髋关节后脱位合并髋臼后壁骨折长期疗效的决定因素

2012-08-21 第五十七回 丁香园

    髋关节骨折脱位是高能量损伤导致的一种严重创伤,约占所有关节脱位的5%,在治疗上需要尽早予以复位以降低股骨头缺血性坏死、创伤性关节炎等并发症的发生率。当髋关节脱位合并存在髋臼或股骨头骨折时,尽管有研究认为保守治疗也能获得良好的疗效,但关节外科医师还是更倾向于采用手术的方法。人们通常认为影响创伤性髋关节脱位长期疗效的因素主要包括:合并损伤、伤后至复位的时间长短、髋

    髋关节骨折脱位是高能量损伤导致的一种严重创伤,约占所有关节脱位的5%,在治疗上需要尽早予以复位以降低股骨头缺血性坏死、创伤性关节炎等并发症的发生率。当髋关节脱位合并存在髋臼或股骨头骨折时,尽管有研究认为保守治疗也能获得良好的疗效,但关节外科医师还是更倾向于采用手术的方法。人们通常认为影响创伤性髋关节脱位长期疗效的因素主要包括:合并损伤、伤后至复位的时间长短、髋关节脱位的方向、以及患者伤前的身体状况。最近,希腊学者Mitsionis GI等对在他们医院接受治疗的19例创伤性髋关节后脱位合并髋臼后壁骨折病例进行了长达18.5年的回顾性随访研究,结果发现良好的骨折复位内固定是这种损伤术后获得良好的长期疗效的主要因素。
    从1983年到1991年间,Mitsionis GI等共治疗了69例创伤性髋关节脱位合并髋臼后壁骨折的连续病例。为了探讨这类损伤接受手术处理术后长期疗效的影响因素,他们确定本研究病例的纳入标准为:创伤性髋关节后脱位合并髋臼后壁骨折(股骨头需完全与髋臼窝分离)、不伴骨盆骨折或脱位、随访时间至少达15年者。按此标准,共19例病例符合研究的纳入标准。到本研究进行前的最后一次随访时,记录患者的详细病史,进行详细的体格检查及阅片(包括骨盆正、侧位及左右45o斜位,即Judet位X片),以Merle d’Aubigne评分评估患者的临床表现,术前术后患者均行髋关节薄层CT扫描,以Brooker标准判断异位骨化形成情况。首次治疗时首先试行髋关节脱位闭合复位,如复位失败则行切开复位同时行骨折内固定,复位成功者经不同时间后行手术处理髋臼后壁骨折,术后根据X片结果判定骨折复位满意程度:移位小于2mm者为解剖复位、移位2-3mm者为复位欠佳、移位大于等于3mm者为复位差。自1987年始,所有患者术后以吲哚美辛75mg口服一天一次,共15天以预防异位骨化形成;术后尽早以低分子肝素预防DVT,共6周。

表1 本组病例按年龄为标准进行分组的情况

    结果显示:
    1、术后随访时间15-23年,平均18.5年;受伤时患者年龄16-54岁,平均36岁;受损伤患者的主要年龄段为20-40岁;主要致伤原因为交通事故(17/19);14例患者合并有其它部位(主要为下肢,尤以膝关节为主)损伤;
    2、除1例患者外,其它病例的髋关节后脱位均成功进行闭合复位,伤后至复位时间1-18小时,平均5小时;无法闭合复位的病例经急诊切开复位并行骨折内固定予以处理,术中证实股骨头经关节囊呈“钮孔”状卡压从而无法闭合复位;
    3、受伤至手术时间为8小时-25天,平均6.5天,延迟手术(7天以上)的原因主要为存在需要较骨折优先处理的合并损伤;
    4、影像结果显示:术后即刻有15例获解剖复位,3例欠佳,1例不良;最后一次随访时影像学结果(Matta标准)则6例优、11例良、2例可、0例差,优和良的比例达89.47%;术后即刻影像结果判定为解剖复位者,最后一次随访时均为优或良(100%),而复位欠佳者仅66.67%者最后一次随访时影像结果为优或良,术后复位差者最后一次随访时结果判定为可;
    5、以Merle d’Aubigne标准,10例临床评分为优,6例为良,3例可,评分值为9-18分,平均15分;临床评分结果与影像结果一致,总共有84.21%的病例临床结果评定为优或良,而术中骨折获得解剖复位者此比例为87.50%;所有病例患髋活动度良好;
    6、16例患者能正常行走,无患髋疼痛;2例虽然有轻中度跛行,但不伴髋关节疼痛或无需借助拐杖;仅1例患者有轻度髋关节疼痛,但能行走较长距离;除伴髋关节疼痛的病例外,其余18例病例均对治疗结果满意;
    7、术后共6例患者出现并发症,包括:3例臀大肌萎缩,其中2例Trendelenburg征阳性;1例术后20天时发生肺栓塞,需要长期抗凝治疗;1例因螺钉进入关节间隙而再次手术取除;1例出现腓总神经麻痹,经保守治疗4月后完全恢复;6例出现异位骨化,其中1例术后16月时达到III级;1例患者术后3年时因股骨头缺血性坏死而行全髋置换。

表2 以手术时骨折复位情况为标准于最后一次随访时获得的影像学及临床效果

表3 最后一次随访时的影像学及临床效果

表4 髋关节异位骨化情况

图1 24岁男性患者发生左髋关节后脱位合并髋臼后壁骨折,伤后1小时闭合复位成功

图2 复位后伤髋正位X片结果,伤后4天髋臼后壁骨折经切开复位并以2枚拉力螺钉固定

图3 术后18年随访X片显示患髋表现出轻度关节炎改变,但患者髋关节功能良好,活动度正常,无髋关节疼痛

    通过上述研究,Mitsionis GI等认为,决定髋关节后脱位合并髋臼后壁骨折病例接受手术治疗后长期疗效的主要因素是术中后壁骨折块的复位质量,解剖复位可以获得良好的远期疗效。而对于创伤性髋关节后脱位的病例,随访24个月时间即足以确定是否会发生股骨头缺血性坏死。

Mitsionis GI, Lykissas MG, Motsis E, Mitsiou D, Gkiatas I, Xenakis TA, Beris AE. Surgical management of posterior hip dislocations associated with posterior wall acetabular fracture: a study with a minimum follow-up of 15 years. J Orthop Trauma. 2012 Aug;26(8):460-5.

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