摘要
背景:对于中晚期(FicatⅢ,Ⅳ期)股骨头缺血性坏死且髋臼基本完好的患者,单纯股骨头表面置换是一种较好的治疗方法。股骨假体位置、下沉影响全髋关节置换术的治疗效果,但假体位置、下沉对半髋表面置换术疗效的影响尚需进一步研究。目的:观察钴铬合金半髋表面置换对中晚期(FicatⅢ,Ⅳ期)股骨头缺血性坏死且髋臼基本完好患者髋关节功能的影响,并分析疗效与股骨假体柄干角、下沉的关系,评估计算机辅助X射平片分析对假体失败的预测价值。设计:病例分析。单位:广西医科大学第一附属医院脊柱骨病科。对象:选择1997-06/2002-07广西医科大学第一附属医院脊柱骨病科收治的中晚期(FicatⅢ,Ⅳ期)股骨头缺血性坏死行半髋表面置换患者41例(48髋),患者手术时的年龄29～49岁,平均(37±9)岁,其中男30例,女11例。其中FicatⅢ期35髋,FicatⅣ期13髋,髋臼均相对正常。所有患者病变部位病理检查均为股骨头缺血性坏死;且均签署知情同意书。方法:①于术前和随访时采用UCLA(UniversityofCaliforniaLosAnge-les)髋关节功能评分标准对患者手术前后疼痛、步行、功能、活动进行评分,每一项记分为1～10分,10分为最佳。优,35～40分,好29～34分,一般22～28分,差<22分。术后评分为随访时评分平均值。②运用计算机辅助的EBRA-FCA法,在术后骨盆的X射线平片上测量股骨假体的柄干角、下沉,并对半髋表面置换术治疗股骨头缺血性坏死的疗效与股骨假体的柄干角、下沉的关系进行分析。③采用复诊的方式进行随访,于术后2个月开始第1次随访,每年随访1次,共随访8年。④两组样本间均数比较采用独立样本t检验(并做方差齐性检验)。在对临床结果的析因分析(posthocanalysis)基础上,比值比(oddsratio)分析用来确定假体早期失败的相对危险性。主要观察指标:①纳入患者半髋表面置换术前后UCLA评分比较。②FicatⅢ期和Ⅳ期患者术后疗效比较。③不同疗效患者随访期间股骨假体柄干角和下沉程度比较。结果:全部病例均获随访,其中8例随访3年,8例随访4年,8例随访5年,7例随访6年,6例随访7年,4例8年。①UCLA髋关节功能评分:疼痛、步行、功能、活动评分别由术前的(3.1±1.2),(4.4±1.7),(5.8±2.3),(5.5±2.7)分提高到术后的(9.1±2.5),(9.2±2.9),(9.1±3.4),(7.1±3.1)分,差异明显(P<0.01)。②疗效:FicatⅢ期35髋术后的满意率为89%与FicatⅣ期13髋术后的满意率相近(69%,P>0.05),其中疗效差8髋为失败组,其余40髋为成功组。③计算机辅助的X射线平片检查结果:失败组6个髋的股骨假体有明显下沉(其柄干角小于130°),2个髋的髋臼有破坏(1个柄干角为128°,1个柄干角为136°)。成功组平均柄干角明显大于失败组,分别为139°±6.2°,127°±5.3°,差异明显(P<0.01)。失败组中,6髋假体头中心和假体柄尖的下沉分别为(5.02±1.3)mm和(4.85±1.1)mm明显大于成功组[(1.48±0.2)和(1.04±0.2)mm,P<0.05];小于130°的柄干角其发生不良后果的机会增加了7.1倍。④股骨假体下沉时间:计算机辅助的X线片分析显示股骨假体下沉超过2mm的时间为(19.5±3.2)个月,明显早于临床出现症状的时间和X射线平片异常的时间[(35.6±4.2),(24.8±2.5)个月,P<0.01]。结论:①钴铬合金半髋表面置换是一种可供选择的向全髋关节置换术过渡的较好的治疗方法,可以恢复中晚期(FicatⅢ,Ⅳ期)股骨头缺血性坏死的且髋臼基本完好的患者的髋关节功能。②假体的松动下沉与假体的位置有关。③用来评估假体柄在骨盆平片上的下沉程度的计算机辅助的平片分析可以预测假体的失败。
BACKGROUND： For patients with osteonecrosis and collapse of the femoral head but with preservation of some acetabular articular cartilage at Ficat stage Ⅲ or stage Ⅳ, the hemisurface replacement of the femoral head has emerged as the treatment of choice. Although the orientation and the migration of the femoral component have been shown to influence the outcome of total hip replacement, to the best of our knowledge, their effect on the clinical outcome of surface arthroplasty and the relationship between the outcome and the femoral component positioning and the migration of an implant have not been studied.
OBJECTIVE： To observe the effect of cobalt-chrome alloy surface hemiarthroplasty of the hip on hip joint function of patients with osteoneerosis of the femoral head but with preservation of some acetabular articular cartiiage at Ficat stage Ⅲ or stage Ⅳ, and to analyze the relationship between the clinical outcome and the femoral component positioning; meanwhile, to evaluate the advantage of computer-assisted Einzel-Bild-Rontgen-Analyse- femoral component analysis （EBRA-FCA） to prognosticate the results of prostheses implant.
DESIGN： Case analysis.
PARTICIPANTS： Between June 1997 and July 2002, of the forty-eight patients with precision-fit surface hemiarthroplasties of the hips performed at the first Affiliated Hospital of Guangxi Medical University, forty-one patients were forty years old or younger at the time of the operation including 30 males and 11 females; with an average age of （37±9） years. There were thirty-five hips at Ficat stage Ⅲ and thirteen at stage Ⅳ with relatively normal acetabula. Fourteen prostheses were implanted in the female and thirty-four in the male. The histopathological observation showed femoral head necrosis in all patients and informed consent was obtained.
METHODS： （1）All hips were evaluated with the University of California at Los Angeles （UCLA） hip score before and after operation.UCLA scoring consists of pain, walking, function, and activity. Each item scores 1 to 10 points, 10 points meant the best, 35-40 points meant excellent： 29-34 points meant good,22-28 meant fair, 〈 22 meant bad. （2）Measurements of the hip reconstruction were made on the anteroposterior pelvic radiograph analyed by EBRA-FCA analysis. The outcome of Precision-fit Surface Hemiarthroplasty and the correlation between the treatment effect and the femoral component positioning （showed by stem-shaft angle ） and the migration of the implant were evaluated. （3）The first follow-up was performed two months after operation and then once one year,total was 8 years. （4） Statistical difference was determined using one way analysis of variance （ANOVA） followed by Student Newman Keulst test. The Student t test was used to calculate the probability that the differences in the radiographic measurements between the groups were due to chance. Odds ratio analysis was used to establish the relative risk of early failure on the basis of a post hoe analysis of clinical results.
MAIN OUTCOME MEASURES： （1）UCLA hip score before and after operation. （2）Therapic effect of the operation in the patients at Fieat Ⅲ and Ⅳ stage. （3） Radiographic evaluation included stem-shaft angle and migration of the implant after operation.
RESULTS： Totally 41 patients（48hips） were involved in the result analysis and follow-up, and 3-,4-,5-,6-,7-,8-year follow-up in 8,8,8,7,6,4,respectively. （1） UCLA hip seore：The mean UCLA hip seore for the overall group improved signifieantly from （3.1±1.2） to （9.1±2.5） points for pain, （4.4±1.7） to （9.2±2.9） points for walking, （5.8±2.3） to（9.1±3.4） points for function, and 5.5±2.7 to 7.1±3.1 points for activity （P 〈 0.01）. （2） Therapie effect：The satisfaetion rate was 89% for thirty-five hips at Ficat stage Ⅲ, 69% for thirteen at Ficat stage Ⅳ; there was not statistieal difference between the two stages （P 〉 0.05）. Bad therapic effeet in eight hips were regarded as failure group,and the rest were regarded as sueeess group. （3） Examination of computer-assisted EBRA-FCA： the prostheses showed significant subsidence in 6 hips（with angle lower than 130°） in failure group, and wear of the aeetabular cartilage in 2 hips（1 with an angle of 128°; 1 with an angle of 136° ）. The mean femoral stem-shaft angle in the success group were greater than in the failure group [139°±6.2° vs 127°±5.3°,P 〈 0.01].Hips with an angle less than 130° had an increase in the relative risk of an adverse outcome by a factor of 7.1. A mean migration of the centre of the head and the tip of the stem of six hips in failure group were bigger than success group[（5.02±1.1）, （4.85±1.1） mm vs （1.48±0.2）, （1.04±0.2） mm, P 〈 0.05]. （4） Time of femoral component subsidence： The onset of femoral eomponent subsidence with migration greater than 2 mm was earlier than that of clinical symptoms or radiological evidence of failure [ （19.5±3.2） months, （35.6±4.2） months,and （24.8±2.5） months respectively, P 〈 0.01].
CONCLUSION： Cobah-chrome alloy surface hemiarthroplasty of the hip is a good alternative to total hip arthroplasty that restores hip function for patients with osteonecrosis and collapse of the femoral head but with preservation of some acetabular articular cartilage at Ficat stage Ⅲ or stage Ⅳ.Subsidenee of the femoral component is correlated with the position of the femoral eomponent. Computer-assisted EBRA-FCA can be used to predict early failure of the implant,and it is a .reliable and valid tool for measuring migration of the femoral component after surface arthroplasty and can be used to predict early failure of the implant.
出处
《中国临床康复》
CSCD
北大核心
2006年第41期216-219,F0003,共5页
Chinese Journal of Clinical Rehabilitation
