成人高位先天性髋关节脱位临床解剖学研究

CLINICAL ANATOMICAL STUDY ON HIGH CONGENITAL DISLOCATION OF HIP IN ADULTS

目的探讨成人高位先天性髋关节脱位解剖形态学异常,为全髋关节置换术(total hip arthroplasty,THA)提供解剖学依据。方法1997年5月-2008年7月,收治49例(57髋)HartofilakidisⅢ型成人先天性髋关节脱位患者。男6例,女43例;年龄18～56岁,平均29.4岁。左侧24髋,右侧33髋。通过术前X线片、CT以及术中观察,测量患髋(脱位组,n=57)股骨长度、峡部、股骨头垂直高度、颈干角、偏心距、前倾角、髓腔闪烁指数、髋臼前后径、髋臼后壁厚度、髋臼深径,术中观察患髋关节情况,测量髋臼前后径、髋臼深径。以上观察指标与健侧正常髋(对照组,n=41)进行比较。结果X线片显示术前脱位高度为(45.41±2.15)mm,双下肢不等长(40.41±2.02)mm。脱位组股骨峡部及股骨头垂直高度短缩,颈干角及偏心距变小,股骨前倾角增大。CT显示脱位组股骨髓腔闪烁指数>4.7,根据Noble等分类股骨为漏斗形;髋臼前后径变小,髋臼后壁增厚,髋臼深径较浅。以上测量指标与对照组比较,差异均有统计学意义(P<0.05)。术中测量髋臼前后径为(32.98±1.02)mm,髋臼深径为(14.21±0.56)mm,与术前影像测量值比较,差异无统计学意义(P>0.05)。髋臼内充满脂肪和纤维组织。40例坐骨神经走行发生改变,为向上外侧。结论成人高位先天性髋关节脱位行THA时,应充分考虑其解剖形态学变异,向髋臼后上方扩臼,避免过大扩髓造成股骨骨折,并选择合适或特制的假体。

Objective To investigate the morphological anatomical abnormalities of high congenital dislocation of hip in adults and provide anatomical basis for the total hip arthroplasty （THA）. Methods From May 1997 to July 2008, 49 patients （57 hips） with high congenital dislocation of hip （Hartofilakidis type III） were treated. There were 6 males and 43 females with an average age of 29.4 years old （18-56 years old）. The locations were left in 24 hips and right in 33 hips. The morphological parameters （including femoral length, isthmus, height of femoral head center, neck-shaft angle, medial head offset, anteversion angle, canal flare index, anteroposterior diameter of the true acetabulum, posterior thickness of the true acetabulum, depth of the true acetabulum） of suffering hips （dislocation group, n=57） were measured by preoperative X-ray, CT and intraoperative clinical observation and were compared with those of contralateral hips （control group, n=41）. The intraoperative situations of hip were observed. Results The height of dislocation was （45.41± 2.15） mm. The length difference of both lower extremities was （40.41 ± 2.02） mm. In dislocation group, isthmus was shortened; height of femoral head center, neck-shaft angle and medial head offset were decreased; and anteversion angle was increased. CT showed that the canal flare index was larger than 4.7, femoral shape was funnel-shaped according to Noble classification. Anteroposterior diameter of the true acetabulum became smaller, posterior thickness of the true acetabulum became thicker, and depth of the true acetabulum was shallower. There were statistically significant differences in the morphological parameters of femur and acetabulum between two groups （P 〈 0.05）. The intraoperative measurements showed that the anteroposterior diameter of acetabulum was （32.98 ±1.02） mm and the depth of acetabulum was （14.21 ± 0.56） mm. There was no statistically significant difference between intraoperative measurements and preoperative measurements （P 〉 0.05）. The acetabulum was full of fat and fibrous tissues. Running of the sciatic nerve in 40 cases were changed and it ran upward and laterally. Conclusion When high congenital dislocation of the hip in adults is treated with THA, anatomical variation must be fully taken into account. The acetabulum is expanded toward posterosuperior, excessive reamed should be avoided to prevent femoral fractures, and appropriate or tailor-made prosthesis was selected.