预防人工全髋关节置换早期后脱位：修复后关节囊及外旋肌群的意义

背景：初次全髋关节置换后脱位是仅次于假体松动的主要并发症之一。关于后外侧入路全髋关节置换时关节囊和外旋肌群是否需要修复,学术界存在争议。 目的：探讨采用髋关节后外侧入路进行初次人工全髋关节置换时修复后关节囊及外旋肌群对预防髋关节后脱位的临床意义。 方法：回顾性分析接受后外侧入路初次全髋关节置换的髋部原发性或继发性骨关节炎患者的临床资料,根据置换过程中不同的软组织修复策略分为2组,对照组不进行后方软组织修复,联合修复组进行关节囊及短外旋肌群的修复。所有患者置换后均已随访超过1年,定义置换后1年内发生的关节脱位为早期脱位。比较不同修复方法对早期脱位率的影响。 结果与结论：共有362例患者,计390例次初次全髋关节置换纳入研究,共发生早期脱位7例,其中对照组6例次（2.2%,6/268）,而修复组1例次（0.8%,1/122）,比较发现修复组和对照组患者的早期脱位率差异有显著性意义,对照组患者髋关节早期脱位率显著高于修复组（P=0.012）。提示对于后外侧入路的初次全髋关节置换,联合修复后方关节囊和短外旋肌群可降低置换后早期脱位率。     

自制外展枕在人工髋关节置换术后的临床应用

我院人工髋关节置换术大都采用后方路入的方法,髋关节后方稳定结构破坏,所采用的人工髋关节假体股骨头直径明显小于正常股骨头。为了防止股骨头脱出,要求患肢保持外展中立位。临床上传统的方法,是用下肢皮牵引和枕头固定防止患肢内收或外旋,但保持患肢外展位缺乏有效和舒适的方法。我科在借鉴国外先进经验的基础上,自行设计和制作了髋关节置换术后专用外展枕。自2003年起,应用于临床462例患者,无一例发生脱位,取得满意效果。现介绍如下。     

小切口保留后方关节囊人工全髋关节置换术的临床研究

目的 研究小切口保留关节囊人工全髋关节置换术(THA)与普通切口不保留关节囊人工全关节髋置换术的疗效以及并发症.方法 小切口保留后方关节囊THA组56例,普通切口不保留关节囊THA组46例,对比观察两组患者手术出血量、手术切口长度、髋关节脱位、假体松动发生率.结果 小切口保留后方关节囊THA组手术出血量较普通切口不保留关节囊THA组少,差异有显著性意义(P< 0.05);小切口保留后方关节囊THA组的平均切口长度(9.1±0.6)cm,普通切口不保留关节囊THA组平均切口长度(13.4±1.4)cm,差异有统计学意义(P< 005);小切口保留后方关节囊组患者术后发生髋关节后脱位1例,发生率为1.78%(1/56),普通切口不保留关节囊组患者术后发生髋关节后脱位3例,发生率为6.52%(3/46),两者之间差异显著(P<0.05).结论 小切口保留关节囊THA具有手术出血少、切口小、创伤少以及早期髋关节脱位发生率低等特点,对合适的患者选用小切口保留关节囊THA具有较好的临床价值.     

自髋臼侧关节囊切开再修补在后路全髋关节置换术中的应用

目的探讨老年股骨颈骨折经后路初次全髋关节置换术中自髋臼侧关节囊切开修补的确切性及其对术后早期脱位的影响。方法回顾性分析了31例全髋关节置换术中采用自髋臼侧关节囊切开修补方法的病例,研究修复成功率和其对预防术后关节脱位的作用。术后6个月通过MRI观察关节囊及外旋肌群的修复成功率,比较双下肢外旋肌力,并采用Harris髋关节评分标准进行评价。结果所有病例未出现髋关节脱位,患侧外旋肌力与健侧比较差异无统计学意义(t=1.81,P0.05),MRI显示外旋肌群修复良好,Harris髋关节评分优良率96.8%。结论自髋臼侧关节囊切开修补能有效预防术后髋关节脱位的发生。     

经后侧入路人工全髋关节置换保留关节囊对关节稳定性的影响

背景:关节囊韧带能够引导关节面的正常运动和限制过度运动的作用,尤为重要的是阻止任何非生理的位移发牛,足稳定髋关节的重要静力结构.既往认为在人工全髋关节置换中应该常规切除关节囊.目的:观察后侧入路人工全髋关节置换过程中保留关节囊结构维持关节稳定性的影响.设计、时间及地点:病例对照实验,2005-01/2006-12在中南大学湘雅二医院骨科住院行人工全髋关节置换治疗61例股骨颈骨折患者的回顾性分析.对象:2006-01/12行人工全髋关节置换保留修复关节囊的29例患者为保留组.2005-01/12行人工全髋关节置换常规切除部分关节囊的32例患者为常规组.两组患者在病例选择,假体选择项目上基线一致,术后处理一致.方法:股骨近端大转子上钻4个孔.用1-0可吸收缝线把上半部分关节囊瓣和原关节囊前上方部分缝合后,再与股骨颁基底部作褥式缝合,缝线暂不打结:另一缝线同样将关节囊瓣下半部分与原关节囊前下方部分缝合后于股骨颈基底下办两个骨孔穿出,外旋下肢.打结缝线,冉修补被切断的外旋肌群.缝合前后可以缓慢屈髋90°和全伸膝位股骨内旋45°,体会关节囊缝合后对加强关节后方稳定的作用.主要观察指标:手术时间、出血量和术后关节脱位情况.结果:①保留组手术时间和出血量低丁常规组(P<0.05).②保留组术后没有脱位发生,常规组术后2例发生脱位,发生率为6.2%.因为数据较少,不能进行统计学检验.因此不具备统计学意义.结论:人工全髋关节置换过程中保留和不保留关节囊对关节稳定性影响还不能作出结论性意见,但保留关节囊手术可以减少手术时间和术中出血,不增加手术风险,并有重建髋关节后侧软组织平衡的作用.     

人工股骨头置换在高龄股骨转子间骨折患者中的应用——附28例报告

目的：探讨人工股骨头置换治疗高龄股骨转子间骨折患者的疗效。方法：采用标准骨水泥型双动人工股骨头行人工股骨头置换术治疗股骨转子间骨折高龄患者28例,手术入路分为后外侧入路和前外侧入路。于术后1年评价手术疗效。结果：术后2周内发生髋关节后脱位2例,均为后外侧入路者,经手法复位,皮牵制动4～6周后痊愈出院。其余26例术后7～14d下地功能锻炼。于术后2～8周顺利出院。28例患者随访12～26个月,复查X线片,骨折均愈合,无假体松动、下沉。术后1年根据Harris评分标准评定髋关节功能,优23例,良3例,可2例,优良率为92％。结论：人工股骨头置换术治疗高龄股骨转子间骨折疗效满意,前外侧入路的疗效优于后外侧入路。     

50例全髋关节置换术病人的康复护理

[目的]总结人工全髋关节置换病人的康复护理措施.[方法]回顾性分析50例人工全髋关节置换术病人的临床资料.[结果]本组50例病人术后均恢复良好,无伤口感染和关节脱位、僵硬等并发症发生.[结论]有针对性加强关节活动和股骨头肌功能锻炼与康复护理是全髋关节置换术病人康复的重要保证.     

可调式髋关节外展架在髋关节置换术后的应用

目的针对人工全髋置换术后关节稳定性差,易脱位,护理困难。自制可调式髋关节外展架限制髋关节过度内收等易引发的脱位。方法通过21例人工全髋置换术后患者配带可调式髋关节外展架,观察其应用效果。结果患者的关节稳定性,翻身活动,褥疮防治等均有良好效果。结论该支架设计合理,操作简便,患者舒适,能有效防止假体脱位、褥疮的发生,方便护理。     

可调式髋关节外展架在髋关节置换术后的应用

目的 针对人工全髋置换术后关节稳定性差,易脱位,护理困难.自制可调式髋关节外展架限制髋关节过度内收等易引发的脱位.方法 通过21例人工全髋置换术后患者配带可调式髋关节外展架,观察其应用效果.结果 患者的关节稳定性,翻身活动,褥疮防治等均有良好效果.结论 该支架设计合理,操作简便,患者舒适,能有效防止假体脱位、褥疮的发生,方便护理.     

全髋关节置换术后髋臼外展角与后脱位的相关性研究

目的探讨全髋关节置换术后髋臼外展角与后脱位的相关性。方法收集2017年1月至2018年12月湖北省宜昌市第一人民医院行初次人工全髋关节置换术患者377例(419髋),术后发生脱位20例。根据术后X线片检查髋臼唇外展角分为四组:髋臼唇外展角<40°组、髋臼唇外展角≥40°~50°组、髋臼唇外展角>50°~60°组、髋臼唇外展角>60°组。结果髋臼唇外展角<40°131例,发生脱位7例,脱位率5.3%;髋臼唇外展角≥40°~50°174例,发生脱位3例,脱位率1.7%;髋臼唇外展角>50°~60°75例,发生脱位8例,脱位率10.7%;髋臼唇外展角>60°19例,发生脱位2例,脱位率10.5%,脱位率组间差异有显著性(χ~2=9.082,P=0.028,R=-0.074)。结论为了减少髋关节置换术后的脱位率,髋臼外展角的角度多应该选择在≥40°~50°,尽可能避免在其他角度。     

The Rottinger approach for total hip arthroplasty: technique and review of the literature

The surgical approach utilized in total hip arthroplasty has been identified as a factor that may affect surgical outcomes. There have been many different approaches and modifications used since the procedure was popularized by Sir John Charnley. The popular approaches today can be grouped by their relationship to the trochanter (anterior or posterior), patient position, leg position for dislocation/femoral preparation, and treatment of the abductors and short external rotators. The Rottinger approach is an anterior approach which utilizes the muscle interval between the tensor fascia lata and abductor musculature. The abductor attachments are preserved and the femur is prepared in extension, adduction, and external rotation. This approach has been shown in literature to be safe with some studies showing improved outcomes both in terms of reduced complications and better function than other standard approaches.     

骨水泥型人工半髋与全髋关节置换治疗高龄股骨颈骨折的比较

背景：采用人工半髋关节置换治疗老年股骨颈骨折还存在一些争议。 目的：观察骨水泥型人工半髋关节置换治疗高龄股骨颈骨折的临床治疗效果,并与人工全髋关节置换对比。 方法：回顾性分析2009年1月至2010年6月的23例高龄股骨颈骨折行人工关节置换患者的临床资料,其中采用骨水泥型人工半髋关节置换的患者11例,人工全髋关节置换的患者12例。比较骨水泥型人工全髋关节置换与人工半髋关节置换患者的下床活动时间、Harris评分,以及围手术期并发症的发生率。 结果与结论：所有患者均获得12-18个月随访,骨水泥型人工半髋关节置换组治疗后主动直腿抬高角度、治疗后下床时间、治疗后早期并发症发生率、治疗后1周Harris评分优于人工全髋关节置换组;治疗后6周、3个月、6个月的Harris评分两组间差异无显著性;但骨水泥型人工半髋关节置换组远期髋关节疼痛的发生率高于人工全髋关节置换组。因此,作者认为高龄股骨颈骨折患者应用骨水泥型人工半髋关节置换后近期疗效较好,但远期综合疗效尚需进一步验证。     

Posterior or anterolateral approach in hip joint arthroplasty - Impact on frontal plane moment

BackgroundAnterolateral surgical approach in hip joint arthroplasty necessitates division of the hip abductor muscle complex, which may compromise postoperative gait observed in the frontal plane. The aim of the study was to compare frontal plane moment after hip joint arthroplasty by anterolateral or posterior approach and to explore which compensatory strategies patients use to decrease frontal plane moment.MethodsTwenty-eight patients were randomized by sealed envelopes to hip resurfacing arthroplasty surgery by anterolateral (ad modum Watson) or posterior (ad modum Moore) approach, performed by two senior surgeons. Gait analyses were performed using 3D motion capture before surgery, 3, and 12 months after surgery. Peak ground reaction force was extracted for early and late stance and the corresponding frontal plane moment was defined. Measures of lateral trunk inclination, pelvic drop and hip abduction were obtained for the stance phase of the affected leg.FindingsAn effect of surgical approach on frontal plane moment for the affected leg was found during early stance phase (p = 0.006) where average frontal plane moment in the anterolateral groups was 202.42 N mm/kg in less compared to the posterior group after one year. A similar effect from baseline to 12 months for trunk inclination (p = 0.03) and an overall negative correlation between frontal plane moment and trunk inclination was found (r = −0.66, p = 0.03).InterpretationFrontal plane moment during early stance was less one year after hip joint arthroplasty through anterolateral compared to posterior approach. Patients' primary strategy to reduce frontal plane moment seems to be increased lateral trunk inclination.     

全髋关节置换术和半髋关节置换术治疗老年股骨颈骨折的效果比较

目的探讨全髋关节置换术和半髋关节置换术治疗老年股骨颈骨折的效果。方法选择2016年12月至2018年12月收治的80例老年股骨颈骨折患者为研究对象,采用随机数字表法将其分为对照组和观察组,各40例。对照组患者给予半髋关节置换术,观察组患者给予全髋关节置换术。比较两组患者手术相关指标、术后并发症发生情况及术后随访1年的疗效。结果观察组手术时间长于对照组,术中出血量多于对照组,住院时间和髋关节功能完全恢复时间明显短于对照组(P<0.05)。观察组术后并发症总发生率为2.50%,显著低于对照组的20.00%(P<0.05)。术后1年,观察组的治疗总有效率为97.50%,显著高于对照组的85.00%(P<0.05)。结论与半髋关节置换术比较,全髋关节置换术治疗老年股骨颈骨折的效果显著,有利于患者术后髋关节功能恢复,术后并发症发生率低。     

Diseases of proximal femur segment in subjects of working age

A high-energy injury in subjects under the age of 50 as a rule leads to hip dislocation. This condition requires urgent orthopedic aid to avoid the risk of femur head osteonecrosis. Given a failure of closed reduction of dislocation (to be performed within 6 hours after the injury), immediate open reduction is indicated. The surgical approach depends on the dislocation type. The Kocher-Langenbeck approach is practiced to treat posterior dislocation and the Smith-Petersen or Watson-Jones approach in case of anterior dislocation. The most frequent and dangerous complications are femur head osteonecrosis (in 4-22% of the cases even after timely reduction) and post-traumatic coxarthrosis. Osteonecrosis is managed by a variety of surgical methods, viz. central decompresson, osteoplasty, corrective osteotomy, endoprosthetics. Its late stages, with sclerosis affecting over 30% of the head surface, are treated by resurfacing arthroplasty, hemiarthroplasty, total surface arthroplasty, uni- and bipolar hemiarthroplasty, total endoprosthetics, and administration of expanded stem cells into the subchondrial layer. The use of tissue-engineering technologies for the treatment of osteonecrosis is not confined to the treatment of its precollaptoid stages. They can be employed to promote osteointegration at the metal-bone interface and thereby to improve secondary stability or prolong the hardware lifetime.     

负重下前交叉韧带断裂对后交叉韧带的影响

[目的]研究负重情况下,前交叉韧带（ACL）断裂对后交叉韧带（PCL）应变的影响.[方法]将6具新鲜膝关节固定在自制夹具上,在膝关节0°、屈曲30°、60°及90°位置加载800N的负荷,比较ACL切断前（完整组）与切断后（断裂组）的PCL的应变数据.[结果]膝关节0°、90°,断裂组ACL前外束与后外束应变均大于完整组,均有明显提高（P〈0.05,P〈0.01）.[结论]ACL完全断裂可以导致PCL在膝关节伸屈过程中生物力学特性的改变.     

Posterior shoulder dislocation: avoiding a missed diagnosis

Posterior shoulder dislocation is a relatively uncommon event, with an incidence of 1% to 4% of all shoulder dislocations. Because of the infrequency of this condition, the diagnosis is often missed, with significant consequences to the patient Injury in the athlete is usually from a direct blow or fall onto an outstretched arm. After such an injury, symptoms may be confused with a shoulder contusion or rotator cuff injury. Significant complications such as chronic posterior dislocation and degenerative disease of the shoulder can occur if the diagnosis is missed. A careful history and physical examination, complete radiographic evaluation, and a high level of suspicion are required to identify posterior shoulder dislocation. Treatment consists of prompt closed reduction, or operative repair if this is unsuccessful.