發(fā)育不良性髖關(guān)節(jié)脫位診斷、分型和手術(shù)

楊述華 劉先哲

（華中科技大學(xué)同濟(jì)醫(yī)學(xué)院附屬協(xié)和醫(yī)院骨科，武漢 430022）

髖關(guān)節(jié)發(fā)育不良（developmental dysplasia of the hip,DDH）是年輕患者髖關(guān)節(jié)骨性關(guān)節(jié)炎的一個(gè)主要病因。在這些患者發(fā)展到終末期骨性關(guān)節(jié)炎之前，有幾種非關(guān)節(jié)置換的手術(shù)方式可以考慮，包括股骨近端和髖臼周圍截骨術(shù)。但是在DDH發(fā)展至終末期骨性關(guān)節(jié)炎，引起嚴(yán)重的疼痛和功能受限時(shí)，全髖關(guān)節(jié)置換術(shù)則是標(biāo)準(zhǔn)的治療方式。與正常髖關(guān)節(jié)相比，發(fā)育不良的髖關(guān)節(jié)異常的接觸應(yīng)力容易誘發(fā)髖關(guān)節(jié)骨性關(guān)節(jié)炎。對(duì)于DDH患者行全髖關(guān)節(jié)置換術(shù)（THA）時(shí)需要考慮許多因素，包括患者的年齡，畸形的解剖結(jié)構(gòu)，以及文獻(xiàn)報(bào)道的高失敗率和翻修率等。1

解剖特征

盡管每個(gè)DDH患者都有獨(dú)特的解剖結(jié)構(gòu)，但對(duì)于髖臼和股骨近端的解剖特征都有很好的描述。髖臼常見前側(cè)和上方的缺損，而股骨近端常見前傾角增大，髓腔變細(xì)，直線輪廓，髖內(nèi)翻或外翻。近來CT研究證明發(fā)育不良的股骨均表現(xiàn)為前傾角增大，股骨頸變短，髓腔變細(xì)，并且發(fā)育不良的程度越嚴(yán)重，股骨前傾角越大。減小的髓腔直徑和更細(xì)的皮質(zhì)厚度也使得發(fā)育異常的髖關(guān)節(jié)易于骨折。因此，在為DDH患者實(shí)施THA之前要特別注意每位患者的解剖特點(diǎn)。

對(duì)于DDH患者，軟組織的因素也要考慮。嚴(yán)重的DDH患者常常合并外展肌群的肌力減退，導(dǎo)致跛行甚至trendelenburg步態(tài)。由于慢性關(guān)節(jié)脫位，髖關(guān)節(jié)內(nèi)收肌群、屈肌群和伸肌群的肌肉萎縮。如果肢體延長(zhǎng)大于3 cm，坐骨神經(jīng)也很容易損傷。據(jù)文獻(xiàn)報(bào)道，THA治療髖關(guān)節(jié)發(fā)育不良時(shí)坐骨神經(jīng)麻痹的發(fā)生率5.2%～13%。

2外展肌的平衡降低，降低步態(tài)效率，導(dǎo)致跛行。由于異常的生物力學(xué)包括髖臼緣負(fù)荷過重，常常繼發(fā)骨性關(guān)節(jié)炎，最終導(dǎo)致疼痛和功能受限。放射學(xué)檢查可以確認(rèn)診斷，明確髖臼和股骨近端解剖異常的特點(diǎn)。

DDH患者的放射學(xué)檢查對(duì)于手術(shù)方案的確定非常重要。標(biāo)準(zhǔn)的放射學(xué)檢查包括骨盆的正位片和髖關(guān)節(jié)的側(cè)位片，這可以在正側(cè)位上反映髖臼對(duì)股骨頭包容性情況。中心邊緣角，即在骨盆正位片上，通過股骨頭的中心垂直線和通過股骨頭中心和髖臼側(cè)緣連線之間的角度，通常＞25°。垂直中心前角，即在髖關(guān)節(jié)側(cè)位片上，通過股骨頭的中心垂直線和通過股骨頭中心和髖臼前緣連線之間的角度，通常＞25°。通過骨盆正位片也可以評(píng)估股骨近端的頸干角。CT有助于評(píng)估髖臼的骨量情況和前傾角。

DDH的分型有助于手術(shù)方案的制定。其中，最常用的分型標(biāo)準(zhǔn)是Crowe等根據(jù)股骨頭從髖臼脫位的嚴(yán)重程度分型。Ⅰ型：股骨頭半脫位，脫位率＜50%（圖1）；Ⅱ型：股骨頭半脫位，脫位率50%～75%（圖2）；Ⅲ型：股骨頭半脫位，脫位率75%～100%（圖3）；Ⅳ型：股骨頭全脫位，脫位率＞100%（圖4）。這種分型標(biāo)準(zhǔn)可以用于指導(dǎo)THA術(shù)中髖臼重建。

Hartofilakidis分型將DDH分為三類：股骨頭在真臼中；股骨頭低脫位，在假臼中，假臼與真臼部分

2 DDDDHH的診斷和分型

DDH常見于年輕患者，起病隱襲，表現(xiàn)為腹股溝區(qū)的疼痛或髖關(guān)節(jié)痛。許多患者有下肢不等長(zhǎng)，而跛行是最常見的功能障礙。髖關(guān)節(jié)高脫位的患者髖關(guān)聯(lián)；股骨頭高脫位，股骨頭不在真臼及假臼中。許多外科醫(yī)生認(rèn)為這種分型更有助于指導(dǎo)手術(shù)。

圖1 Ⅰ型：股骨頭半脫位，脫位率＜50%，股骨頭仍在真臼中

圖2 Ⅱ型：股骨頭半脫位，脫位率50%～75%

圖3 Ⅲ型：股骨頭半脫位，脫位率75%～100%

圖4 Ⅳ型：股骨頭全脫位，脫位率＞100%

3 不同方法全髖置換手術(shù)要點(diǎn)

標(biāo)準(zhǔn)的手術(shù)入路包括髖關(guān)節(jié)前側(cè)入路、前外側(cè)入路以及后側(cè)入路。對(duì)于嚴(yán)重的髖關(guān)節(jié)發(fā)育不良，伴股骨頭半脫位的患者，后側(cè)入路更有利于股骨頭和髖臼的充分暴露。此外，對(duì)于嚴(yán)重的髖關(guān)節(jié)發(fā)育不良，往往需要轉(zhuǎn)子下短縮截骨術(shù)，以擴(kuò)展股骨近端，充分暴露髖關(guān)節(jié)后側(cè)。

3.1 髖臼重建

CroweⅠ型的髖關(guān)節(jié)，髖臼假體通常直接放置于真臼中。其臼杯可以與髖臼有充分的骨接觸。Garvin等[13]指出髖臼外上方大約20%的不接觸不會(huì)增加手術(shù)失敗的風(fēng)險(xiǎn)。對(duì)于CroweⅠ型的髖關(guān)節(jié)，骨水泥型和壓配型的臼杯假體都可以考慮，骨水泥型似乎有更高的機(jī)械失敗率。

CroweⅡ型和Ⅲ型髖臼外上方的骨缺損造成了臼杯的不充分骨接觸，影響臼杯假體的安放。這些是髖關(guān)節(jié)重建中最常見的問題。特殊的假體，小髖臼杯可以解決髖臼假體骨接觸不足的問題。髖臼缺損可以通過下面的幾種方法改善：①通過骨塊在髖關(guān)節(jié)的解剖中心重建髖臼（圖5）；②在假臼外側(cè)重建髖臼（圖6）；③結(jié)構(gòu)性骨移植重建髖臼加網(wǎng)杯重建髖臼（圖7）。通過骨塊重建髖臼，臼杯有更多的解剖位置，在未來翻修手術(shù)中髖關(guān)節(jié)也有更多的骨量。

使用大塊的股骨頭自體移植是一種有效的方法，髖臼骨缺損的部位提供了一個(gè)良好的有血供的植骨床，而且股骨頭的松質(zhì)骨部分可以很好的塑形以匹配髖臼缺損，并由兩枚或更多的螺釘固定在髂骨上。為了預(yù)防移植物的機(jī)械失敗，Mulroy和Harris指出，宿主骨對(duì)髖臼杯的骨接觸應(yīng)大于70%。

CroweⅣ型髖關(guān)節(jié)，同樣是髖臼發(fā)育不良，但是其髖臼上方的缺損并不比CroweⅡ～Ⅲ型髖關(guān)節(jié)更嚴(yán)重。因此，可以選擇在髖關(guān)節(jié)解剖中心放置一個(gè)較小的非骨水泥型臼杯。通常并不需要骨塊移植。

圖5 自體股骨頭髖關(guān)節(jié)解剖中心重建髖臼

圖6 在假臼外側(cè)重建髖臼

圖7 結(jié)構(gòu)性骨移植重建髖臼加網(wǎng)杯重建髖臼

3.2 股骨重建

CroweⅠ～Ⅱ型髖關(guān)節(jié)，不需要股骨短縮截骨來將股骨端放置于髖關(guān)節(jié)解剖中心的安全位置。由于髓腔較窄以及股骨前傾角，可以使用DDH特殊的細(xì)柄，包括骨水泥型及非骨水泥型假體柄。細(xì)柄骨水泥型假體柄可以控制前傾角；如果選用非骨水泥型的壓配型假體，術(shù)者必須注意避免前傾角過大，因?yàn)楣晒潜旧泶嬖谝欢ǖ那皟A角。

全髖關(guān)節(jié)置換術(shù)可以成功地治療伴有關(guān)節(jié)疼痛和活動(dòng)障礙的成人先天性髖關(guān)節(jié)高脫位患者。CroweⅢ型髖關(guān)節(jié)，股骨重建的原則與CroweⅠ～Ⅱ型髖關(guān)節(jié)相同。然而，這個(gè)技術(shù)要求高，且并發(fā)癥發(fā)生率高。高脫位的股骨頭必須被復(fù)位至真臼，髖關(guān)節(jié)的作用力降低，改善外展力臂，延長(zhǎng)髖臼假體的使用壽命。當(dāng)髖臼杯置入假臼中,由于外展肌群松弛Trendelenburg步態(tài)和肢體不等長(zhǎng)不能得到糾正。當(dāng)髖臼杯置入真髖臼，由于肌肉緊張和神經(jīng)損傷的風(fēng)險(xiǎn),髖關(guān)節(jié)復(fù)位幾乎不可能。為克服這些困難，兩種技術(shù)應(yīng)運(yùn)而生：①髂股牽引逐步延長(zhǎng)肢體（圖8），②股骨短縮截骨術(shù)（圖9）。由于前者僅應(yīng)用于少數(shù)或單側(cè)病例,股骨短縮截骨術(shù)便成為治療成人先天性髖關(guān)節(jié)高脫位的標(biāo)準(zhǔn)方法。

在某些情況下，如果重建髖關(guān)節(jié)解剖中心，也可能需要股骨短縮截骨。股骨短縮截骨在CroweⅣ型髖關(guān)節(jié)中的應(yīng)用更為常見。

Anwar等報(bào)道通過股骨近端短縮截骨29%的患者骨不連，Trendelenburg步態(tài)的頻率增加。因此，近來更推薦選擇轉(zhuǎn)子下截骨術(shù)，能夠維持外展肌群的穩(wěn)定并糾正旋轉(zhuǎn)畸形。

短中期的隨訪研究表明，對(duì)于CroweⅣ型髖關(guān)節(jié)發(fā)育不良患者，通過轉(zhuǎn)子下股骨短縮截骨術(shù)，并使用非骨水泥型股骨假體柄，髖關(guān)節(jié)解剖中心重建，術(shù)后骨愈合率較好。總的研究結(jié)果表明隨訪14年，生存率為75%，通過轉(zhuǎn)子下截骨并股骨假體重建后，Harris髖關(guān)節(jié)評(píng)分較術(shù)前改善。而使用新一代的高交聯(lián)聚乙烯內(nèi)襯長(zhǎng)期的隨訪結(jié)果尚待研究。

圖8 髂股牽引逐步延長(zhǎng)肢體

圖9 轉(zhuǎn)子下截骨及固定和股骨近端短縮截骨X線片

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