微创全髋关节置换后的影像学评估

doi:10.3969/j.issn.2095-4344.2337

中国组织工程研究 ›› 2020, Vol. 24 ›› Issue (33): 5379-5384.doi: 10.3969/j.issn.2095-4344.2337

• 骨与关节综述 bone and joint review • 上一篇下一篇

微创全髋关节置换后的影像学评估

张聿达1，王昌耀2，王向宇1

¹青岛大学医学部，山东省青岛市 266071；²青岛大学附属医院，山东省青岛市 266071

收稿日期:2020-02-12 修回日期:2020-02-22 接受日期:2020-04-03 出版日期:2020-11-28 发布日期:2020-10-13
通讯作者: 王昌耀，博士，副主任医师，青岛大学附属医院，山东省青岛市 266071
作者简介:张聿达，男，1996年生，山东省高青县人，汉族，青岛大学医学部在读硕士，主要从事关节方向的研究。
基金资助:
国家自然科学基金项目(81772329)

Imaging evaluation after minimally invasive total hip arthroplasty

Zhang Yuda1, Wang Changyao2, Wang Xiangyu1

¹Medical College of Qingdao University, Qingdao 266071, Shandong Province, China; ²Affiliated Hospital of Qingdao University, Qingdao 266071, Shandong Province, China

Received:2020-02-12 Revised:2020-02-22 Accepted:2020-04-03 Online:2020-11-28 Published:2020-10-13
Contact: Wang Changyao, MD, Associate chief physician, Affiliated Hospital of Qingdao University, Qingdao 266071, Shandong Province, China
About author:Zhang Yuda, Master candidate, Medical College of Qingdao University, Qingdao 266071, Shandong Province, China
Supported by:
the National Natural Science Foundation of China, No. 81772329

摘要/Abstract

摘要：

文题释义：

微创全髋关节置换：具有独特和创新性的切口与深层剥离手段，强调从肌间隙进入，不切断臀中肌外旋肌等肌群，并保留髋关节囊。其具有手术切口小、出血量少、患者住院周期短、恢复快等优点。

影像学评估：借助介质(射线、电磁场、超声波等)把人体内部组织器官结构、密度以影像方式来为医生提供诊断、治疗依据；并可借助影像学手段对术后并发症进行及时、准确的诊断并做出相应处理。

背景：微创全髋关节置换后难免发生并发症，目前临床常用术后评估的影像学手段多种多样，各有利弊。

目的：介绍X射线片、CT、MRI等影像学检查在微创全髋关节置换后疗效评估方面的应用价值及研究进展。

方法：由第一作者检索 PubMed 数据库、中国知网、万方数据库中2000至2020年出版的文献，英文检索词为“surgical injury，MRI，minimally invasive，muscle trauma”；中文检索词为“微创全髋关节置换术，影像，评估，肌肉损伤”，对微创全髋关节置换过程中不同入路的特点及其对髋周肌群影响的影像检查结果进行总结分析。

结果与结论：①X射线片是全髋关节置换后患者复查的首选检查；②骨单光子发射CT不易受到金属伪影的影响，在关节置换患者中显示出更高的敏感性和特异性；③MRI成为评估髋周肌群，特别是肌肉形态学改变的金标准；④血清炎性细胞因子水平作为肌肉损伤的标志物，是评估微创全髋关节置换的一种特异而客观的方法；⑤提示微创全髋关节置换极大地避免了肌肉和肌腱的切开或剥离，减少了术后髋关节脱位及脂肪液化坏死等风险；老年患者因其肌肉修复再生能力减弱，在进行全髋关节置换过程中使用微创术式有着独特的临床价值；影像学检查能够客观准确地评估微创手术的患者获益。

ORCID: 0000-0002-1746-7526(张聿达)

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

关键词: 关节, 假体, 微创, 全髋关节置换, 影像, MRI, 肌肉, 因子, 综述

Abstract:

BACKGROUND: Complications are unavoidable after minimally invasive total hip arthroplasty. At present, the imaging methods commonly used in clinical postoperative evaluation are diverse, and each has advantages and disadvantages.

OBJECTIVE: To introduce the application value and research progress of X-ray, CT, MRI and other imaging examination in the evaluation of curative effect after minimally invasive total hip arthroplasty.

METHODS: The first author retrieved the literature published in the PubMed, CNKI, and Wanfang database from 2000 to 2020. The key words were “surgical injury, MRI, minimally invasive, muscle trauma” in English, and “minimally invasive total hip arthroplasty, imaging, evaluation, muscle injury” in Chinese. The characteristics of different approaches of minimally invasive total hip arthroplasty and the imaging examination results of their effects on hip muscles were summarized and analyzed.

RESULTS AND CONCLUSION: (1) X-ray is the first choice for reexamination of patients after total hip arthroplasty. (2) Single photon emission CT of bone is not easy to be affected by metal artifacts, and shows higher sensitivity and specificity in patients with joint replacement. (3) MRI is the gold standard for the evaluation of peripheral muscle groups, especially muscle morphological changes. (4) The level of serum inflammatory cytokines, as a marker of muscle injury, is a specific and objective method for evaluating minimally invasive total hip arthroplasty. (5) Minimally invasive total hip arthroplasty can greatly avoid the incision or separation of muscles and tendons and reduce the risk of hip dislocation and fat liquefaction and necrosis after operation. Because of the weakening of muscle repair and regeneration ability in elderly patients, minimal invasion in total hip arthroplasty has a unique clinical position. Imaging examination plays an important role in the evaluation of minimally invasive surgery.

Key words: joint, prosthesis, minimally invasive, total hip arthroplasty, imaging, MRI, muscle, factor, review

中图分类号:

张聿达, 王昌耀, 王向宇.

微创全髋关节置换后的影像学评估 [J]. 中国组织工程研究, 2020, 24(33): 5379-5384.

Zhang Yuda, Wang Changyao, Wang Xiangyu. Imaging evaluation after minimally invasive total hip arthroplasty[J]. Chinese Journal of Tissue Engineering Research, 2020, 24(33): 5379-5384.

图/表（结果） 3

1.4 质量评估  通过上述计算机检索与手工检索，共检索到360篇参考文献。按入选标准进行人工筛选，排除与主题相关性差及重复、陈旧的文献，最终纳入41篇文献，见图1。纳入研究的文献包括研究原著、综述、临床试验、述论等。

2.1.3  MRI  在暴露股骨颈及髋臼时，不可避免的要分离或切开髋周肌群，造成肌肉损伤。MRI是评估微创全髋关节置换术中肌肉损伤的重要影像学检查手段^[10]。MRI结合了优越的组织对比度和检测骨髓水肿的能力，为软组织和骨性病理提供了准确和灵敏的评估，它可以确定全髋关节术后患者疼痛的肌肉原因，直观、准确地显示手术相关创伤的效果^[11]。MüLLER等^[12]针对接受直接外侧或微创全髋关节置换患者，在其术后3-12个月使用MRI评估了臀中肌的脂肪变性，结论显示使用微创方法可明显减少肌肉创伤，在老年人和超重患者中尤为明显。除软组织显像以外，MRI对人工假体周围骨组织显像也有独特价值，假体周围骨折MRI的诊断特点是急性期皮质、松质骨呈线性低信号改变，伴有周围骨髓水肿，而骨应力反应显示局限性水肿，其特征是髓腔、皮质、骨膜和邻近软组织高信号^[13]。骨溶解患者的MR成像显示局灶性骨吸收区域，最常见的是等信号且边缘清晰的硬化灶。非特异性滑膜炎是指MRI显示单纯性关节液呈均匀的液体信号强度，滑膜厚度和信号强度正常或轻度增加的情况^[14]，这一直接的影像学证据在评估手术入路和置入技术的优劣性方面有很大的好处。肌腱缺损和脂肪萎缩是与臀中肌、臀小肌、外展肌、外旋肌群等肌肉功能直接相关的结构变化，而MRI能够将活体形态学与个体功能结果关联起来^[15]。因此MRI已经成为评价肌肉，特别是肌肉形态学改变的金标准^[4]。此文筛选并总结3篇文献共197例患者，从全髋关节置换术后发生骨溶解、无菌性松动、假体周围感染3方面分析与评价X射线片、CT、MRI三者的诊断阳性率。经分析数据发现，X射线片诊断骨溶解、无菌性松动、感染的阳性率分别为78.4%，83.7%，35.0%；CT诊断阳性率为88.2%，88.3%，40.0%；MRI诊断阳性率为84.3%，95.3%，98.3%。因此在诊断感染方面，MRI阳性率明显大于X射线和CT，见图2，3。但在诊断无菌性松动和骨溶解方面，3种检查无明显差异^[16]。这一现象与临床相符，也普遍被临床医师所接受。

2.1.3  MRI  在暴露股骨颈及髋臼时，不可避免的要分离或切开髋周肌群，造成肌肉损伤。MRI是评估微创全髋关节置换术中肌肉损伤的重要影像学检查手段^[10]。MRI结合了优越的组织对比度和检测骨髓水肿的能力，为软组织和骨性病理提供了准确和灵敏的评估，它可以确定全髋关节术后患者疼痛的肌肉原因，直观、准确地显示手术相关创伤的效果^[11]。MüLLER等^[12]针对接受直接外侧或微创全髋关节置换患者，在其术后3-12个月使用MRI评估了臀中肌的脂肪变性，结论显示使用微创方法可明显减少肌肉创伤，在老年人和超重患者中尤为明显。除软组织显像以外，MRI对人工假体周围骨组织显像也有独特价值，假体周围骨折MRI的诊断特点是急性期皮质、松质骨呈线性低信号改变，伴有周围骨髓水肿，而骨应力反应显示局限性水肿，其特征是髓腔、皮质、骨膜和邻近软组织高信号^[13]。骨溶解患者的MR成像显示局灶性骨吸收区域，最常见的是等信号且边缘清晰的硬化灶。非特异性滑膜炎是指MRI显示单纯性关节液呈均匀的液体信号强度，滑膜厚度和信号强度正常或轻度增加的情况^[14]，这一直接的影像学证据在评估手术入路和置入技术的优劣性方面有很大的好处。肌腱缺损和脂肪萎缩是与臀中肌、臀小肌、外展肌、外旋肌群等肌肉功能直接相关的结构变化，而MRI能够将活体形态学与个体功能结果关联起来^[15]。因此MRI已经成为评价肌肉，特别是肌肉形态学改变的金标准^[4]。此文筛选并总结3篇文献共197例患者，从全髋关节置换术后发生骨溶解、无菌性松动、假体周围感染3方面分析与评价X射线片、CT、MRI三者的诊断阳性率。经分析数据发现，X射线片诊断骨溶解、无菌性松动、感染的阳性率分别为78.4%，83.7%，35.0%；CT诊断阳性率为88.2%，88.3%，40.0%；MRI诊断阳性率为84.3%，95.3%，98.3%。因此在诊断感染方面，MRI阳性率明显大于X射线和CT，见图2，3。但在诊断无菌性松动和骨溶解方面，3种检查无明显差异^[16]。这一现象与临床相符，也普遍被临床医师所接受。

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微创全髋关节置换后的影像学评估

Imaging evaluation after minimally invasive total hip arthroplasty

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