强直性脊柱炎髋关节骨性强直的功能重建

Total hip arthroplasty in patients with ankylosing spondylitis and bila teral hip bony ankylosis

目的探讨强直性脊柱炎合并双侧髋关节骨性强直时的全髋关节置换方法及其注意事项。方法对17例24～52岁强直性脊柱炎患者骨性强直的34侧髋关节行Zweimüller非骨水泥型全髋关节置换手术。髋关节强直在屈曲0°～100°(平均37°),其中超过90°强直者3例6髋。术前需助行器者7例。生活不能完全自理者9例。所有患者均在一次性经口腔(10例)或鼻腔(7例)气管插管麻醉下完成双侧手术。3例患者后期行脊柱后凸畸形矫正术。结果患者髋关节活动度由术前的0°改善为术后复查时的屈伸平均77°(55°～120°),屈伸、收展、内外旋总活动度平均为150°(105°～230°)。术中有1例因股骨颈截骨造成髋臼后壁缺损,经修补后恢复。术后近期无神经血管损伤、关节脱位、感染等并发症发生,随访18～47个月无假体松动、移位。除2例3髋长时间行走有轻微疼痛外,其余患者无疼痛,患者的生活质量明显提高,1例患者仍需助行器。结论手术技术熟练者可一次顺利完成强直性脊柱炎双髋骨性强直的双侧髋关节置换术,采用Watson-Jones入路可在完成骨性强直的髋关节置换的同时完成髋关节前方的软组织松解;术中注意神经、血管的保护可顺利完成90°以上屈曲骨性强直畸形髋关节的置换;术后康复的重点是锻炼患者的肌力和肌肉活动的协调性;

Objective Concern has been expressed regardin g the operative procedure,techniqu e and outcomes in the patients with ankylosing spondylitis and bilateral h ip bony ankylosis undergone bilateral total hip replacement in one operati ve setting;this study evaluated the efficacy of total hip replacement in these patients,and discussed the problem s encountered in surgery.Methods Thirty-four primary Zweimüller non-cemented total hip arthroplasties were performed in 17male patient s with ankylosing spondylitis and bi -lateral hip bony ankylosis and were a vailable for clinical and radiograp hic study in the follow-up period of 18to47months.The average age at the time of surgery was 33.5years(range,24to 52years).The average flexion deformity of the 17patients(34hips)was 37°(ranged from 0°to 100°);there were 6hips in 3patients with the flexion deformity of bony an kylosis over 90°,and 7of the 17patie nts need the facilitation of a crutch or other equipment in daily activity before surgery.Bilateral operatio ns for all patients were undertaken u nder endo-tracheal intubation anesthesia in one operative setting.Because of fixed cervical spinal position an d the patients difficult airway,nasal-tracheal intubation anesthesia had to be undertaken in 7patients.Results The cumulative range of motion was im proved averagely from 0°before surg ery to 150°(105°to 230°)at the follow-up time,flexion from 0°to 77°(55°to 120°).Solid fusion was seen in 4hips of 2patients and the original femoral heads were large en ough,so the cup prostheses were fixe d in the remains of the head.Pos-terior acetabular wall damage happened in 1hip because of incorrect femo ral neck osteotomy,which was re-paired instantly with bone grafting.No complications such as nerve or bl ood vessel injuries,dislocation,o r deep infection happened.In spite of the over 90°deformity in some patien ts,it was mostly overcomed in 3days after the operation with intensive rehabilitation.By the time of th e final follow-up,there were no sign s of migration and loosening either on th e cup side or on the stem side.Thirty-one hips in 16patients were com-pletely free of pain and the remainders had only slight pain when walking more than 20minutes.All of the patients had substantial improveme nt of function and the range of motion as well as the posture.GradeⅢand gradeⅣheterotopic ossification were not developed in any of the patients according to Brookers classification.Additional spinal operation for their kyphosis was required in 3patient s.Conclusion With skillful operative technique,total joint replacement on bony ankylosis hips can be finished bilaterally at the one setting.With Watson -Jones approach,both hip rep lacement and soft tissue releasing c an be easily undertaken.Nerve or blood vessel injuries can be avoided if the hip is stretched carefully and the soft tissue is manipulated carefully when patients hip bony ankylosis in flexion deformity is over 90°.Posto perative rehabilitation should be s pe-cially stressed on the functional re covery of muscles around the hip.Nasal-tracheal intubation technique may facilitate the anesthesia in patien ts with severe ankylosing spondylitis.