脊柱楔形截骨并人工全髋关节置换术治疗强直性脊柱炎后凸畸形并髋关节重度屈曲挛缩畸形

SPINAL WEDGED OSTEOTOMY COMBINED WITH TOTAL HIP ARTHROPLASTY FOR KYPHOSIS AND SEVERE HIP FLEXTION CONTRACTURE CAUSED BY ANKYLOSING SPONDYLITIS

目的 探讨脊柱楔形截骨并人工全髋关节置换术（total hip arthroplasty，THA）治疗强直性脊柱炎（ankylosing spondylitis，AS）脊柱后凸畸形并髋关节重度屈曲挛缩畸形疗效。 方法 2008年12月－2011年11月，收治25例37髋AS后凸畸形并髋关节重度屈曲挛缩畸形患者。其中男22例，女3例；年龄29～38岁，平均35.6岁。病程8～16年，平均13.2年。其中术前髋关节屈伸、外展活动度丧失18例；脊柱严重后凸畸形16例（后凸Cobb角 ≥60°）。先行脊柱楔形截骨术，术后8周行单侧或双侧THA。测量后凸Cobb角评价脊柱后凸畸形矫形效果，并观察截骨处骨融合情况。采用Harris评分评价髋关节功能恢复情况；并测量手术前后髋关节屈伸及外展活动度；采用疼痛视觉模拟评分（VAS）评价THA术后疼痛改善情况；根据国际资料创建与评估系统（IDES）提出的THA术后假体松动影像学标准评判假体是否发生无菌性松动。 结果 25例均获随访，随访时间12～14个月，平均13个月。脊柱楔形截骨术后1例出现脊柱Ⅱ度滑脱，经二次手术后滑脱矫正；患者均无血管及脊髓损伤。术后6个月脊柱截骨均已达骨性融合。术后12个月后凸Cobb角为（25.4 ± 5.5）°，较术前（83.5 ± 10.4）°显著改善（t=24.63，P=0.00）。THA术后1例出现股神经牵拉伤症状，于术后9个月肌肉功能自行恢复正常，其余患者均无相关并发症及死亡。根据IDES影像学标准，1例臼杯向外上方移位，但移位距离〈 5 mm，且无明显临床症状；1例髋臼周围骨溶解，但臼杯无移位。25例37髋股骨柄假体侧均未见明显透亮带等松动表现。术后髋关节屈曲强直畸形明显改善，仅10例残余屈曲畸形15～20°，平均17.6°。术后3 个月，VAS评分为（2.31 ± 0.82）分，较术前（6.71 ± 1.14）分显著改善（t=42.26，P=0.00）；Harris评分为（85.92 ± 6.04）分，较术前（26.87 ± 4.23）分显著改善（t=28.72，P=0.00）。术后髋关节屈伸活动度较术前明显提高，达60～100°，平均72.0°；髋关节外展活动度达20～40°，平均28.7°。 结论 脊柱楔形截骨术并THA是治疗AS后凸畸形并髋关节重度屈曲挛缩畸形的较佳手术方案。

Objective To evaluate the effectiveness of spinal wedged osteotomy and total hip arthroplasty （THA） for treatment of kyphosis and severe hip flexion contracture caused by ankylosing spondylitis （AS）.Methods Between December 2008 and November 2011, 25 patients （37 hips） with kyphosis and severe hip flexion contracture caused by AS were treated. There were 22 males and 3 females, aged 29-38 years （mean, 35.6 years）. The disease duration was 8-16 years （mean, 13.2 years）. Of them, 18 cases had complete limitation of hip motion, and 16 cases had severe spine deformity （Cobb’s angel≥60°）. All 25 cases underwent spinal wedged osteotomy at first, and then received THA after 8 weeks. The effectiveness was evaluated by Harris hip score, range of motion （ROM） of the hip, visual analogue scale （VAS） score, Cobb’s angle, and information and data exchange system （IDES） criteria for aseptic loosening, respectively.Results The patients were followed up 12-14 months （mean, 13 months）. Spondylolisthesis （II degree） occurred in 1 case spinal after wedged osteotomy, and was corrected after second operation. No vascular injury or spinal cord injury was observed. Bony fusion was obtained at osteotomy ends at 6 months after operation. The Cobb’s angle was significantly corrected from （83.5 ± 10.4）° preoperatively to （25.4 ± 5.5）° （t=24.63, P=0.00） 12 months postoperatively. One case had traction injury of the femoral nerve after THA, and the muscle function recovered at 9 months after operation. According to IDES criteria, up-displacement of cup （〈 5 mm） was observed in 1 patient, who had no obvious clinical symptoms; periacetabular osteolysis occurred in 1 patient, with no displacement of cup. No obvious radiolucent was seen in 37 hips. The Harris hip score was significantly improved from （26.87 ± 4.23） preoperatively to （85.92 ± 6.04） （t=28.72, P=0.00） 3 months postoperatively; the VAS score was significantly decreased from （6.71 ± 1.14） preoperatively to （2.31 ± 0.82） （t=42.26, P=0.00） 3 months postoperatively; and the flexion-extension ROM of the hip was significantly improved to 60-100° （mean, 72.0°） at post-operation, and the abduction ROM of the hip was improved to 20-40° （mean, 28.7°）.Conclusion Spinal wedged osteotomy combined with THA is an efficient treatment for kyphosis and severe hip flexion contracture caused by AS.