头颈比不同人工髋关节臼杯安置角度的安全范围

doi:10.3969/j.issn.2095-4344.2014.35.003

摘要/Abstract

摘要：

背景：由于假体安置角度不当时常导致臼柄撞击而使人工髋关节活动范围受限，不能满足正常的日常生活需要。目前人工全髋关节置换的臼杯安置角度一直存在争议，且对不同头颈比的人工髋关节置换中臼杯安置没有针对性指导。
目的：探讨不同头颈比人工髋关节臼杯安置角度的安全范围。
方法：参照人工髋关节内旋和外旋活动范围计算公式、人工髋关节内收和外展活动范围计算公式、人工髋关节前曲和后伸活动范围计算公式、髋臼外展角和前倾角动态变化的数学表达式，根据Widmer人工髋关节正常活动范围标准得不等式组：①外旋活动范围至少40°，内旋活动范围至少80°。②外展活动范围至少50°，内收活动范围至少50°。③前屈活动至少130°，后伸活动至少40°。解上述3组不等式得出不同头颈比人工髋关节臼杯安置角度安全范围。
结果与结论：不同头颈比的人工髋关节臼杯安置角度的安全范围不同。为满足正常髋关节活动范围人工髋关节头颈比应大于22/12，人工髋关节活动范围随头颈比增大逐渐增大，随头颈比增大臼杯安置外展角和前倾角度安全范围逐渐增大，具体头颈比臼杯外展角安全范围的上下极值随前倾角增大在一定的范围内逐渐增大，且极差亦逐渐增大。外展角安全范围的上极值随前倾角增大逐渐减小，而下极值逐渐增大对称波动于45°上下且逐渐趋向于45°，最大前倾时外展角均为45°。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

关键词: 植入物, 人工假体, 头颈比, 人工髋关节, 外展角, 前倾角, 颈干角

Abstract:

BACKGROUND: Improper angle of prosthesis placement often induces acetabular cup impact, and limits the scope of activity of artificial hip joint, and cannot meet the requirement of daily life. At present, the angle of acetabular cup installation remains controversial during total hip arthroplasty. Moreover, there is lack of targeted guide for the acetabular cup installation during hip arthroplasty with different head-neck ratios.
OBJECTIVE: To explore the safe range of the artificial acetabular cup installation angle for different head-neck ratios.
METHODS: In accordance with the calculation formula of range of internal rotation and external rotation, abduction and adduction, flexion and extension after total hip replacement, interpretation of dynamical variety law of acetabular abduction and anteversion, and deriving inequalities depending on Widmer’s standard of artificial hip joint normal activities range: (1) external rotation range was at least 40°, and internal rotation range was at least 80°. (2) Abduction range was at least 50°, and adduction range was at least 50°. (3) Anteflexion range was at least 130°, and extension range was at least 40°. The safety scope of artificial hip joint installation angle at different head-neck ratios was determined by solving the above three groups of inequality.
RESULTS AND CONCLUSION: The safe range of the artificial acetabular cup installation angle for different head-neck ratios was different. To meet the normal hip joint activities, the head-neck ratios of artificial hip should be greater than 22/12. Artificial hip joint activities gradually increase with the enlargement of head neck ratios. With enlarging the head-neck ratios, the acetabular cup installation safety angle scope of abduction and anteversin gradually increases and the extreme of abduction increases gradually, then with anteversion increasing gradually, the abduction upper extreme of the security scope gradually decrease and lower extreme of the security scope gradually increase, tending to 45° symmetrically. When anteversion is the biggest, the abduction should be 45°.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: arthroplasty, replacement, hip, joint prosthesis, hip prosthesis

中图分类号:

R318

张振华，孙付杰，胡克正，聂文波，汪明星. 头颈比不同人工髋关节臼杯安置角度的安全范围[J]. 中国组织工程研究, 2014, 18(35): 5589-5594.

Zhang Zhen-hua, Sun Fu-jie, Hu Ke-zheng, Nie Wen-bo, Wang Ming-xing. Safe range of artificial acetabular cup installation angle for different head-neck ratios[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(35): 5589-5594.

图/表（结果） 2

参考文献

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引言

材料方法

讨论

随着全髋关节置换技术的日趋成熟以及人们对生活质量的要求提高，全髋关节置换被越来越多的患者所接受．全髋关节置换可以重建髋关节结构，缓解疼痛，改善关节功能。但由于假体安置角度不当时常导致臼柄撞击而使人工髋关节活动范围受限，不能满足正常的日常生活需要，且由于臼柄撞击的发生导致早期假体脱位、磨损加剧、假体松动、持续疼痛和晚期骨溶解等严重并发症。目前人工全髋关节置换臼杯安置角度中臼杯前倾角的安全范围为5°-25°^[10-15]，臼杯外展角的安全范围为35°-55°^[12-16]，但一直存在争议^[7^，^9-15]，且对不同头颈比的人工髋关节置换中臼杯安置没有针对性指导。

3.1 人工髋关节活动范围的要求正常个体之间存在着年龄和体质的不同，髋关节的平均活动范围有较大的差异，越来越多的研究表明，人工髋关节活动范围受众多因素的影响，单纯从假体设计和安置角度考虑，人工髋关节活动范围应该比正常髋关节的活动范围更大些，才能满足全髋关节置换后日常活动的需要^[22-26]。D’Lima等^[12]提出现代认为可以接受的一般标准为：前屈>110°，前屈90°位内旋>30°，外旋>40°，后伸>30°; 严格标准为：前屈>120°，90°位内旋>45°，外旋、后伸度同一般标准。Widmer等^[6]认为，为了满足日常生活需要，人工髋关节活动范围应达到下列要求：前屈至少130°，后伸至少40°，内收外展至少各50°，外旋至少40°，内旋至少要80°。

3.2 头颈比对人工髋关节的活动范围的影响 D’Lima等^[12]应用计算机模拟技术测试了不同头颈比对人工髋关节的活动范围的影响，结果头颈比越大，人工髋关节的活动范围也越大。Yoshimine^[27-28]应用数学公式证明了头颈比与人工髋关节的活动范围的直接关系，提出了摆动角(oscillation，Osa.) 的概念，摆动角是髋假体最大的活动范围通过假体头中心的夹角，其值大小依赖于臼杯开口平面设计和头颈比。头颈比越大，摆动角就越大，理论上人工髋关节的活动范围也就越大，在进行假体安置时，要达到术前预定的活动范围所允许的臼杯外展角和前倾角的安全范围就越大。Kluess等^[29]通过三维有限元分析发现增大头颈比可减小由臼柄撞击引起的脱位的危险。本文结果亦表明：头颈比越大，人工髋关节的活动范围也就越大，在进行臼杯安置时，要达到术前预定的活动范围所允许的臼杯外展角和前倾角的安全范围就越大。

3.3 假体安置方位对关节活动范围的影响假体安置方位包括臼杯安置方位和假体柄的安置方位。臼杯安置方位又包括臼杯外展角和臼杯前倾角，Nadzadi等^[30]应用有限元方法分析了直径为22 mm假体头配臼杯5个不同前倾角度和5个不同外展角度的共25种不同组合下人工髋关节的活动范围、关节面应力和脱位倾向的影响，结果关节活动范围对外展角的改变更敏感，关节面应力和脱位倾向对前倾角的改变更敏感。假体柄的安置方位主要是头颈的前倾角或扭转角，在临床操作中常常与个体股骨颈的前倾角或扭转角一致，D’Lima等^[12]应用计算机模拟技术测试的结果表明，其值越大，术后患髋屈曲和内旋活动度越大，但后伸和外旋活动度减小、撞击机会增大。因此，过大的假体柄前倾角易导致假体前脱位。费俊梁等^[31]随访全髋置换后患者352例发现全髋置换的疗效与髋臼前倾角、外展角、股骨头旋转中心及偏心距密切相关，前倾角在15°-25°、外展角45°-56°及合适的股骨头旋转中心位置和偏心距者术后疗效满意。罗志平等^[32]应用计算机模拟技术建立人工全髋关节三维计算机模型，模拟测试3种不同头颈直径比全髋假体在体外不同安置方位的活动范围发现人工全髋关节相对较大的头颈直径比在合适的安置方位内产生最佳的活动范围，可减少全髋关节置换后假体撞击机会。Barrack^[7]应用计算机模型研究发现髋臼杯最佳外展角度45°-55°，当臼杯外展角小于55°时应有股骨柄和臼杯各有10°-20°前倾角以减小撞击和脱位的危险。本文结果表明，随头颈比增大臼杯安置外展角和前倾角度安全范围逐渐增大，具体头颈比臼杯外展角安全范围的上下极值随前倾角增大在一定的范围内逐渐增大，且极差亦逐渐增大。然后随前倾角逐渐增大外展角安全范围的上极值随前倾角增大逐渐减小，而下极值逐渐增大对称波动于45°上下且逐渐趋向于45°，最大前倾时外展角均为45°。

综上所述，为满足正常髋关节活动范围人工髋关节头颈比应大于22/12，人工髋关节活动范围随头颈比增大逐渐增大，随头颈比增大臼杯安置外展角和前倾角度安全范围逐渐增大，具体头颈比臼杯外展角安全范围的上下极值随前倾角增大在一定的范围内逐渐增大，且极差亦逐渐增大。外展角安全范围的上极值随前倾角增大逐渐减小，而下极值逐渐增大对称波动于45°上下且逐渐趋向于45°，最大前倾时外展角均为45°。本文不足之处在于仅基于半球形设计假体的安置角度考虑且没有将其他因素如软组织或骨撞击、术前的关节活动度、术前骨盆或脊柱的畸形等考虑在内，但仍为临床不同头颈比人工髋关节假体置换臼杯安置方位安全范围提供了针对性的参考，以利于手术建立良好的臼杯外展角和前倾角匹配关系，获得满意的活动范围，避免由于臼柄撞击导致早期假体脱位，磨损加剧，假体松动，持续疼痛和晚期骨溶解等严重并发症，提高人工髋关节的使用寿命。同时亦适用于术后疗效分析、指导康复期关节功能锻炼减少意外的发生。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程
全文链接：