Abstract
目的
探讨侧卧位直接前方入路（direct anterior approach，DAA）自体股骨头髋臼结构性植骨人工全髋关节置换术（total hip arthroplasty，THA）治疗CroweⅢ、Ⅳ型发育性髋关节发育不良（developmental dysplasia of the hip，DDH）的可行性及临床疗效。
方法
2016年6月—2020年7月，采用侧卧位DAA自体股骨头髋臼结构性植骨THA治疗12例（12髋）CroweⅢ、Ⅳ型DDH患者。男2例，女10例；年龄50～79岁，平均60.2岁。Crowe分型为Ⅲ型10髋、Ⅳ型2髋。术前髋关节Harris评分为（48.8±7.5）分，双下肢长度差异（3.0±0.7）cm，活动时疼痛视觉模拟评分（VAS）为（7.2±0.9）分。记录手术切口长度、手术时间、术中出血量、并发症情况；术后观察髋臼、股骨假体位置及压配情况，测量双下肢长度差异变化；测量髋臼杯水平覆盖率，植骨块与宿主骨愈合情况、假体有无松动；采用Harris评分评估髋关节功能，VAS评分评估患者活动时疼痛情况。
结果
手术切口长度平均9.3 cm，手术时间平均117 min，术中出血量平均283 mL。术中2例患者（16.7%）予以输血。术中无髋臼及股骨骨折；术后切口均Ⅰ期愈合，无脱位、假体周围感染、坐骨神经损伤、下肢深静脉血栓形成等并发症发生；术后1例出现股外侧皮神经损伤症状。出院时复查X线片示髋臼杯水平总覆盖率为93%～100%，平均 97.8%；髋臼杯植骨块水平覆盖率为25%～45%，平均31.1%。12例患者均获随访，随访时间22～71个月，平均42.2个月。末次随访时，髋关节Harris评分为（89.7±3.9）分，双下肢长度差异为（0.9±0.4）cm，活动时VAS 评分为（1.1±0.6）分，与术前比较差异均有统计学意义（P<0.05）。随访期间无1例患者因假体松动需行髋关节翻修手术。末次随访时植骨块和宿主骨之间无透亮线、已融合，位置良好，未见明显移动。其中1例患者植骨块的1枚螺钉断裂合并植骨块外缘骨吸收，但植骨块未移位且愈合良好。
结论
侧卧位DAA自体股骨头髋臼结构性植骨THA治疗CroweⅢ、Ⅳ型DDH安全可靠，近期疗效满意。
Keywords: 发育性髋关节发育不良, 结构性植骨, 直接前方入路, 人工全髋关节置换术
Abstract
Objective
To explore the feasibility and effectiveness of total hip arthroplasty (THA) with acetabulum structural bone grafting using autogenous femoral head through direct anterior approach (DAA) in lateral decubitus position in the treatment of Crowe type Ⅲ and Ⅳ developmental dysplasia of the hip (DDH).
Methods
Between June 2016 and July 2020, 12 patients with Crowe type Ⅲ and Ⅳ DDH were treated with THA with acetabulum structural bone grafting using autogenous femoral head through DAA in lateral decubitus position. There were 2 males and 10 females with an average age of 60.2 years (range, 50-79 years). Crowe classification was type Ⅲ in 10 hips and type Ⅳ in 2 hips. The preoperative Harris score of hip joint was 48.8±7.5, the difference in length of both lower extremities was (3.0±0.7) cm, and the visual analogue scale (VAS) score during activity was 7.2±0.9. The surgical incision length, operation time, intraoperative blood loss, and complications were recorded; the position and press-fitting of acetabulum and femoral prosthesis were observed after operation, and the difference in length of both lower extremities was measured; the horizontal coverage of acetabular cup and bone graft were measured, the healing with the host bone and the loosening of the prosthesis were evaluated; Harris score was used to evaluate hip joint function, and VAS score was used to evaluate patients’ pain during activity.
Results
The average surgical incision length was 9.3 cm, the average operation time was 117 minutes, and the average intraoperative blood loss was 283 mL. Two patients (16.7%) received blood transfusion during operation. There was no acetabular and femoral fractures during operation. All incisions healed by first intention, without dislocation, periprosthetic infection, sciatic nerve injury, deep venous thrombosis, and other complications. One patient had lateral femoral cutaneous nerve injury after operation. X-ray films at discharge showed a total acetabular cup level coverage of 93%-100%, with an average of 97.8%, and a bone graft level coverage of 25%-45%, with an average of 31.1%. All the 12 patients were followed up 22-71 months, with an average of 42.2 months. At last follow-up, the Harris score of hip joint was 89.7±3.9, the difference in length of both lower extremities was (0.9±0.4) cm, and the VAS score during activity was 1.1±0.6, which were significantly different from those before operation (P<0.05). During follow-up, there was no patient who needed hip revision surgery because of prosthesis loosening. At last follow-up, there was no translucent line between the graft and the host bone, the graft was fused, the position was good, and there was no obvious movement. One patient had one screw fracture and bone resorption at the outer edge of the graft, but the bone graft did not displace and healed well.
Conclusion
THA with acetabulum structural bone grafting using autogenous femoral head through DAA in lateral decubitus position in the treatment of Crowe type Ⅲ and Ⅳ DDH is safe and reliable, and has satisfactory short-term effectiveness.
Keywords: Developmental dysplasia of the hip, structural bone graft, direct anterior approach, total hip arthroplasty
CroweⅢ、Ⅳ型发育性髋关节发育不良（developmental dysplasia of the hip，DDH）患者髋关节畸形明显，主要表现为髋臼浅平、外上方骨缺损、前倾角增大、假臼形成、股骨侧颈干角和前倾角增大、股骨近端髓腔直径减小等。此类患者髋臼外上方存在不同程度骨缺损，因此人工全髋关节置换术（total hip arthroplasty，THA）中髋臼旋转中心解剖重建困难。文献报道将股骨头复位至真臼可降低无菌性假体松动发生率，延长假体使用寿命[1]。术中旋转中心解剖重建的前提是需行髋臼重建，包括应用自体股骨头、金属垫块等进行重建。金属垫块由于不能增加髋臼周围骨量且价格昂贵，临床使用有限；使用大块自体股骨头行结构性植骨重建髋臼，具有股骨头易获得且可修剪成任意合适弧形、可更好地将旋转中心下移和内移等优点，同时髋臼侧自体骨量增加为后期可能的翻修手术奠定基础。尽管有文献报道自体股骨头结构性植骨存在骨吸收问题，但随着手术技术的进步及各种有效涂层髋臼假体的使用，传统后外侧、外侧入路行自体股骨头结构性植骨THA的中远期效果良好[2-3]。
但传统后外侧入路THA治疗DDH术后康复时间长，由于关节本身结构异常，术后容易出现脱位。直接前方入路（direct anterior approach，DAA）是经神经间隙和肌肉间隙入路，具有肌肉损伤少、出血量少、术后患者开始活动时间更早、脱位发生率低等优点[4-5]。国外文献报道采用DAA行THA联合髋臼侧自体股骨头结构性植骨是治疗DDH的有效手段[6-7]，国内相应文献较少。现回顾分析蚌埠医学院第一附属医院采用侧卧位DAA髋臼侧大块自体股骨头结构性植骨THA治疗的CroweⅢ、Ⅳ型DDH患者临床资料，探讨该术式的可行性和临床疗效。报告如下。
1. 临床资料
1.1. 一般资料
患者纳入标准：① Crowe Ⅲ、Ⅳ型DDH患者，通过测量下肢全长X线片确定术中无需行股骨短缩截骨；② 患髋关节疼痛明显，功能活动明显受限，髋关节既往无外伤、感染病史；③ 初次THA治疗；④ 术前评估能耐受手术，采用侧卧位DAA髋臼侧大块自体股骨头结构性植骨THA治疗。2016年6月—2020年7月，共12例（12髋）Crowe Ⅲ、Ⅳ型DDH患者符合标准纳入研究。
本组男2例，女10例；年龄50～79岁，平均60.2岁。左髋3例，右髋9例。身体质量指数为17.5～28.0 kg/m2，平均22.3 kg/m2。临床表现为行走时髋关节疼痛不适伴不同程度跛行。Crowe分型为Ⅲ型10髋、Ⅳ型2髋。术前髋关节Harris评分（48.8±7.5）分，双下肢长度差异（3.0±0.7）cm，活动时疼痛视觉模拟评分（VAS）为（7.2±0.9）分。
1.2. 术前处理
术前常规摄双侧髋关节正位、双下肢站立位全长正位、腰椎正侧位X线片，必要时行髋关节CT平扫+三维重建，了解髋臼直径、位置、骨量，脱位高度，腰椎退变情况及双下肢长度差异。术前常规行实验室检查，包括血常规、生化全套、尿常规、凝血功能、C反应蛋白、红细胞沉降率，要求数值均在正常范围以内。嘱患者术前加强营养支持、肺功能锻炼、下肢肌力锻炼；患者入院第1天皮下注射促红细胞生成素，术前1 d晚上口服镇静催眠药。
1.3. 手术方法
术前30 min常规应用头孢抗生素及氨甲环酸。全身麻醉下取健侧卧位，通过阔筋膜张肌和缝匠肌、臀中肌和股直肌间隙进入髋关节前方。由于髋关节无手术病史，患者髋臼周围软组织比较柔软，常规切除髋关节前方关节囊、切断后方关节囊，将髋臼周围软组织贴骨膜应用电刀松解、必要时部分松解髂腰肌，于股骨小转子上方1 cm处截断股骨颈取出股骨头颈残端，根据脱位高度适度减少保留股骨颈的长度，尽量不破坏股骨距，将股骨头去除软骨及软骨下骨，备用。用骨刀去除髋臼增生骨赘，显露髋臼时必须应用DAA的Hoffman拉钩撬拨股骨颈残端放置于髋臼后远侧，根据Harris窝确定髋关节旋转中心，髋臼磨锉打磨髋臼内软骨直至均匀点状渗血。安装髋臼试模后，观察试模上方髋臼骨缺损范围，如果缺损范围>25%，取自体股骨头行髋臼结构性植骨。
彻底清除髋臼骨缺损处软组织，髋臼磨锉、骨刀打磨髋臼骨缺损处硬化的骨皮质至骨面渗血，以促进移植股骨头和植骨床的愈合。用摆锯去除股骨头坏死部分及骨皮质，剩余股骨头的松质骨根据髋臼骨缺损形状切割成植骨块，植骨块和髋臼植骨床紧密接触并打压夯实，避免二者形成“跷跷板”效应。用2～3 枚松质骨螺钉将植骨块牢固固定于髋臼骨缺损处，避免微动导致植骨块不愈合，用骨膜剥离器挤压松质骨泥填充骨块间缝隙。再次使用髋臼磨锉将植骨块磨除一部分，使髋臼成同心圆，选择大小合适的假体植入并夯实，用2枚螺钉固定髋臼假体，植入股骨假体。常规放置引流管1根，缝合阔筋膜张肌筋膜层后在关节腔内注射2 g氨甲环酸，关闭切口。本组假体类型为Allofit生物型髋臼和ML楔形柄（捷迈公司，美国），人工股骨头与髋臼内衬界面为陶瓷对高交联聚乙烯。
1.4. 术后处理
术后禁止双下肢交叉，于腘窝处垫软垫，膝关节稍屈曲，预防髋关节脱位发生并减轻坐骨神经牵拉。术后常规行预防感染、下肢深静脉血栓形成及消肿、止痛治疗。术后第1天患者开始床上双下肢自由活动，3周后拄双拐下地1/4负重活动，之后根据髋关节X线片显示植骨块愈合情况决定完成负重行走时间；6个月内避免患肢极度内收、内旋动作，预防髋关节脱位。
1.5. 疗效评价指标
记录患者手术切口长度、手术时间、术中出血量、输血率、并发症发生情况。术后摄髋关节正位X线片观察髋臼、股骨假体位置及压配情况，测量双下肢长度差异；测量髋臼杯水平覆盖率（图1）[3，8]，包括髋臼杯植骨块水平覆盖率（植骨块水平覆盖距离/髋臼杯水平距离×100%）和髋臼杯水平总覆盖率 ［（宿主骨水平距离+植骨块水平距离）/髋臼杯水平距离×100%］。术后3、6个月及每年摄髋关节正位X线片观察自体股骨头植骨块与宿主骨的愈合、吸收情况，髋臼杯有无松动，植骨块与宿主骨接触面透亮线的改变，有无桥接骨小梁出现等[9]。采用Harris评分评估髋关节功能，VAS评分评估患者活动时疼痛情况。
图 1.
Schematic diagram of horizontal coverage of acetabular cup measurement
髋臼杯水平覆盖率测量示意图
A：髋臼杯水平距离 B：宿主骨水平距离 C：植骨块水平距离
A: Horizontal distance of the acetabular cup B: Horizontal distance of the host bone C: Horizontal distance of the graft
1.6. 统计学方法
采用Graphpadprism 7统计软件进行分析。计量资料经正态性检验，均符合正态分布，数据以均数±标准差表示，手术前后比较采用配对t检验；检验水准α=0.05。
2. 结果
本组患者手术切口长度8.3～11.9 cm，平均9.3 cm；手术时间90～210 min，平均117 min；术中出血量150～800 mL，平均283 mL。术中2例患者（16.7%）予以输血纠正失血。术中无髋臼及股骨骨折；术后切口均Ⅰ期愈合，无关节脱位、假体周围感染、坐骨神经损伤、下肢深静脉血栓形成等并发症发生。术后1例患者出现股外侧皮神经损伤症状，经口服甲钴胺治疗，术后6个月麻木症状明显缓解。出院时复查髋关节正位X线片示髋臼杯水平总覆盖率为93%～100%，平均 97.8%；髋臼杯植骨块水平覆盖率为25%～45%，平均31.1%；6髋（50%）髋臼杯植骨块水平覆盖率为25%～30%，6髋（50%）>30%。
12例患者均获随访，随访时间22～71个月，平均42.2个月。末次随访时，髋关节Harris评分为（89.7±3.9）分，双下肢长度差异为（0.9±0.4）cm，活动时VAS 评分为（1.1±0.6）分，与术前比较差异均有统计学意义（t=15.980，P<0.001；t=8.343，P<0.001；t=18.300，P<0.001）。随访期间无1例患者因假体松动需行髋关节翻修手术。末次随访时移植骨块和宿主骨之间无透亮线、已融合，位置良好，未见明显移动。其中1例患者植骨块的1枚螺钉断裂合并移植骨块外缘骨吸收，但植骨块未移位且愈合良好。见图2、3。
图 2.
A 64-year-old female patient with right Crowe type Ⅲ DDH
患者，女，64岁，右侧CroweⅢ型DDH
a. 术前髋关节正位X线片；b. 术后3个月髋关节正位X线片示植骨块和螺钉稳定在位，髋臼假体位置良好；c. 术后48个月切口愈合后长度；d. 术后48个月髋关节正位X线片示移植骨块外缘部分骨吸收，1枚螺钉断裂，植骨块完全融合；e. 术后48个月患者髋关节功能良好
a. Anteroposterior X-ray film of hip joint before operation; b. Anteroposterior X-ray film of hip joint at 3 months after operation showed that the bone graft and screws were stable in place, the position of the acetabular prosthesis was good; c. The incision length after healed at 48 months after operation; d. Anteroposterior X-ray film of the hip joint at 48 months after operation showed that the outer edge of the bone graft was partially resorbed, 1 screw was fractured, and the bone graft was fully fused; e. The hip function was good at 48 months after operation
图 3.
A 59-year-old female patient with right Crowe type Ⅳ DDH
患者，女，59岁，右侧Crowe Ⅳ型DDH
a. 术前髋关节正位X线片；b. 术中侧卧位DAA切口示意图；c. 术后2 d髋关节正位X线片示植骨块和螺钉稳定在位，髋臼假体位置良好；d. 术后38个月髋关节正位X线片示植骨块完全融合，无吸收；e. 术后38个月患者髋关节功能良好
a. Anteroposterior X-ray film of the hip joint before operation; b. Incision diagram of DAA in lateral decubitus position during operation; c. Anteroposterior X-ray film of the hip joint at 2 days after operation showed that the bone graft and screws were stable in place, and the acetabular prosthesis was in good position; d. Anteroposterior X-ray film of the hip joint at 38 months after operation showed that the bone graft was completely fused without resorption; e. The hip function was good at 38 months after operation
3. 讨论
3.1. 髋臼重建方法
DDH患者因髋臼和股骨近端畸形造成髋关节不同程度脱位，髋关节最终会形成骨关节炎，THA是治疗DDH的有效手术方式。对于股骨近端畸形，THA术中可采用非常规股骨假体，如Wagner cone、S-ROM；对于髋臼畸形可采用自体股骨头结构性植骨髋臼重建技术、高位放置的髋臼重建技术、髋臼内移技术、生物型小臼杯技术等。
3.2. 自体股骨头结构性植骨疗效分析
结构性植骨材料首选自体股骨头，具有取材便利、无免疫排斥、有良好骨传导和骨诱导作用、比同种异体骨愈合率高等优点。髋臼结构性植骨后可以稳定地将髋臼杯放置于真臼区域，提高髋臼杯覆盖率，最大程度恢复髋关节正常旋转中心以及缩小肢体长度差异，提供了大量骨储备，为后续翻修术奠定基础。因此，术中利用自体股骨头结构性植骨在临床上获得了较好的中远期疗效[10-12]。
但仍有文献报道髋臼结构性植骨远期疗效不佳。Mulroy等[13]报道了46例行结构性植骨THA患者平均随访11.8年结果，因植骨块松动需要二次手术9例，影像学髋臼松动者12例，髋臼假体松动率高达46%。Zahar等[14]报道115例行结构性植骨THA患者平均随访11.6年结果，27%髋臼杯周围出现透亮线，无菌性松动引起的翻修率达16%，根据Kaplan-Meier生存曲线分析术后15年假体生存率会迅速降低。
但上述结构性植骨预后不佳的报道为早期研究，随着术中重视植骨块与髋臼植骨床的处理，包括彻底打磨髋臼缺损处植骨床、去除股骨头软骨及软骨下骨、术中选择正确直径和长度的松质骨螺钉以及假体材质和涂层的升级等，越来越多文献报道结构性植骨远期疗效满意。Saito等[15]报道了一组行结构性植骨THA患者平均随访18.5年结果，术后2～6个月（平均4个月）可观察到移植股骨头-宿主骨有骨小梁桥接，髋臼假体存活率为 94.5%。Maruyama等[16]报道了102例行结构性植骨THA患者平均随访10年结果，术后3年6个月内101例患者髋关节X线片显示骨小梁重塑成功并且无塌陷，仅有1例髋关节因髋臼假体松动行翻修手术。
我们的经验是：① 植骨块选择股骨头内良好的松质骨，外形须与髋臼骨缺损形状匹配；髋臼植骨床去皮质化呈现点状渗血；植骨块在植骨床上不能形成“跷跷板”效应，两者之间缝隙用松质骨泥填充，根据植骨块大小尽量选择直径较大的螺钉。② 术中不能在安装髋臼杯后再植骨，这样安装的植骨块和髋臼不能紧密贴服，建议植骨块固定后再用髋臼锉打磨至少大1号。本研究遵循上述经验，随访结果显示患者植骨块和髋臼植骨床完全愈合，表明了髋臼结构性植骨THA治疗DDH的可行性和安全性。
3.3. 采用DAA行THA的优势
近年，关节置换术后加速康复理念逐渐受到外科医生重视，采用DAA行THA是经过真正的肌肉间隙和神经界面，具有不损伤肌腱、恢复快、出血少、无禁忌体位术后即可下床活动、髋关节脱位率低等优势，在临床得到越来越广泛应用。Viamont-Guerra等[17]报道采用DAA髋臼结构性植骨THA治疗29例CroweⅢ、Ⅳ型DDH患者平均随访8.4年结果，证明了上述DAA优点。
国内采用DAA行结构性植骨THA治疗CroweⅢ、Ⅳ型DDH的相关文献较少。我们通过分析患者术前临床资料，成功经DAA行髋臼结构性植骨THA治疗CroweⅢ、Ⅳ型DDH，而无需转换其他手术入路，说明采用DAA行结构性植骨可行。末次随访时，患者髋关节Harris评分较术前明显升高，活动时VAS评分明显降低，说明DAA结构性植骨THA治疗CroweⅢ、Ⅳ型DDH可取得良好临床结果。
CroweⅢ、Ⅳ型DDH患者行THA时充分显露髋臼是手术成功的关键。后外侧入路切口较大且切断外旋肌群利于充分显露，与之相比，采用侧卧位及DAA拉钩同样可以充分显露股骨近端、髋臼外上方骨缺损，尤其容易显露前外侧髋臼缺损区域，这是DAA特有的优点，与Sako等[18]报道一致。侧卧位DAA的另一优点在于手术可在普通手术床完成，且患肢后伸、外旋、内收范围更大，更有利于暴露股骨近端。术后髋关节X线片测量示髋臼杯水平总覆盖率为93%～100%，髋臼杯植骨块水平覆盖率为25%～45%，说明经DAA可以很好地完成自体股骨头髋臼结构性植骨操作。根据髋臼窝内残留的脂肪组织确定髋关节旋转中心，通过处理髋臼植骨床及股骨头，使两者紧密贴合后以螺钉固定，再行髋臼锉打磨髋臼，这样既增加了髋臼杯稳定性，也满足了髋臼覆盖要求。术后测量本组患者双下肢长度差异由术前（3.0±0.7）cm缩短至末次随访时的（0.9±0.4）cm，差异有统计学意义，说明经DAA可以将髋臼杯置于髋关节旋转中心。末次随访时，本组均无因髋关节假体松动而行翻修手术者。
3.4. DAA行THA的难点
虽然侧卧位DAA结构性植骨THA治疗CroweⅢ、Ⅳ型DDH患者取得了良好临床效果，但DAA学习曲线较长[19]。建议外科医生最初开展DAA行THA时首选合适的患者，例如偏瘦、肌肉不发达、股骨颈长的非DDH患者，随着术者经验积累和手术技术提高，逐渐过渡到DDH、髋关节畸形等患者[20]。
本组术后1例患者出现股外侧皮神经损伤，经口服营养神经药物明显好转。通过回顾解剖及临床实践，我们认为切口起点位于髂前上棘向下、向外3 cm，切口延长方向指向腓骨小头偏后，可明显降低股外侧皮神经损伤发生率，与周宏博等[21]报道一致。术后1例患者出现1枚植骨块螺钉断裂合并植骨块外缘部分骨吸收，我们分析螺钉断裂可能是患者过早自行去除拐杖下地行走以及术后早期经常负重引起；但植骨块通常用2～3枚螺钉固定，因此1枚螺钉断裂并未影响植骨块愈合，观察X线片可见植骨块未移位且愈合良好，随访时该例患者功能良好。
综上述，采用侧卧位DAA髋臼结构性植骨THA治疗CroweⅢ、Ⅳ型DDH患者可以提供髋臼杯初始稳定性，提高髋臼杯覆盖率，是一种可靠手术方式。但本研究属于回顾性研究、随访时间短、样本量较小、缺乏对照组，患者复查时仅进行髋关节正位X线片检查，无法进一步观察植骨块的细节变化，虽然取得了良好近期疗效，但远期疗效还需进一步随访予以明确。
利益冲突 在课题研究和文章撰写过程中不存在利益冲突；课题经费支持没有影响文章观点和对研究数据客观结果的统计分析及其报道
伦理声明 研究方案经蚌埠医学院第一附属医院医学伦理委员会批准（2022KY035）；患者均知情同意
作者贡献声明 裴立家：参与研究设计、统计分析及论文撰写；吴一凡、刘扬、薛亚东、孟繁宇、刘犇：数据采集；周新社：手术实施，研究设计，对文章的知识性内容作批评性审阅及文章修改
Funding Statement
蚌埠医学院自然科学基金重点项目（BYKY2019030ZD）
Key Project of Natural Science Foundation of Bengbu Medical College (BYKY2019030ZD)
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