全髋关节置换术后股骨骨不连伴假体远端断裂1例

2019-06-13 窦一鸣 杨育辉 文兴贵 中国矫形外科杂志

患者,女,51岁。2018年1月以“左髋置换术后14个月,左大腿疼痛3个月”为主诉入本院。双髋正位X线片提示,左侧股骨截骨处未愈合、假体远端断裂。患者因双侧DDH(左侧CroweⅣ型)于2016年11月行左全髋关节置换、髋臼植骨重建、股骨转子下截骨术治疗,髋关节复位时大粗隆外缘劈裂,骨折复位后克氏针张力带固定。2017年3月行右髋关节置换、髋臼植骨重建、股骨转子下截骨术。两次手术均采用组配假体。术

临床资料

患者,女,51岁。2018年1月以“左髋置换术后14个月,左大腿疼痛3个月”为主诉入本院。双髋正位X线片提示,左侧股骨截骨处未愈合、假体远端断裂。患者因双侧DDH(左侧CroweⅣ型)于2016年11月行左全髋关节置换、髋臼植骨重建、股骨转子下截骨术治疗,髋关节复位时大粗隆外缘劈裂,骨折复位后克氏针张力带固定。2017年3月行右髋关节置换、髋臼植骨重建、股骨转子下截骨术。两次手术均采用组配假体。术后恢复良好,活动无明显异常。2017年10月活动后出现左侧大腿疼痛、活动受限,至入本院前症状持续加重,入院时仅能室内拄拐行走。入院查体:双下肢基本等长;左髋部压痛(-),左股骨近端压痛(-)、纵向叩击痛(-);左髋关节活动度:90°(屈)-(伸)0°,20°(内旋)-(外旋)30°,20°(内收)-(外展)45°。

左膝关节活动度:80°(屈)-(伸)0°。完善术前检查后,行手术治疗。手术方法:行后外侧入路,显露髋臼,髋臼假体位置可,探查证实固定牢靠。显露股骨近端,见6道钢丝固定于股骨近端,股骨大粗隆处骨折未愈合,骨皮质较薄弱,于股骨近折端,使用撑开器打开股骨近折端假体与袖套间隙,打拔器将股骨近端假体取出,可见股骨假体折断。探查见袖套骨长入确实,薄骨刀分离袖套与股骨近端骨皮质,将袖套取出,可见袖套表面大量骨长入,向远端显露,见股骨近端截骨断端未愈合,咬骨钳清除断端增生的纤维肉芽组织及增生的硬化骨。

根据术前X线片,在股骨远端距假体尾端约5CM处,电钻钻孔,气动摆锯于股骨正前方开槽,大小约0.4CM×3CM,显露假体尾端,用圆形骨凿将远折端假体向近端敲出,取出2块远折端假体。复位骨折断端,扩髓并安装200mm长全涂层非骨水泥翻修柄,假体远端超过开窗位置。在股骨近端前外侧及后外侧分别放置1枚骨板,使其紧密贴附骨质,骨缺损处植入同种异体骨叩打确实,同种异体骨板以3枚捆绑带固定。安装股骨头,髋关节复位后张力适中,髋关节稳定。闭合切口。术后1、3个月X线片示假体位置佳。

讨论

转子下截骨是实现CroweⅣ型DDH患者安全地解剖复位的重要手段。其疗效得到广泛认可。尽管术后可能有截骨处骨不连的风险,但发生率一般很低,wang等人曾对49例(56髋)进行了THA合并转子下截骨的CroweⅢ、Ⅳ型患者进行了随访,结果仅有2例发生骨不连。T?zünR等对49例(66髋)THA合并转子下截骨的CroweⅣ型患者进行了随访,结果仅有3例发生骨不连。卢巍等对5个DDH行全髋置换伴或不伴转子下截骨的研究(260例患者)Meta分析,结果显示截骨组与未截骨组Harris评分差异无统计学意义,截骨组术后并发症发生率低于未截骨组,差异有统计学意义,说明此类患者转子下截骨是有效的。但该患者初次置换中大粗隆骨折,股骨近端骨膜广泛剥离,血供遭到严重破坏,同时行转子下截骨后并未将截下来的股骨劈开固定于截骨处进行植骨。这些是导致骨不连的重要原因,反观对侧,尽管对侧转子下截骨后未进行自体植骨,但是因股骨近端血运保持良好,截骨处顺利愈合。初次置换选用仿S-ROM假体,其原理为提供近端固定,当截骨骨不连后,假体长期受到股骨不稳所带来的应力刺激进而疲劳断裂。由此可见,假体固定的稳定与否直接决定了其使用年限。



本次翻修假体断端的取出难度较大,而假体近端固定确实,近端假体的取出也十分困难。本手术于股骨精准开窗,顺利取出假体断端,同时采用加长翻修柄进行翻修,应用同种异体骨板对截骨端进行环扎固定。给予固定的同时,提供了大量骨量,显著提高了骨不愈合的治疗效果。术后患者髋关节功能恢复良好,术前Harris评分26分,术后1个月65分、3个月74分。患者影像资料见图1。

原始出处:

窦一鸣,杨育辉,文兴贵,左建林.全髋关节置换术后股骨骨不连伴假体远端断裂1例报告[J].中国矫形外科杂志,2019,27(08):763-765.

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