communist Youth League talk system group To weave individual conversation and collective conversation, to st

24、rengthen the committees of all levels, the Standing Committee of the Standing Committee, the establishment of a sound system of central group learning, the system of investigation and study, the system of important issues and the reporting system.(two) to strengthen the work of education and trainin

25、g of cadres to conscientiously implement the Central Committee. On the implementation of grassroots cadres training project and opinions on carrying out the mission municipal CYL Cadres training project implementation opinions, full implementation of the project of the City Youth League cadres train

26、ing education. Focus on the county grassroots cadres and workers focused on training, the new school system vocational training League cadres, for the Municipal Organization Department jointly held the third session of the Communist Youth League system training cadres in party. Focusing on the const

27、ruction of new socialist countryside, strengthening village cadres and rural construction team group member of the young team, the county organizations at various levels throughout the year is expected to train 100 00 rural grassroots cadres, plans to train 1000 village secretary of the village Part

28、y branch.(three) actively promote grassroots cadres election work. Under the unified leadership of the party organization, to strengthen grassroots organizations direct work, standardize the election work rules and procedures, in the designated candidate, open competition to democratically elected b

29、ranch secretary at the same time, actively and steadily the development of Township, streets and other grassroots organizations in the direct election of the pilot work, on the basis of summarizing the experience and gradually expand the scope of the pilot, and gradually formed a set of measures and

30、 cadres election system.(four) to strengthen the cadres testing exercise. To study the development of XX city from 2006 to 2008 cadres testing exercise planning. To select outstanding cadres to the central mission in Beijing, Shanghai, Guangzhou and other central organs and sending work in developed

31、 areas. With the Central Committee the implementation of the western region and ethnic minorities cadres training plan . To carry out the eighth batch of municipal organs attachment cadre management, selection, training work. The outstanding cadres to start the National Development Bank XX branch te

32、sting exercise.(five) to strengthen the group construction. The main position to play the role of Youth League cadre education and training as the city, in accordance with the requirements of post training, further curriculum scientifically and rationally, adopt arrangement menu course, basic theory

33、 includes group work, focus, hot and difficult issues, to enhance the content and practice; to strengthen the construction of teaching staff, the integration of teachers, establish a quality teacher training team, establish and implement course evaluation system; take delivery of training to the cou

34、ntryside, on-site training, and increase the rural grassroots cadres training efforts.Four, efforts to strengthen the work of young talent(a) to tenth XX young 54 medal in recognition of the publicity, and actively explore the XX youth service. 54 Medal of institutionalization, standardization and s

35、ocialization mechanism. Give full play to the XX award in recognition of 54 youth medal Association, Youth Award winner in the 54 chapter, investigation activities. Who won the Youth Service medal, dedication to the society to create conditions, build the stage. During the 54, named in recognition o

36、f the tenth XX young 54 medal. The association of XX editing of young talent , the exchange of information and communication platform for the XX of outstanding young talents.(two) the establishment of municipal Party committee of young talent information database. In accordance with the feasible, ef

37、fective, classification management, implement step by step principle, the establishment of municipal Party committee of youth talent database; guiding organizations at various levels generally established the young talent database, construction of city, county (directly under the Communist Youth Lea

38、gue), grassroots organizations three young talent information database the relevant information collection system, and gradually establish the citys young people, the Communist Youth League youth talent information network, provide information platform for young talent resource development.Five, tak

39、e effective measures to strengthen the mission management(a) to strengthen the mission management work. Strengthen the dues collection and management, continue to adhere to the dues collection regularly reporting system, the annual comprehensive award in recognition of the tour and the tour one vote

40、 veto system audit system. Do statistical work in the group. The group service award in recognition of the advanced units, standardization, promoting group management work institutionalized.(two) to strengthen the organization of research and information exchange efforts. Grassroots carry out resear

41、ch, efforts to form a number of theoretical results. Make full use of the network carrier, to explore the establishment of electronic group service system, promote the work of Communist Youth League information.Attachment 4:XX municipal Party Committee Propaganda Department of the Communist Youth Le

42、ague work pointsIn 2006, the Communist Youth League propaganda ideological work XX to Deng Xiaoping theory and the important thought of Three Represents as guidance, study and implement the partys sixteen and the spirit of the the fifth Plenary Session of the 16th CPC Central Committee implementatio

43、n of the eight plenary session of the two committee, the citys cultural work conference, the Propaganda Department of the meeting and the the fourth Plenary Session of the 15th CPC Central Committee permanent mission spirit, closely around 11th Five-Year XX the goal of full implementation of Scienti

44、fic Outlook on Development, emancipating the mind, seeking truth from facts, keep pace with the times, close to reality, close to life, close to the young, persevere grasp orientation, grasping deepening, grasping construction innovation, further improve the groups propaganda and ideological work ab

45、ility, unity To guide the majority of members of the youth to achieve the 11th Five-Year planning tasks, the overall construction of a well-off society, building a socialist harmonious society to make new contributions.One, adhere to the Three Represents important thought and Scientific Outlook on D

46、evelopment education to guide the youth, to further strengthen the ideological and political education of youth(a) armed with youth science theory. Unremittingly with Deng Xiaoping theory and the important thought of Three Represents armed members of youth education, to promote the study and impleme

47、nt to expand the depth and breadth. To study and implement the important thought of Three Represents with the establishment and implementation of Scientific Outlook on Development combine with the implementation of the requirements of constructing socialist harmonious society with Scientific Outlook

48、 on Development, carry out education as an important part of the theory of armed youth in the new period, strengthen the establishment and implementation of Scientific Outlook on Development education, educate and guide the youth to fully understand the great significance of establishment and implementation of Scientific Outlook on Development, in-depth understanding of the Scientific Outlook on Development era back The king, the practice foundation, basic