类风湿性关节炎继发严重髋臼内陷的全髋关节置换

目的探讨类风湿性关节炎继发严重髋臼内陷患者行全髋关节置换术治疗的临床疗效。 方法2011年1月至2014年11月，对解放军兰州总医院收治18例(20髋)类风湿性关节炎的严重髋臼内陷患者进行随访观察，其中男6例，女12例；年龄37～68岁，平均(46±8)岁。纳入病例均类风湿性关节炎继发严重髋臼内陷，髋臼内陷依Sotello-Garza和Charnley分型：Ⅰ型(内陷1～5 mm)0例，Ⅱ型(内陷6～15 mm)15例(17髋)，Ⅲ型(内陷>15 mm)3例(3髋)。排除标准为先天性、创伤性或髋关节骨关节炎所继发的髋臼内陷。手术采用后外侧入路，股骨颈截骨后股骨头逆行取出，取自体松质颗粒骨打压植骨重建髋臼，采用压配方式植入生物型多孔髋臼假体。随访时采用Harris髋关节评分评估髋关节功能，X线平片观察假体是否有松动和再次内陷以及植骨愈合情况。对手术前、后髋关节功能、股骨头中心到Kohler线的距离等计量资料采用t检验分析。 结果手术时间为55～131 min，平均(89±8)min。失血量为165～480 ml，平均(295±11)ml。术中未发生血管、神经损伤以及髋臼和股骨劈裂骨折。随访时间2.5～6年，平均(4.5±1.7)年。术后X线片示4.5个月自体移植骨均与髋臼融合。末次随访的Harris髋关节评分由术前(55±9)分(40～65分)提高至(92±13)分(89～95分)，差异有统计学意义(t ＝22.81，P <0.01)。股骨头中心到Kohler线的距离由置换前的(20± 4)mm增加到置换后的(21±3)mm，差异有统计学意义(t ＝2.312，P <0.01)；随访期间均无髋臼假体松动发生。 结论类风湿性关节炎继发严重髋臼内陷的髋臼骨质菲薄且局部骨质疏松严重，髋臼形态不规则。采用自体股骨头颗粒骨移植填充髋臼结合生物型钽金属骨小梁髋臼杯假体，可恢复髋关节旋转中心并获得满意的近中期临床效果。

Total hip arthroplasty for treatment of acetabular protrusion secondary to rheumatoid arthritis

ObjectiveTo explore the clinical efficacy of total hip arthroplasty for the treatment of severe acetabular protrusion secondary to rheumatoid arthritis. MethodsFrom January 2011 to November 2014, 18 patients(20 hips) with were treated with total hip arthroplasty (THA), including six males (six hips) and 12 females(14 hips). The age ranged from 37 to 68 years, (46±8)years on average.Inclusion criteria: protrusio acetabuli secondary to hip rheumatoid arthritis, according to the classification of Sotello-Garza and Charnley, no hip was type Ⅰ (protrusio acetabuli 1~5 mm), 15 cases (17 hips) were type Ⅱ (6~15 mm), and three cases (three hips) were type Ⅲ (>15 mm). Exclusion criteria: protrusio acetabuli secondary to congenital, traumatic or osteoarthritis. THA was accomplished through posterolateral approach. The femoral heads were moved out with retrograde method after the osteotomy of femoral neck. Autolgous-bone grafting was used to repair acetabular defects and cementless tantalum trabecular metal cups were planted with press-fit skills. At the follow-up, radiographic measurement was performed with hip X-ray films to assess the cup loosening, re-protrusion and the union of graft hone. The range of motion and the Harris scores were used to evaluate the clinical efficacy. The preoperative and postoperative data of Harris hip score and the distance between the center of femoral head to Kohler’ line were analyzed by paired t test. ResultsThe average operation time and blood loss was(89±8)min (55 to 131 min) and(295±11)ml (165 to 480 ml) respectively. The meantime of follow-up was (4.5±1.7)years (range, 2.5 to six years). According to X-ray films, bone grafting fusion was observed within 4.5 months after operation. At the last follow-up, the average Harris hip score improved from (55±4) points preoperatively to (92±4) points post-operatively (t=12.81, P <0.01). The distance between the center of femoral head to Kohler’ line improved from (20±4) mm preoperatively to (21±3) mm post-operatively, showing significant difference(t=2.312, P <0.01). No loosening of acetabular components was found in this group. ConclusionsThe acetabular protrusion secondary to rheumatoid arthritis has the characteristic of hip osteoporosis and abnormal shape of acetabulum. Restoration hip rotation center and satisfied clinical outcome benefit from impacted allograft bone transplant combined with tantalum trabecular metal cup.