-
骨性关节炎属于退行性疾病,包括年龄、劳损、肥胖、创伤、先天性关节异常、关节畸形等众多原因造成的软骨退化损伤以及软骨下骨、关节边缘反应性增生是其发病主要原因[1]。临床表现为进行性关节压痛、疼痛、僵硬、肿胀、功能受限以及关节畸形等,药物治疗虽然一定程度上能缓解疼痛及炎症反应,但大多数学者建议对于退变明显、疼痛严重以及明显关节活动受限的病人应进行手术治疗以达到根治目的[2]。全髋关节置换术(total hip arthroplasty,THA)是治疗骨性关节炎的主要方案,国内外众多临床报道均证实THA在治疗包括骨性关节炎、股骨颈骨折等疾病中具有优良疗效。但值得注意的是,THA虽然能使病人髋功能获得恢复,但术后并发症问题一直是影响THA预后的主要因素[3]。NEWMAN等[4]报道THA病人术后髋关节脱位发生率为4.65%~14.96%,术后髋关节早期脱位已成为THA较为常见的并发症,返修手术对病人造成经济负担及生理痛苦。因此,探寻术后脱位发生的危险因素,对采取针对性措施防治术后脱位具有十分重要的意义。本研究通过分析骨性关节炎THA病人的病历资料,探讨骨性关节炎THA术后脱位发生情况及危险因素,旨在提出针对性预防措施减少THA术后脱位,改善远期预后效果。现作报道。
-
266例骨性关节炎病人THA术后脱位25例,脱位率9.40%,左侧14例(56.00%),右侧11例(44.00%)。
-
2组病人年龄、人工股骨头直径、髋关节手术史、手术失血量、术后股骨假体前倾角、术后股骨偏心距差异有统计学意义(P < 0.05~P < 0.01),而性别、BMI、手术入路、合并糖尿病、手术时间、术后输血率、术后引流量、手术侧别差异无统计学意义(P>0.05)(见表 1)。
项目 脱位组(n=25) 未脱位组(n=241) χ2 P 性别 男 10(40.00) 133(55.19) 2.10 >0.05 女 15(60.00) 108(44.81) 年龄/岁 ≤75>75 16(64.00)9(36.00) 288(78.01)53(21.99) 6.93 <0.01 人工股骨头直径/mm <30 12(48.00) 50(20.75) ≥30 13(52.00) 191(79.25) 9.41 <0.01 髋关节手术史 4(16.00) 12(4.98) 4.87 <0.05 手术入路 前外侧后外侧 7(28.00)18(72.00) 108(44.81)133(55.19) 2.61 >0.05 合并糖尿病 8(32.00) 40(16.60) 3.63 >0.05 BMI/(kg/m2) 22.45±1.87 22.87±1.90 1.05△ >0.05 手术时间/min 57.65±6.56 55.65±6.70 1.42△ >0.05 术后输血率 6(24.00) 54(22.41) 0.03 >0.05 术后引流量/mL 93.66±9.34 95.03±10.02 0.65△ >0.05 手术失血量/mL 323.82±32.77 309.76±29.02 2.28△ <0.05 手术侧别 左 14(56.00) 133(55.19) 0.01 >0.05 右 11(44.00) 108(44.81) 股骨假体前倾角(°) 9.54±1.32 7.96±0.98 7.40△ <0.01 术后股骨偏心距/mm 40.23±3.23 42.65±3.17 3.63△ <0.01 △示t值 表 1 骨性关节炎病人THA术后脱位单因素分析[n;百分率(%)]
-
多因素logistic回归分析结果显示,年龄>75岁、女性、人工股骨头直径<30 mm、髋关节手术史、后外侧入路、术后股骨假体前倾角>10°是骨性关节炎THA术后脱位的独立危险因素(P < 0.05)(见表 2)。
变量 β SE Wald P OR(95%CI) 年龄>75岁 0.834 0.265 8.667 <0.05 2.34(1.12~8.93) 女性 1.322 0.365 9.376 <0.05 2.90(1.41~9.03) 人工股骨头直径<30 mm 1.154 0.360 8.187 <0.05 2.70(1.14~989) 髋关节手术史 1.336 0.375 11.288 <0.05 3.57(1.49~12.32) 后外侧入路 0.956 0.297 7.518 <0.05 2.30(1.20~7.67) 术后股骨假体前倾角>10° 0.855 0.310 6.754 <0.05 2.12(1.27~7.18) 表 2 骨性关节炎病人THA术后脱位多因素分析
-
男性,77岁,图 1A正位X线片显示右髋臼发育不良、骨性关节炎;图 1B:接受后外侧入路THA治疗1周复查显示内固定良好;术后2月病人髋关节明显活动性疼痛,关节运动受限,下肢左侧外旋,图 1C正位X线显示髋关节脱位。
骨性关节炎全髋关节置换术术后脱位发生情况及其影响因素研究
Study on the occurrence of postoperative dislocation of total hip arthroplasty in patients with osteoarthritis, and its multivariate analysis
-
摘要:
目的研究骨性关节炎全髋关节置换术(total hip arthroplasty,THA)术后脱位发生情况及其危险因素分析。 方法选取266例骨性关节炎病人,均采用THA治疗,术后随访6个月,记录髋关节脱位发生情况,将术后髋关节脱位病人设为脱位组,未脱位病人设为未脱位组。记录2组病人手术相关指标及病历资料,经单因素分析、logistic回归分析探讨骨性关节炎THA术后脱位的独立危险因素。 结果266例骨性关节炎病人THA术后脱位25例,脱位率9.40%;2组病人年龄、人工股骨头直径、髋关节手术史、手术失血量、术后股骨假体前倾角、术后股骨偏心距差异有统计学意义(P < 0.05~P < 0.01),而性别、BMI、手术入路、合并糖尿病、手术时间、术后输血率、术后引流量、手术侧别差异无统计学意义(P>0.05)。多因素logistic回归分析显示,年龄>75岁、女性、人工股骨头直径 < 30 mm、髋关节手术史、后外侧入路、术后股骨假体前倾角>10°是骨性关节炎THA术后脱位的独立危险因素(P < 0.05)。 结论骨性关节炎THA术后容易发生髋关节脱位,年龄>75岁、女性、人工股骨头直径 < 30 mm、髋关节手术史、后外侧入路均可增加其脱位风险。 Abstract:ObjectiveTo study the occurrence and risk factors of dislocation after total hip arthroplasty(THA) for osteoarthritis. MethodsA total of 266 patients with osteoarthritis were treated with THA, and followed up for 6 months.The occurrence of dislocation of the hip joint was recorded.The patients with postoperative dislocation of the hip joint were set as the dislocation group, and the patients without dislocation were set as undislocation group.The surgical indicators and medical record in two groups were analyzed using univariate and logistic regression analysis to explore the independent risk factors of postoperative dislocation in patients treated with THA. ResultsAmong 266 patients with osteoarthritis, 25 cases with dislocation after THA were found, and the dislocation rate was 9.40%.The differences of the age, artificial femoral head diameter, history of hip surgery, postoperative blood loss, anterior angle of femoral prosthesis and postoperative femoral eccentricity between two groups were statistically significant(P < 0.05 to P < 0.01), and the differences of the gender, body mass index, surgical approach, combined diabetes mellitus, operative time, postoperative transfusion rate, postoperative drainage volume and operative side between two groups were not statistically significant(P>0.05).The results of multivariate logistic regression analysis showed that age >75 years, female, diameter of artificial femoral head < 30 mm, history of hip surgery, posterolateral approach and anteversion of femoral prosthesis >10° were the independent risk factors of dislocation after aosteoarthritis treated with THA(P < 0.05). ConclusionsThe hip joint with osteoarthritis is prone to dislocation after THA, the age >75 years, female, artificial femoral head diameter < 30 mm, hip surgery history and posterior lateral approach can increase the risk of dislocation. -
Key words:
- osteoarthritis /
- total hip arthroplasty /
- postoperative dislocation /
- risk factor
-
表 1 骨性关节炎病人THA术后脱位单因素分析[n;百分率(%)]
项目 脱位组(n=25) 未脱位组(n=241) χ2 P 性别 男 10(40.00) 133(55.19) 2.10 >0.05 女 15(60.00) 108(44.81) 年龄/岁 ≤75>75 16(64.00)9(36.00) 288(78.01)53(21.99) 6.93 <0.01 人工股骨头直径/mm <30 12(48.00) 50(20.75) ≥30 13(52.00) 191(79.25) 9.41 <0.01 髋关节手术史 4(16.00) 12(4.98) 4.87 <0.05 手术入路 前外侧后外侧 7(28.00)18(72.00) 108(44.81)133(55.19) 2.61 >0.05 合并糖尿病 8(32.00) 40(16.60) 3.63 >0.05 BMI/(kg/m2) 22.45±1.87 22.87±1.90 1.05△ >0.05 手术时间/min 57.65±6.56 55.65±6.70 1.42△ >0.05 术后输血率 6(24.00) 54(22.41) 0.03 >0.05 术后引流量/mL 93.66±9.34 95.03±10.02 0.65△ >0.05 手术失血量/mL 323.82±32.77 309.76±29.02 2.28△ <0.05 手术侧别 左 14(56.00) 133(55.19) 0.01 >0.05 右 11(44.00) 108(44.81) 股骨假体前倾角(°) 9.54±1.32 7.96±0.98 7.40△ <0.01 术后股骨偏心距/mm 40.23±3.23 42.65±3.17 3.63△ <0.01 △示t值 表 2 骨性关节炎病人THA术后脱位多因素分析
变量 β SE Wald P OR(95%CI) 年龄>75岁 0.834 0.265 8.667 <0.05 2.34(1.12~8.93) 女性 1.322 0.365 9.376 <0.05 2.90(1.41~9.03) 人工股骨头直径<30 mm 1.154 0.360 8.187 <0.05 2.70(1.14~989) 髋关节手术史 1.336 0.375 11.288 <0.05 3.57(1.49~12.32) 后外侧入路 0.956 0.297 7.518 <0.05 2.30(1.20~7.67) 术后股骨假体前倾角>10° 0.855 0.310 6.754 <0.05 2.12(1.27~7.18) -
[1] 袁普卫, 康武林, 李小群, 等.骨性关节炎发病机制及相关细胞因子的研究进展[J].中国矫形外科杂志, 2016, 24(11):1010. [2] HOMMA Y, BABA T, SANO K, et al.Lateral femoral cutaneous nerve injury with the direct anterior approach for total hip arthroplasty[J].Int Orthop, 2016, 40(8):1587. doi: 10.1007/s00264-015-2942-0 [3] KOBAYASHI H, HOMMA Y, BABA T, et al.Surgeons changing the approach for total hip arthroplasty from posterior to direct anterior with fluoroscopy should consider potential excessive cup anteversion and flexion implantation of the stem in their early experience[J].Int Orthop, 2016, 40(9):1813. doi: 10.1007/s00264-015-3059-1 [4] NEWMAN EA, HOLST DC, BRACEY DN, et al.Incidence of heterotopic ossification in direct anterior vs posterior approach to total hip arthroplasty:a retrospective radiographic review[J].Int Orthop, 2016, 40(9):1967. doi: 10.1007/s00264-015-3048-4 [5] 中华医学会风湿病学分会.骨关节炎诊断及治疗指南[J].中华风湿病学杂志, 2010, 14(6):416. doi: 10.3760/cma.j.issn.1007-7480.2010.06.024 [6] 贾金领, 侯文根, 张君, 等.髋关节置换术后发生脱位的危险因素分析[J].中国矫形外科杂志, 2016, 24(17):1624. [7] ARABNEJAD S, JOHNETON B, TANZER M, et al.Fully porous 3D printed titanium femoral stem to reduce stress-shielding following total hip arthroplasty[J].Orthop Res, 2017, 35(8):1774. doi: 10.1002/jor.23445 [8] YORK PJ, SMARCKC T, JUDET T, et al.Total hip arthroplasty via the anterior approach:tips and tricks for primary and revision surgery[J].Int Orthop, 2016, 40(10):2041. doi: 10.1007/s00264-016-3125-3 [9] 罗肖, 陈敬忠, 张怀学, 等.髋关节置换术后发生早期脱位的危险因素分析[J].局解手术学杂志, 2014, 23(1):46 [10] YOSHIMOTO K, NAKASHIMA Y, AOTA S, et al.Re-dislocation after revision total hip arthroplasty for recurrent dislocation:a multicentre study[J].Int Orthop, 2017, 41(2):1. [11] BUCKLAND AJ, PUVANESARAJAH V, VIGDORCHIK J, et al.Dislocation of a primary total hip arthroplasty is more common in patients with a lumbar spinal fusion[J].Bone Joint J, 2016, 16(10):S263. [12] TAKEGAMI Y, KOMATSU D, SEKI T, et al.Total hip arthroplasty after failed curved intertrochanteric varus osteotomy for avascular necrosis of the femoral head[J].Nagoya J Med Sci, 2016, 78(1):89. [13] 罗殿中, 张洪.一项基本的保髋手术技术:髋关节外科脱位技术[J].中华解剖与临床杂志, 2015, 20(5):475. doi: 10.3760/cma.j.issn.2095-7041.2015.05.025 [14] 董玉雷, 翁习生.全髋关节置换术后脱位的防治[J].中华解剖与临床杂志, 2014, 19(1):67. [15] YOSHIMOTO K, NAKASHIMA Y, YAMAMOTO T, et al.Dislocation and its recurrence after revision total hip arthroplasty[J].Int Orthop, 2016, 40(8):1625. doi: 10.1007/s00264-015-3020-3 [16] 李志昌, 李儒军, 柯岩, 等.人工髋关节置换术后股骨假体周围骨折的分型与治疗[J].中华骨科杂志, 2017, 37(15):952. doi: 10.3760/cma.j.issn.0253-2352.2017.15.008 [17] 李文龙, 范亚楠, 张蕾蕾, 等.微创全髋关节置换术直接前侧入路与外侧小切口入路的对比研究[J].中医正骨, 2016, 28(3):24. [18] 卢仲琳, 曹志强, 高国梁, 等.股骨假体颈干角、前倾角变化对全髋关节置换术后预后的影响[J].中国现代医学杂志, 2018, 28(11):68. [19] KIM MW, CHUNG YY, LEE JW, et al.Effect of femoral head size and surgical approach on risk of revision for dislocation after total hip arthroplasty[J].Acta Orthop Belg, 2017, 29(2):91.