全髋关节置换术治疗强直性脊柱炎累及髋关节的疗效观察

Effectiveness of total hip arthroplasty in the treatment of involved hips in patients with ankylosing spondylitis

目的总结全髋关节置换术(total hip arthroplasty,THA)治疗强直性脊柱炎(ankylosing spondylitis,AS)累及髋关节的中远期疗效,并对影响疗效的因素进行探讨。方法 1999年3月—2011年5月采用THA治疗32例(42髋)AS累及髋关节患者。男26例,女6例;年龄20~78岁,平均39岁。病程2~41年,中位病程10年。假体摩擦界面采用金属-聚乙烯者19髋,陶瓷-陶瓷者23髋;股骨头假体采用36 mm直径者15髋,28 mm直径者27髋;假体均采用生物学固定。手术前后测量并记录患者髋关节总活动度(屈-伸、内收-外展、内旋-外旋活动度总和),髋关节功能采用Harris评分、疼痛程度采用疼痛视觉模拟评分(VAS)评价。根据X线片,髋臼侧和股骨侧假体分别采用De Lee分区和Gruen分区描述;异位骨化程度采用Brooker标准。结果术后患者切口均Ⅰ期愈合,无麻醉意外、感染及神经、血管损伤等并发症。术后29例(39髋)获随访,随访时间5~17年,平均9年。术后股骨头假体28 mm直径组24髋中发生髋关节前脱位2例(2髋),36 mm直径组15髋无脱位发生。末次随访时,所有患者VAS评分、Harris评分及髋关节总活动度均较术前显著改善(P<0.05)。其中术前病程越短,术后Harris评分越高、髋关节总活动度越大(P<0.05);股骨头假体直径越大,术后髋关节总活动度越大(P<0.05)。末次随访时臼杯和股骨柄假体均固定良好。采用金属-聚乙烯假体的18髋中,臼杯周围显示有广泛性骨溶解者9髋(50%),但假体尚无松动;采用陶瓷-陶瓷假体的21髋中无任何骨溶解和假体松动征象。7髋发生异位骨化,其中BrookerⅠ级5髋,Ⅱ级2髋。结论 THA是治疗AS累及髋关节的有效手段;术前病程短,并采用大直径股骨头陶瓷-陶瓷假体行THA者,术后疗效更好。

Objective To summarize the mid- to long-term effectiveness of total hip arthroplasty （THA） in the treatment of the involved hips in patients with ankylosing spondylitis （AS）, and to investigate its influencing factors. Methods Between March 1999 and May 2011, 32 patients （42 hips） with AS and involved hip underwent THA. There were 26 males and 6 females with a mean age of 39 years （range, 20-78 years）. The disease duration ranged from 2 to 41 years, with a median of 10 years. Metal-on-polyethylene bearings were used in 19 hips, and ceramic-on-ceramic bearings in 23 hips. The diameter of prosthetic femoral head was 36 mm in 15 hips and was 28 mm in 27 hips; and all the prostheses were fixed biologically. The Harris score, visual analogue scale （VAS） score, and total range of motion （ROM） of the hip were compared between at pre- and post-operation to evaluate the effectiveness. The DeLee zone was used for describing acetabular prosthesis, the Gruen zone for describing femoral prosthesis, and the Brooker criterion for evaluating the heterotopic ossification. Results Healing of incision by first intention was achieved in all patients after operation. There was no complication of anesthetic accident, infection, or neurovascular injury. Twenty-nine cases （39 hips） were followed up 5-17 years （mean, 9 years）. Anterior dislocation of hip joint occurred in 2 hips of 24 hips （28 mmdiameter）, but did not in 15 hips （36 mm diameter）. At last follow-up, the Harris score, VAS score, and the total hip ROM were significantly improved （P〈0.05）. The shorter the disease duration was, the higher postoperative Harris score and the greater postoperative total hip ROM would be （P〈0.05）; the bigger diameter of prosthetic femoral head was, the greater postoperative total hip ROM would be （P〈0.05）. All the acetabular components and femoral stems were well fixed at last follow-up. The osteolysis rate around the acetabular cup in the metal-on-polyethylene bearing group （50%, 9/18） was higher than that in the ceramic-on-ceramic bearing group （0, 0/21）. No prosthetic loosening was observed in 2 groups. Seven hips were found to have heterotopic ossification, including 5 hips of Brooker grade I and 2 hips of Brooker grade II. Conclusion THA is an effective method to treat involved hips in patients with AS; especially for patients having shorter duration of the disease, THA shows better effectiveness when the bigger diameter of prosthetic femoral head and ceramic- on-ceramic bearing are used.