高龄骨质疏松陈旧性股骨颈骨折：应根据股骨距-髓腔比率选择股骨假体

doi:10.3969/j.issn.2095-4344.2015.17.002

摘要/Abstract

摘要：

背景：高龄骨质疏松陈旧性股骨颈骨折手术难点多，术中术后并发症较多且远期效果不佳。

目的：探索高龄骨质疏松陈旧性股骨颈骨折病患者髋关节置换的临床疗效。

方法：收集2012年10月至2014年7月收治高龄骨质疏松陈旧性股骨颈骨折患者20例，采用后外侧入路进行人工髋关节置换治疗，其中14例行全髋关节置换初次置换生物型假体，6例行半髋置换使用柱形翻修直柄生物型假体。

结果与结论：置换后获3-24个月随访。高龄骨质疏松陈旧性股骨颈骨折患者髋关节Harris评分与置换前相比明显上升。置换后X射线片显示股骨柄生物充填固定良好，置换后3个月X射线片上均获骨性固定。说明高龄骨质疏松陈旧性股骨颈骨折可采用髋关节置换的外科治疗方法，而根据高龄骨质疏松陈旧性股骨颈骨折患者股骨距-髓腔比率选择股骨假体类型及手术方式，可以使患者更有效地恢复髋关节功能。

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, 陈旧性股骨颈骨折, 骨质疏松, 关节置换, Dorr分型, 假体选择, 关节周围挛缩, 手术技巧, 临床疗效

Abstract:

BACKGROUND: Old femoral neck fractures with senile osteoporosis have more surgical difficulties. There are a lot of intraoperative and postoperative complications and long-term effects are poor.

OBJECTIVE: To explore the clinical outcomes of hip arthroplasty in patients with old femoral neck fractures with senile osteoporosis.

METHODS: From October 2012 to July 2014, 20 patients with old femoral neck fractures and senile osteoporosis were enrolled in this study. Posterolateral approach was used to perform hip arthroplasty. Of them, 14 patients received primary total hip arthroplasty with biological prosthesis, and 6 patients were subjected to semi-hip arthroplasty with straight shank cylindrical renovated biological prosthesis.

RESULTS AND CONCLUSION: The patients were followed up for 3 to 24 months. Harris score was apparently increased after arthroplasty in patients with old femoral neck fractures and senile osteoporosis compared with pre-arthroplasty. Postoperative radiographs revealed that femoral stem biological fixation was good. Bone fixation was visible in radiographs at 3 months after arthroplasty. These findings suggested that old femoral neck fractures and senile osteoporosis could be treated with hip arthroplasty. To select the type of prosthesis and surgical methods according to the femoral calcar-medullary cavity ratio in patients with old femoral neck fractures and senile osteoporosis can effectively restore the function of hip joint.

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: Femoral Neck Fractures, Arthroplasty, Replacement, Hip, Hip Prosthesis, Osteoporosis

中图分类号:

R318

朱旭日，孙光权，刘锌，陈国庆，杜斌. 高龄骨质疏松陈旧性股骨颈骨折：应根据股骨距-髓腔比率选择股骨假体[J]. 中国组织工程研究, 2015, 19(17): 2631-2636.

Zhu Xu-ri, Sun Guang-quan, Liu Xin, Chen Guo-qing, Du Bin. Old femoral neck fractures with senile osteoporosis: choice of femoral prosthesis according to femoral calcar-medullary cavity ratio[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(17): 2631-2636.

图/表（结果） 4

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引言

材料方法

设计：回顾性研究。

时间及地点：试验于2014年10月江苏省中医院骨伤科完成。

对象：收集2012年10月至2014年7月江苏省中医院骨伤科关节组收治高龄骨质疏松陈旧性股骨颈骨折患者。

诊断标准： ①临床症状、体征和病史以腹股沟、臀部和大腿部位为主的关节痛，股骨颈骨折病史至少3个月。②行保守治疗或内固定治疗后复查髋关节X射线片骨折端位置丢失。

纳入标准： ①符合诊断标准。②患者病历资料完整。③骨折前均有一定行走能力。④置换前骨密度检查显示均合并严重的骨质疏松。⑤行髋关节置换治疗。⑥置换后获得随访记录。

排除标准： ①病历资料不完整。②骨折前丧失行走能力。③具有手术禁忌，不能耐受。④骨密度检测无骨质疏松。⑤未能获得随访。

最终收集高龄骨质疏松陈旧性股骨颈骨折患者20例，其中男7例，女13例；年龄75-92岁，平均83.5岁。均为陈旧性骨折，骨折病史8-28个月(平均16个月)，其中5例未行任何外科治疗，15例行空心钉内固定。20例置换前均存在患肢短缩(2.65±0.68 cm)。

材料：柱形翻修直柄生物型假体购自美国Smith& Nephew公司，具有Echelon 钛微孔涂层生物柄。股骨柄假体购自法国Depuy公司，具有Corail 钛合金全羟基磷灰石涂层柄。

方法：

影像学评估：所有病例均拍髋关节正侧位X射线片(DF-211医用高频X射线光机，ORICH公司)。所有20例在X射线片上见均合并股骨颈短缩畸形愈合或消失以及股骨头吸收、萎缩，股骨头旋转中心上移，其中也包括内固定失败后造成的骨折错位。根据髋关节X射线正位片上股骨近段髓腔形态行Dorr分型其中B型12例，C型8例，其中C型病例股骨峡部骨皮质指数(峡部外径除峡部内外侧皮质厚度和)为2.56±0.43(1.27-3.41)^[4]。

置换前准备：入院后全面术前检查，明确基础疾病并请相关科室协助诊治并评价手术耐受性。做好术前风险评估及术前准备，评估髋臼及股骨上段骨质疏松程度及骨储备情况以选择髋关节置换方式及适配的髋关节假体。

髋关节置换：患者麻醉成功后，健侧卧位，取后外侧切口。在髋臼上方髂骨上打一克氏针，并在大转子上做一标记，测量两点距离，确定植入试模后的下肢长度，钝性分离臀大肌纤维后显露转子部，切开外旋肌群，对髋关节囊及周围软组织挛缩进行分层松解，看清楚头臼关系，打开后关节囊，脱出股骨头，采用保留股骨矩1.0-1.5 cm截骨的方法修整股骨颈断面，显露髋臼，切除增生关节囊及盂唇，找到髋臼横韧带，逐步增大髋臼锉磨锉髋臼，植入合适假体。按前倾15°开髓后逐步扩大股骨上段髓腔，插入股骨柄试模并依据正常侧偏心距选择合适长度的股骨头颈，将髋关节复位，观察髋关节松紧程度、各方向活动的关节稳定性以及下肢长度。取出试模并插入适配的生物型股骨柄假体并安装对应长度的人工股骨头，牵引下肢复位髋关节，屈曲内收内旋髋关节确认关节无脱位征象，关闭切口。全髋关节置换中2例因髋臼软骨下骨质疏松明显植入比髋臼锉大两号的假体以增加初期稳定性，并未出现髋臼骨折。

其中6例行半髋关节置换采用柱形翻修直柄生物型假体，14例行全髋关节置换选择初次置换股骨柄假体。股骨柄假体均采用生物型人工髋关节假体进行固定。

术后处理及随访：置换后常规应用抗生素2 d预防感染，仰卧维持髋关节外展位“丁字鞋”固定。置换后24 h拔除负压引流管。置换后第3天即可适应性下地行走。置换后第3，6个月及1年门诊随访，以后每年随访1次。

髋关节功能的评价：髋关节功能评分主要依据人工全髋置换Harris评分评估患肢髋关节功能：优，90-100分；良，80-89分；可，70-79分；差< 69分^[5]。

影像学分析：X射线平片评估置换后即刻的假体柄的生物压配效果以及随访期假体生物学固定效果，后者根据Engh固定/稳定标准评定^[6]：骨性固定：有明显骨长入，假体周围无骨硬化带形成，多孔表面涂层区无X射线透光线，假体无下沉；纤维性稳定：假体周围有≤1 mm连续性X射线透亮线，但呈非进展性，临床上无不稳定症状；假体不稳定：假体-骨界面的X射线透亮线持续性增加，假体进行性下沉> 2 mm，或出现新的内、外翻。

主要观察指标：置换前后髋关节功能的变化。

统计学分析：采用SPSS 16.0统计软件件进行分析。数据以x(_)±s表示，组间比较计量指标采用t 检验，P < 0.05为差异有显著性意义。

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

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讨论

3.1 骨质疏松陈旧性股骨颈骨折病理变化特性老年骨质疏松者发生股骨颈骨折较为常见，多数高龄骨质疏松股骨颈骨折患者因各种原因导致治疗延误或内固定失败可转变为股骨颈陈旧性骨折^[7]，局部病理改变包括：①骨折断端骨吸收、骨丢失严重，股骨颈明显短缩。②骨折远端向上移位致肢体短缩，常伴有髋关节周围软组织的继发性挛缩^[8]。③股骨头缺血坏死、萎缩。④在老年人全身骨质疏松症基础上的肢体废用可进一步加重髋部的骨质疏松^[9]。⑤骨折后血肿肌化可造成髋关节周围软组织瘢痕挛缩^[10-13]。高龄患者陈旧性股骨颈骨折除严重影响患者的生活和生存质量外，对手术要求及术后并发症均高于初次关节置换^[14-16]。

老年骨质疏松股骨颈骨折及骨性关节炎患者保守治疗无效，且对患者生活和生存质量极大影响。带血运骨瓣植骨辅加内固定以及转子下截骨适用于骨量储备良好、延迟愈合及股骨头完整的年轻患者^[7-8^，^16-17]，对高龄骨质疏松髋关节病患者，髋关节置换是最佳的外科治疗方法，其优势在于处理骨折端的同时重建髋关节功能，可有效避免内固定手术带来的诸多并发症，是陈旧性股骨颈骨折外科治疗中有效的补救性方法^[3^，^18-20]。

3.2 不同类型的股骨的假体选择高龄骨质疏松陈旧性股骨颈骨折由于股骨颈畸形愈合、短缩或关节周围骨质吸收骨质疏松，行髋关节置换时为达到较好的初期稳定和远期固定对假体类型的选择和压配方式的选择要求均较高，应依据髋部骨质疏松情况、髓腔形态、患者心肺功能等情况以及术者技术来选择骨水泥型固定假体还是非骨水泥型假体^[21]。

近年来高龄患者使用骨水泥型假体出现较多的争议，在注入骨水泥的过程中心血管风险较大，除了使血压下降，而且会直接抑制心肌，表现为心肌收缩力减弱或传导系统异常，常出现心律失常、严重时偶发心跳骤停，增加术后血栓形成风险^[22-26]。尤其对严重骨质疏松所致的粗大烟囱型股骨髓腔需过量的骨水泥进行灌注，这对高龄患者重则危及生命^[5^，^27-31]。随着生物型髋关节假体在柄型设计、表面涂层处理以及置换手术技术的极大提高，高龄患者选择生物型股骨假体柄在临床上已取得较好的中远期效果^[7^，^32-36]。对陈旧性股骨颈骨折进行髋关节置换时，应依据老年人股骨髓腔形态和股骨距的完整性选择柄型适配的股骨柄假体^[37-40]。对骨折断端过度磨损造成股骨距不完整者，不应选择以股骨距为主要承载结构的带领股骨柄假体，而应选择加长型股骨生物柄以增加股骨上段对假体柄的把持力并维持股骨和假体之间的稳定^[8^，^41-43]。而对重度骨质疏松所致异常粗大的烟囱状(Dorr C型)股骨髓腔，应选择与髓腔形态相匹配的圆柱型锥形柄，其中在临床上应用较为广泛的第三代的圆锥柱状生物翻修柄在假体柄型上与粗大的烟囱状髓腔有极佳的形态匹配，同时尺寸上也能较好地满足宽大髓腔的充填要求，假体柄整体粗糙金刚砂表面处理可提供广泛的假体-骨接触面^[44-48]。选择合适的固定方式，获得理想的填充和压配。

根据患者年龄、髋臼侧骨质疏松程度、患肢肌力、术前下肢行走能力以及术中髋臼软骨情况考量选择全髋置换还是半髋置换^[35^，^49-51]。全髋关节置换的优势在于人工关节有更长的使用时间以及置换后髋部疼痛较轻，而半髋关节置换具有手术时间短、创伤相对较小且置换后不易脱位的优点^[11^，¹⁴^，^52-55]，且目前双极头设计可极大减少金属股骨头对髋臼的磨损。

3.3 骨质疏松陈旧性股骨颈骨折髋关节周围改变和手术处理技巧高龄骨质疏松陈旧性股骨颈骨折，术中发现绝大部分都因为关节周围瘢痕组织增生，关节囊增厚对髋关节活动度有较大的限制，且造成肢体短缩。进行髋关节置换需要注意术中必须充分清理髋臼周围软组织，有效地对髋关节囊及周围软组织挛缩进行分层松解，看清楚头臼关系。患肢屈曲挛缩，关节前方软组织必须进行大量松解，一般需要松解的组织有髂腰肌、股直肌、髂胫束和缝匠肌以及内收肌。对超过4 cm肢体短缩需置换前需行患肢牵引，降低术中置换时关节复位的难度。保留1 cm左右股骨距长度，能够为股骨生物柄假体提供良好的承载力。对股骨疏松严重者，在股骨扩髓前可在股骨上段先行钢丝环扎以减少避免股骨劈裂的可能。选择全髋关节置换时出现髋臼侧严重骨质疏松，为实现臼杯生物压配效果，可将股骨头颈部松质骨修剪成颗粒状进行填塞打压植骨，若未能达到初始稳定性则可以考虑使用更大一号(比臼锉大两号)的髋臼杯植入^[56-61]；陈旧性股骨颈骨折患者下肢长期处于外旋位，有前脱位的倾向，术中髋臼或股骨柄的前倾角可在允许的范围内稍小。对后关节囊进行修补缝合能够有效防止向后脱位。

高龄骨质疏松陈旧性股骨颈骨折进行全髋关节置换，置换前通过充分评估骨折上移错位程度、股骨髓腔形态与皮质骨质量、髋臼形状以及髋部骨质疏松情况来选择适配的生物型髋关节假体，实现术中初始稳定性是手术成功的关键。

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
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