楊述華 劉先哲

（華中科技大學同濟醫(yī)學院附屬協(xié)和醫(yī)院骨科，武漢 430022）

髖關節(jié)發(fā)育不良（developmental dysplasia of the hip,DDH）是年輕患者髖關節(jié)骨性關節(jié)炎的一個主要病因。在這些患者發(fā)展到終末期骨性關節(jié)炎之前，有幾種非關節(jié)置換的手術方式可以考慮，包括股骨近端和髖臼周圍截骨術。但是在DDH發(fā)展至終末期骨性關節(jié)炎，引起嚴重的疼痛和功能受限時，全髖關節(jié)置換術則是標準的治療方式。與正常髖關節(jié)相比，發(fā)育不良的髖關節(jié)異常的接觸應力容易誘發(fā)髖關節(jié)骨性關節(jié)炎。對于DDH患者行全髖關節(jié)置換術（THA）時需要考慮許多因素，包括患者的年齡，畸形的解剖結構，以及文獻報道的高失敗率和翻修率等。1

解剖特征

盡管每個DDH患者都有獨特的解剖結構，但對于髖臼和股骨近端的解剖特征都有很好的描述。髖臼常見前側和上方的缺損，而股骨近端常見前傾角增大，髓腔變細，直線輪廓，髖內翻或外翻。近來CT研究證明發(fā)育不良的股骨均表現(xiàn)為前傾角增大，股骨頸變短，髓腔變細，并且發(fā)育不良的程度越嚴重，股骨前傾角越大。減小的髓腔直徑和更細的皮質厚度也使得發(fā)育異常的髖關節(jié)易于骨折。因此，在為DDH患者實施THA之前要特別注意每位患者的解剖特點。

對于DDH患者，軟組織的因素也要考慮。嚴重的DDH患者常常合并外展肌群的肌力減退，導致跛行甚至trendelenburg步態(tài)。由于慢性關節(jié)脫位，髖關節(jié)內收肌群、屈肌群和伸肌群的肌肉萎縮。如果肢體延長大于3 cm，坐骨神經(jīng)也很容易損傷。據(jù)文獻報道，THA治療髖關節(jié)發(fā)育不良時坐骨神經(jīng)麻痹的發(fā)生率5.2%～13%。

2外展肌的平衡降低，降低步態(tài)效率，導致跛行。由于異常的生物力學包括髖臼緣負荷過重，常常繼發(fā)骨性關節(jié)炎，最終導致疼痛和功能受限。放射學檢查可以確認診斷，明確髖臼和股骨近端解剖異常的特點。

DDH患者的放射學檢查對于手術方案的確定非常重要。標準的放射學檢查包括骨盆的正位片和髖關節(jié)的側位片，這可以在正側位上反映髖臼對股骨頭包容性情況。中心邊緣角，即在骨盆正位片上，通過股骨頭的中心垂直線和通過股骨頭中心和髖臼側緣連線之間的角度，通常＞25°。垂直中心前角，即在髖關節(jié)側位片上，通過股骨頭的中心垂直線和通過股骨頭中心和髖臼前緣連線之間的角度，通常＞25°。通過骨盆正位片也可以評估股骨近端的頸干角。CT有助于評估髖臼的骨量情況和前傾角。

DDH的分型有助于手術方案的制定。其中，最常用的分型標準是Crowe等根據(jù)股骨頭從髖臼脫位的嚴重程度分型。Ⅰ型：股骨頭半脫位，脫位率＜50%（圖1）；Ⅱ型：股骨頭半脫位，脫位率50%～75%（圖2）；Ⅲ型：股骨頭半脫位，脫位率75%～100%（圖3）；Ⅳ型：股骨頭全脫位，脫位率＞100%（圖4）。這種分型標準可以用于指導THA術中髖臼重建。

Hartofilakidis分型將DDH分為三類：股骨頭在真臼中；股骨頭低脫位，在假臼中，假臼與真臼部分

2 DDDDHH的診斷和分型

DDH常見于年輕患者，起病隱襲，表現(xiàn)為腹股溝區(qū)的疼痛或髖關節(jié)痛。許多患者有下肢不等長，而跛行是最常見的功能障礙。髖關節(jié)高脫位的患者髖關聯(lián)；股骨頭高脫位，股骨頭不在真臼及假臼中。許多外科醫(yī)生認為這種分型更有助于指導手術。

圖1 Ⅰ型：股骨頭半脫位，脫位率＜50%，股骨頭仍在真臼中

圖2 Ⅱ型：股骨頭半脫位，脫位率50%～75%

圖3 Ⅲ型：股骨頭半脫位，脫位率75%～100%

圖4 Ⅳ型：股骨頭全脫位，脫位率＞100%

3 不同方法全髖置換手術要點

標準的手術入路包括髖關節(jié)前側入路、前外側入路以及后側入路。對于嚴重的髖關節(jié)發(fā)育不良，伴股骨頭半脫位的患者，后側入路更有利于股骨頭和髖臼的充分暴露。此外，對于嚴重的髖關節(jié)發(fā)育不良，往往需要轉子下短縮截骨術，以擴展股骨近端，充分暴露髖關節(jié)后側。

3.1 髖臼重建

CroweⅠ型的髖關節(jié)，髖臼假體通常直接放置于真臼中。其臼杯可以與髖臼有充分的骨接觸。Garvin等[13]指出髖臼外上方大約20%的不接觸不會增加手術失敗的風險。對于CroweⅠ型的髖關節(jié)，骨水泥型和壓配型的臼杯假體都可以考慮，骨水泥型似乎有更高的機械失敗率。

CroweⅡ型和Ⅲ型髖臼外上方的骨缺損造成了臼杯的不充分骨接觸，影響臼杯假體的安放。這些是髖關節(jié)重建中最常見的問題。特殊的假體，小髖臼杯可以解決髖臼假體骨接觸不足的問題。髖臼缺損可以通過下面的幾種方法改善：①通過骨塊在髖關節(jié)的解剖中心重建髖臼（圖5）；②在假臼外側重建髖臼（圖6）；③結構性骨移植重建髖臼加網(wǎng)杯重建髖臼（圖7）。通過骨塊重建髖臼，臼杯有更多的解剖位置，在未來翻修手術中髖關節(jié)也有更多的骨量。

使用大塊的股骨頭自體移植是一種有效的方法，髖臼骨缺損的部位提供了一個良好的有血供的植骨床，而且股骨頭的松質骨部分可以很好的塑形以匹配髖臼缺損，并由兩枚或更多的螺釘固定在髂骨上。為了預防移植物的機械失敗，Mulroy和Harris指出，宿主骨對髖臼杯的骨接觸應大于70%。

CroweⅣ型髖關節(jié)，同樣是髖臼發(fā)育不良，但是其髖臼上方的缺損并不比CroweⅡ～Ⅲ型髖關節(jié)更嚴重。因此，可以選擇在髖關節(jié)解剖中心放置一個較小的非骨水泥型臼杯。通常并不需要骨塊移植。

圖5 自體股骨頭髖關節(jié)解剖中心重建髖臼

圖6 在假臼外側重建髖臼

圖7 結構性骨移植重建髖臼加網(wǎng)杯重建髖臼

3.2 股骨重建

CroweⅠ～Ⅱ型髖關節(jié)，不需要股骨短縮截骨來將股骨端放置于髖關節(jié)解剖中心的安全位置。由于髓腔較窄以及股骨前傾角，可以使用DDH特殊的細柄，包括骨水泥型及非骨水泥型假體柄。細柄骨水泥型假體柄可以控制前傾角；如果選用非骨水泥型的壓配型假體，術者必須注意避免前傾角過大，因為股骨本身存在一定的前傾角。

全髖關節(jié)置換術可以成功地治療伴有關節(jié)疼痛和活動障礙的成人先天性髖關節(jié)高脫位患者。CroweⅢ型髖關節(jié)，股骨重建的原則與CroweⅠ～Ⅱ型髖關節(jié)相同。然而，這個技術要求高，且并發(fā)癥發(fā)生率高。高脫位的股骨頭必須被復位至真臼，髖關節(jié)的作用力降低，改善外展力臂，延長髖臼假體的使用壽命。當髖臼杯置入假臼中,由于外展肌群松弛Trendelenburg步態(tài)和肢體不等長不能得到糾正。當髖臼杯置入真髖臼，由于肌肉緊張和神經(jīng)損傷的風險,髖關節(jié)復位幾乎不可能。為克服這些困難，兩種技術應運而生：①髂股牽引逐步延長肢體（圖8），②股骨短縮截骨術（圖9）。由于前者僅應用于少數(shù)或單側病例,股骨短縮截骨術便成為治療成人先天性髖關節(jié)高脫位的標準方法。

在某些情況下，如果重建髖關節(jié)解剖中心，也可能需要股骨短縮截骨。股骨短縮截骨在CroweⅣ型髖關節(jié)中的應用更為常見。

Anwar等報道通過股骨近端短縮截骨29%的患者骨不連，Trendelenburg步態(tài)的頻率增加。因此，近來更推薦選擇轉子下截骨術，能夠維持外展肌群的穩(wěn)定并糾正旋轉畸形。

短中期的隨訪研究表明，對于CroweⅣ型髖關節(jié)發(fā)育不良患者，通過轉子下股骨短縮截骨術，并使用非骨水泥型股骨假體柄，髖關節(jié)解剖中心重建，術后骨愈合率較好?？偟难芯拷Y果表明隨訪14年，生存率為75%，通過轉子下截骨并股骨假體重建后，Harris髖關節(jié)評分較術前改善。而使用新一代的高交聯(lián)聚乙烯內襯長期的隨訪結果尚待研究。

圖8 髂股牽引逐步延長肢體

圖9 轉子下截骨及固定和股骨近端短縮截骨X線片

[1]Sanchez-Sotelo J,Trousdale RT,Berry DJ,et al.Surgical treatment of developmental dysplasia of the hip in adults:I.Nonarthroplasty options.J Am Acad Orthop Surg,2002,10(5):321-333.

[2]Sanchez-Sotelo J,Berry DJ,Trousdale RT,et al.Surgical treatment of developmental dysplasia of the hip in adults:II.Arthroplasty options.J Am Acad Orthop Surg,2002,10(5):334-344.

[3]Brand RA.Hip osteotomies:a biomechanical consideration.JAmAcad Orthop Surg,1997,5(5):282-291.

[4]Argenson JN,Flecher X,Parratte S,et al.Anatomy of the dysplastic hip and consequences for total hip arthroplasty.Clin Orthop Relat Res,2007,465:40-45.

[5]Engesaeter LB,Furnes O,Havelin LI.Developmental dysplasia of the hip--good results of later total hip arthroplasty:7135 primary total hip arthroplasties after developmental dysplasia of the hip compared with 59774 total hip arthroplasties in idiopathic coxarthrosis followed for 0 to 15 years in the Norwegian Arthroplasty Register.J Arthroplasty 2008,23:235-240.

[6]Noble PC,Kamaric E,Sugano N,et al.Three-dimensional shape of the dysplastic femur:implications for THR.Clin Orthop Relat Res,2003,417:27-40.

[7]Perka C,Fischer U,Taylor WR,et al.Developmental hip dysplasia treated with total hip arthroplasty with a straight stem and a threaded cup.J Bone Joint Surg Am,2004,86-A:312-319.

[8]Lewallen DG.Neurovascular injury associated with hip arthroplasty.Instr Course Lect,1998,47:275-283.

[9]Nunley RM,Prather H,Hunt D,et al.Clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients.J Bone Joint SurgAm,2011,93 Suppl 2:17-21.

[10]Delaunay S,Dussault RG,Kaplan PA,et al.Radiographic measurements of dysplastic adult hips.SkeletalRadiol,1997,26:75-81.

[11]Crowe JF,Mani VJ,Ranawat CS.Total hip replacement in congenital dislocation and dysplasia of the hip.J Bone Joint SurgAm,1979,61:15-23.

[12]Hartofilakidis G,Stamos K,Karachalios T,et al.Congenital hip disease in adults.Classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip arthroplasty.J Bone Joint Surg Am,1996,78:683-692.

[13]Garvin KL,Bowen MK,Salvati EA,et al.Long-term results of total hip arthroplasty in congenital dislocation and dysplasia of the hip.A follow-up note.J Bone Joint Surg Am,1991,73:1348-1354.

[14]Mulroy RD,Harris WH.Failure of acetabular autogenous grafts in total hip arthroplasty.Increasing incidence:a follow-up note.J Bone Joint SurgAm,1990,72:1536-1540.

[15]Morsi E,Garbuz D,Gross AE.Total hip arthroplasty with shelf grafts using uncemented cups.A long-term follow-upstudy.JArthroplasty,1996,11:81-85.

[16]Gross AE,Catre MG.The use of femoral head autograft shelf reconstruction and cemented acetabular components in the dysplastic hip.Clin Orthop Relat Res,1994,298:60-66.

[17]Gerber SD,Harris WH.Femoral head autografting to augment acetabular deficiency in patients requiring total hip replacement.A minimum five-year and an average seven-year follow-up study.J Bone Joint Surg Am,1986,68:1241-1248.

[18]Kim M,Kadowaki T.High long-term survival of bulk femoral head autograft for acetabular reconstruction in cementless THA for developmental hip dysplasia.Clin Orthop Relat Res,2010,468:1611-1620.

[19]Rodriguez JA,Huk OL,Pellicci PM,et al.Autogenous bone grafts from the femoral head for the treatment of acetabular deficiency in primary total hip arthroplasty with cement.Long-term results.J Bone Joint Surg Am,1995,77:1227-1233.

[20]Dorr LD,Tawakkol S,Moorthy M,et al.Medial protrusio technique for placement of a porous-coated,hemispherical acetabular component without cement in a total hip arthroplasty in patients who have acetabular dysplasia.J Bone Joint SurgAm,1999,81:83-92.

[21]Linde F,Jensen J.Socket loosening in arthroplasty for congenital dislocation of the hip.Acta Orthop Scand,1988,59:254-257.

[22]Stans AA,Pagnano MW,Shaughnessy WJ,et al.Resultsof total hip arthroplasty for Crowe Type III developmental hip dysplasia.Clin Orthop Relat Res,1998,348:149-157.

[23]Delp SL,Wixson RL,KomattuAV,et al.How superior placement of the joint center in hip arthroplasty affects the abductor muscles.Clin Orthop Relat Res,1996,328:137-146.

[24]Kaneuji A,Sugimori T,Ichiseki T,et al.Minimum ten-year results of a porous acetabular component for Crowe I to III hip dysplasia using an elevated hip center.J Arthroplasty,2009,24:187-194.

[25]Krych AJ,Howard JL,Trousdale RT,et al.Total hip arthroplasty with shortening subtrochanteric osteotomy in Crowe type-IV developmental dysplasia:surgical technique.J Bone Joint SurgAm,2010,92 Suppl 1 Pt 2:176-187.

[26]Thillemann TM,Pedersen AB,Johnsen SP,et al.Implant survival after primary total hip arthroplasty due to childhood hip disorders:results from the Danish Hip Arthroplas-ty Registry.Acta Orthop,2008,79:769-776.

[27]Charnley J,Feagin JA.Low-friction arthroplasty in congenital subluxation of the hip.Clin Orthop Relat Res,1973,91:98-113.

[28]Boyle MJ,Frampton CM,Crawford HA.Early results of total hip arthroplasty in patients with developmental dysplasia of the hip compared with patients with osteoarthritis.J Arthroplasty,2012,27:386-390.

[29]MacKenzie JR,Kelley SS,Johnston RC.Total hip replacement for coxarthrosis secondary to congenital dysplasia anddislocation of the hip.Long-term results.J Bone Joint SurgAm,1996,78:55-61.

[30]Sochart DH,Porter ML.The long-term results of Charnley low-friction arthroplasty in young patients who have congenital dislocation,degenerative osteoarthrosis,or rheumatoid arthritis.J Bone Joint SurgAm,1997,79:1599-1617.

[31]Numair J,Joshi AB,Murphy JC,et al.Total hip arthroplasty for congenital dysplasia or dislocation of the hip.Survivorship analysis and long-term results.J Bone Joint Surg Am,1997,79:1352-1360.

[32]Silber DA,Engh CA.Cementless total hip arthroplasty with femoral head bone grafting for hip dysplasia.J Arthroplasty,1990,5:231-240.

[33]Lee BP,Cabanela ME,Wallrichs SL,et al.Bone-graft augmentation for acetabular deficiencies in total hip arthroplasty.Results of long-term follow-up evaluation.J Arthroplasty,1997,12:503-510.

[34]Schutzer SF,Harris WH.High placement of porous-coated acetabular components in complex total hip arthroplasty.J Arthroplasty,1994,9:359-367.

[35]Russotti GM,Harris WH.Proximal placement of the acetabular component in total hip arthroplasty.A long-term follow-up study.J Bone Joint SurgAm,1991,73:587-592.

[36]KlapachAS,Callaghan JJ,Miller KA,et al.Total hip arthroplasty with cement and without acetabular bone graft for severe hip dysplasia.A concise follow-up,at a minimum of twenty years,of a previous report.J Bone Joint Surg Am,2005,87:280-285.

[37]Kim YH.The results of a proximally-coated cementless femoral component in total hip replacement:a five-to 12-year follow-up.J Bone Joint Surg Br,2008,90:299-305.

[38]Hallan G,Lie SA,Furnes O,et al.Medium-and long-term performance of 11,516 uncemented primary femoral stems from the Norwegian arthroplasty register.J Bone Joint Surg Br,2007,89:1574-1580.

[39]Mortazavi SM,Restrepo C,Kim PJ,et al.Cementless femoral reconstruction in patients with proximal femoral deformity.JArthroplasty,2011,26:354-359.

[40]Anwar MM,Sugano N,Masuhara K,et al.Total hip arthroplasty in the neglected congenital dislocation of the hip.A five-to 14-year follow-up study.Clin Orthop Relat Res,1993,295:127-134.

[41]Krych AJ,Howard JL,Trousdale RT,et al.Total hip arthroplasty with shortening subtrochanteric osteotomy in Crowe type-IV developmental dysplasia.J Bone Joint Surg Am,2009,91:2213-2221.

[42]Bernasek TL,Haidukewych GJ,Gustke KA,et al.Total hip arthroplasty requiring subtrochanteric osteotomy for developmental hip dysplasia:5-to 14-year results.J Arthroplasty,2007,22:145-150.

[43]Biant LC,Bruce WJ,Assini JB,et al.Primary total hip arthroplasty in severe developmental dysplasia of the hip.Ten-year results using a cementless modular stem.J Arthroplasty,2009,24:27-32.