混合型初次人工全髋关节置换术的临床应用

目的探讨混合型初次人工全髋关节置换术的适应证及临床疗效。方法回顾性研究2004年1月至2007年12月施行混合型初次人工全髋关节置换术42例（45髋）,全部得到随访,临床资料完整,平均随访（34．1±1．2）个月,对假体生存率、Harris髋关节评分、疼痛、步态、大腿痛等方面进行评估。放射学资料完整者39例（42髋）,平均随访（31．5±1．6）个月,对假体放射学松动率、骨水泥鞘分级、异位骨化等方面进行评估。结果假体生存率为97．7％,以髋臼或股骨假体无菌性松动为观察终点,则假体生存率为100％。Harris髋关节评分比术前平均（48±20）分（10～85分）改善为平均（90±8）分（56～100分）,仅1髋股骨头坏死为轻度疼痛,其余44髋均为轻微疼痛或无疼痛。2例为中度跛行,10例为轻度跛行,30例无跛行。无一例出现大腿痛,无一例出现髋臼或股骨假体的放射学松动。2例（2髋）发生异位骨化,均为BrookerⅠ级。结论混合型初次人工全髋关节置换术治疗晚期髋关节疾患效果良好。     

髋关节常见疾病的影像学诊断（二）

三、髋关节退行性骨关节病 1．临床特点：退行性骨关节病是一种由于关节软骨的退变所造成的慢性关节病，目前发病机制不明，分为原发性和继发性两种。原发性多见于45岁后，约占70％，女性多于男性；继发性的平均年龄较小，一般在40岁左右，病因很多，有数十种，常为先天性髋关节脱位、髋臼发育不良、骨折、脱位和股骨头坏死等。本病起病缓慢，主要症状为髋关节活动不灵和疼痛，多在早晨起床或久坐后明显，活动后消失，     

全髋关节置换术治疗髋臼发育不良

目的探讨全髋关节置换术治疗因髋臼发育不良(developmentaldysplasiaofthehip,DDH)致髋关节骨性关节炎的手术方法。方法1986年2月～2004年11月,对24例因DDH致髋关节骨性关节炎患者行全髋关节置换术。其中男4例,女20例。年龄33～59岁,平均47岁。双侧8例,单侧16例。主要症状为疼痛及跛行。根据Hartofilakidis分类方法,半脱位2髋,低位脱位21髋,高位脱位9髋,术前Harris评分分别为56.70±2.75、36.09±4.16及29.45±2.16分。结果术后均获随访6个月～8年,平均3年4个月。半脱位、低位脱位及高位脱位患者术后Harris评分分别为93.10±2.10、92.73±3.20及88.09±3.67分,与术前比较差异均有统计学意义(P<0.01)。术后6侧下肢轻度跛行,均无疼痛,可以长距离行走。X线片示人工髋关节位置佳,无明显松动及下沉。结论加深髋臼、内移髋关节活动中心及改进植骨方法,是增加人工臼稳定性手术成功的关键。     

体外高能震波治疗股骨头缺血性坏死

目的观察体外高能震波治疗股骨头缺血性坏死的近期疗效。方法自2004年10月～2005年10月，采用体外高能震波治疗股骨头缺血性坏死30例40髋。根据X线片及MRI进行股骨头坏死的ARCO分期：Ⅰ期8髋，Ⅱ期17髋，Ⅲ期15髋。采用X线透视结合MRI影像对坏死病灶进行定位，每侧股骨头选择4个震波治疗点，震波治疗参数：电压28kV、脉冲频率4Hz、每点冲击数1000次。震波治疗后2～3个月内患肢不负重。采用疼痛VAS评分、Harris髋关节功能评分、X线及MRI评估疗效。结果12例18髋治疗后局部出现瘀斑、皮下出血和轻微肿胀，未发现其它并发症。所有患者平均随访11．2个月，自觉症状改善33髋，无变化7髋。疼痛VAS评分治疗前平均（6．7±2．0）分，治疗后平均（2．5±2．3）分，差异有统计学意义（P〈0．05）。Harris评分治疗前平均（64．3±14．7）分，治疗后平均（81．9±9．3）分，差异有统计学意义（P〈0．05），去除疼痛得分后Harris评分治疗前后差异无统计学意义（P〉0．05）。随访期内MRI影像学改善15髋，无变化20髋，病变进展5髋，有2例2髋接受全髋关节置换术。结论体外高能震波治疗早中期股骨头缺血性坏死的近期疗效明显，主要表现为疼痛症状减轻和功能改善，具有操作简便和无创等优点，是一种较好的替代治疗方法。     

混合型初次人工全髋关节置换术的短期随访研究

目的 探讨混合型初次人工全髋关节置换术的适应证及治疗效果.方法 回顾性研究2001年1月～2004年12月由同一术者施行的混合型初次人工全髋关节置换术患者63例( 80髋),失访5例(5髋),临床随访资料完整者58例(75髋),对假体生存率、Harris 髋关节评分、疼痛、步态、大腿痛等方面进行评估;放射学资料完整者49 例(64髋),对假体放射学松动率、骨水泥鞘分级、异位骨化等方面进行评估.结果 75例(58髋)术后获随访(33.9±1.3)个月平均(15～57个月),假体生存率为97.3%,以髋臼或股骨假体无菌性松动为观察终点,则假体生存率为100%.Harris 髋关节评分从术前的平均(46±20)分(10～85分)改善为平均(92±8)分(56～100分). 56例(73髋)患者中,术后95.9%的患者(70髋)无疼痛或仅有轻微疼痛.4例(7.1%)为中度跛行,14例(25%)为轻度跛行,38 例(67.9%)无跛行.无一例出现大腿痛、髋臼或股骨假体的放射学松动.49例(64髋)放射学资料完整患者股骨假体骨水泥鞘分级:A级37髋, B 级20髋,C1级4髋, C2级3髋.4例(4髋)发生异位骨化,均为Brooker I级.结论 混合型初次人工全髋关节置换术近期随访效果良好.     

髋腰综合征诊断与治疗研究进展

正髋关节和腰椎退行性疾病患者常见症状为下腰部、臀部、髋周及下肢的疼痛,甚至出现跛行,统称为髋腰综合征[1]。临床上由于髋腰综合征患者主诉相似且髋、腰部病变常同时出现,很难与髋关节骨性关节炎和腰椎管狭窄症鉴别。髋关节骨性关节炎患者不仅有明显的腿部症状,同时也出现下腰痛,而腰椎管狭窄症患者出现下腰痛的同时合并髋关节骨性关节炎患者相关跛行步态。     

髋关节骨性强直或融合后的全髋关节置换术

目的　探讨髋关节骨性强直或融合后行全髋关节置换术的可行性。方法　对 10例髋关节骨性强直或融合患者行全髋关节置换术的临床疗效及手术相关问题进行分析。结果　随访 6～ 30个月 (平均 18个月 ) ,10例 12个髋关节活动度术前为 0° ,术后总的活动度平均 16 3° ,屈髋平均 89°;Har ris评分术前平均 15 6分 ,术后平均 89分。术后髋痛消失 ,膝痛、下腰痛明显改善 ,步态基本恢复正常 ,8例重返工作岗位。结论　髋关节骨性强直或融合后如果发生严重的下腰痛、对侧髋关节、同侧膝关节疼痛或髋关节融合在非功能位上 ,髋关节周围软组织条件好 ,外展肌基本正常 ,应行全髋关节置换术     

膝关节退行性骨关节病的治疗

运用养血活血、内外结合治疗膝关节退行性骨关节病，取得满意疗效，现介绍如下。临床资料１．８０例中男２７例，女５３例；平均年龄６４岁。右膝４９例，左膝３１例。随机分为两组，治疗组为６０例，对照组为２０例。２．临床表现：膝关节开始活动时痛，上下楼梯时特别明显，稍活动以后症状可减轻，负重和活动多时疼痛又会加重。并伴有关节肿胀，僵硬，部分患者因病久而出现股四头肌萎缩，关节活动明显受限。３．Ｘ线表现：可在骸骨后上角或后下角，胫骨平台一侧或两侧见有骨质增生，胫骨髁间隆起变尖，部分患者可见膝关节内侧或外侧间隙部…     

全髋置换治疗先天性髋臼发育不良临床疗效观察

[目的]了解全髋置换治疗先天性髋臼发育不良术后的中远期疗效。[方法]采用人工全髋关节假体，对23例25个先天性髋臼发育不良继发髋关节骨关节炎患者行全髋关节置换（THR），Pemer分型Ⅰ度15例，17个髋；Ⅱ度5例，5个髋；Ⅲ度2例，2个髋；Ⅳ度1例，1个髋。固定方法：髋臼侧，5髋为骨水泥固定，20髋为非骨水泥固定；股骨侧，7髋为骨水泥固定，18髋为非骨水泥固定。[结果]1例术中发生小转子劈裂，1例术后发生下肢静脉炎，3例两侧肢体不等长2am以上。随访3—11年，平均8．2年，术前Harris评分最高59分，最低25分，平均44．5分。所有患者术后髋关节疼痛消失，关节活动度增加，Harris评分最高97分，最低63分，平均85．6分。[结论]先天性髋关节脱位的全髋关节置换术，手术相对比较复杂并发症较多，手术中特别需要考虑两侧肢体的长度、外展肌的平衡、软组织的松解、髋臼骨缺损的处理及假体的选择。     

人工全髋关节置换术治疗56例强直性脊柱炎的临床研究

[目的]探讨人工全髋关节置换术治疗强直性脊柱炎的疗效。[方法]对56例（98髋）强直性脊柱炎患者行人工全髋关节置换术，其中42例（76髋）进行了平均5．6（2．5～10．5）a的随访。[结果]至末次随访时，Harris评分由术前的平均26．8（4～51）分提高到了术后的平均85．2（55～94）分，优良率为89．5％。1例感染行Ⅱ期翻修；2例在扩髓时出现股骨颈或股骨距裂缝骨折，但未到达小粗隆以下，未予特殊处置；1例出现足下垂，术后3个月后恢复，1例深静脉血栓，余病例无假体松动、断裂以及脱位发生。异位骨化发生率9．2％（7髋），但对功能无明显影响。[结论]人工全髋关节置换术治疗强直性脊柱炎可以明显缓解髋关节疼痛，恢复关节功能，与其它病因的全髋关节置换术相比，并无较高的危险因素。     

The mechanical cause of congenital dislocation of the hip joint: Dynamic ultrasound study of 5 cases

5 hip joints with untreated congenital dislocation of the hip were examined for hip movement by ultrasound. With the hip joint flexed, the direction of the dislocated femoral head was posterior to the acetabulum. The dislocated femoral head displaced more posteriorly when the knee joint was extended, with the hip joint held in flexed position. As the dislocated hip was extended, on the other hand, the direction of the dislocated femoral head was anterior to the acetabulum. The dislocated femoral head displaced more anteriorly when the baby tried to bend the hip with the joint held in extended position.

These findings indicate that a fetal posture with the hip flexed and the knee extended predisposes to the development of CDH by the action of hamstrings, and that an infant posture with the hip extended is likely to provoke femoral head dislocation by the action of the iliopsoas.     

The influence of surgically introduced muscle tension on the function of total hip prostheses (author's transl)]

The functional results of total hip prosthesis are influenced significantly by the tension given to the glutaeus medium muscle at operation. Low tension may result in a limp (positive Trendelenburg sign), high tension may decrease movement. In 206 cases of total hip replacement the Trendelenburg sign (grades from 0-3), the movement (in grades 0-4) and a grade of extension (distance or prosthetic femoral head and plastic acetabulum in cm at maximal extension after resection of the capsule) have been evaluated. In 191 hip joints not operated before the Trendelenburg sign was negativ before operation in only 31%, after operation it was negativ in 73%. The evaluation of the partial correlation coefficient showed a definite relation between Trendelenburg sign and the grade of extension. The higher the extensibility of the hip joint the more pronounced the Trendelenburg sign. In 71% of 191 cases the movement was increased after total hip replacement. With increased extensibility, the movement becomes better. However it is also related to the movement before operation. The optimal muscular tension and movement of the hip joint can be expected at an extension grade of 1.5-2.0 cm (distance between the prosthetic femoral head and the plastic acetabulum at maximal extension during operation).     

Subchondral cysts arise in the anterior acetabulum in dysplastic osteoarthritic hips

The distribution of subchondral cysts in 57 dysplastic osteoarthritic hips of 38 patients was assessed by computed tomography and by a new computerized technique. The cyst count in osteoarthritic hips was inversely correlated with the width of the joint space. A greater accumulation of cysts was found in the acetabulum than in the femoral head, and more cysts were found in the anterior part of the hip than in the posterior part. Osteoarthritic change was more predominant in the acetabulum than in the femoral head, and was more predominant in the anterior part of the hip than in the posterior part.     

Differential diagnosis of hip disease versus spine disease

Many clinicians find it difficult to differentiate between symptoms caused by a spine disorder or a hip disorder. If surgery is indicated, the order in which these operations take place is an important factor in the patient's long-term outcome. A prospective evaluation and retrospective chart review of patients with lower extremity pain was performed at the principal investigator's clinic to determine which signs and symptoms best predict the primary source of pain in patients with hip and spine disorders. Medical histories, physical examinations, and diagnostic tests were done on 97 patients with lower extremity pain to determine which signs and symptoms were the best predictors of a primary source of the pain (a hip or a spine disorder). The presence of a limp, groin pain, or limited internal rotation of the hip significantly predicted the diagnosis of a disorder as originating primarily from the hip, as opposed to originating from the spine. Patients with a limp were seven times more likely to have a hip disorder only or a hip and spine disorder than a spine only disorder. Similarly, patients with groin pain or limited internal rotation of the hips were seven and 14 times, respectively, more likely to have a hip disorder only or a hip and spine disorder than a spine only disorder. These variables are of primary importance to the clinician when making a differential diagnosis between hip disease and spine disease.     

Viscosupplementation in symptomatic severe hip osteoarthritis: a review of the literature and report on 60 patients

Osteoarthritis of the hip is a frequent joint disorder in adults aged 50 years and older. The management focuses on pain reduction, by means of non-steroidal anti-inflammatory drugs and analgesics, physical therapy and weight reduction. When these treatments fail, total hip replacement can be considered. Viscosupplementation is a local therapeutic approach with the objective to decrease pain and to improve joint mobility. The treatment consists of injecting hyaluronic acid or hyaluronate derivatives intra-articularly. Although this approach is frequently used in young sportive adults to avoid knee surgery, its use in the severe osteoarthritic hip is less well documented. Moreover the injection of the hip joint is more difficult than injection of the knee joint, and on another hand the general condition of the patients is often already compromised. In this article we present a literature review on the subject and report the results in 60 patients who received intraarticular viscosupplementation of the hip with the objective to delay total hip replacement surgery.     

A 5-year randomized controlled, double-blind study of glycosaminoglycan polysulphuric acid complex (Rumalon) as a structure modifying therapy in osteoarthritis of the hip and knee

OBJECTIVE: To determine the structure (disease) modifying effect of a glycosaminoglycan polypeptide association complex (GP-C; Rumalon) in patients with knee and hip osteoarthritis (OA). METHODS: Double-blind, randomized, placebo-controlled five-year study. Primary assessment criterion was change in radiographic joint space width between baseline and follow-up at 5 years. Secondary outcome criteria included Lequesne algofunctional index (LAI), pain on passive motion and consumption of non-steroidal antiinflammatory drugs (NSAIDs). The patients received 10 courses of injections of placebo or GP-C 2 ml intramuscularly in 5 years (two courses each year). Each course included 15 injections administered twice weekly. RESULTS: There were 277 patients with knee OA and 117 patients with hip OA. Control and GP-C treated groups were comparable as to sex, age, duration of disease, body weight, X-ray stage and value of LAI at the baseline. Knee joint space at 5 years decreased 0.37+/-0.08 (mean+/-standard deviation) mm for GP-C and 0.42+/-0.08 mm for placebo groups (P=0.68). Hip joint space at 5 years decreased 0.21+/-0.08 mm for GP-C and 0.22+/-0.08 mm for placebo groups (P=0.53). In a subset of patients with hip OA, Kellgren-Lawrence> or =2 and JSW> or =1 mm, there was a trend in favor of GPC for lower joint space narrowing in 5 years (P=0.11). In addition, there were no statistical differences between the treatment groups in LAI, pain on passive motion and consumption of NSAIDs. Side-effects after GP-C (14.5%) were rare, mild and not more frequent than in the placebo group (15%). CONCLUSION: We were not able to demonstrate a structure modifying effect of GP-C in OA of the hip or knee. Radiographic progression of OA in both knee and hip OA was lower than expected in both study groups.     

儿童髋关节一过性滑膜炎特殊类型关节内滑膜嵌顿型

对4例以跛行、患肢外展畸形、髋关节活动受限伴疼痛为主要症状的儿童,经核磁共振(MRI)检查、手术检查及其它治疗反应,发现髋关节内滑膜嵌顿的事实。对命名、分型及临床意义、发病机理、区别诊断提出讨论。定名为儿童髋关节一过性滑膜炎特殊型——关节内滑膜嵌顿型。     

Rotational acetabular osteotomy with a resection of the lateral edge of the acetabulum for the treatment of advanced coxarthrosis

Introduction We compared the functional and radiological results of a rotational acetabular osteotomy (RAO) with and without a resection of the lateral edge of the acetabulum. The purpose of the resection was to obtain good joint congruency. Materials and methods RAO was performed on 71 hips to treat advanced coxarthrosis caused by acetabular dysplasia. RAO without a resection (non-resection group) was performed in 54 patients (57 hips) with a median age of 43.1 years. The remaining 14 patients (14 hips), who had a median age of 44.6 years, received RAO with a resection of the lateral edge of the acetabulum (resection group). Results The average postoperative total hip joint score was better than the average preoperative score in the non-resection group (P < 0.001), but not in the resection group. In the resection group, all hips displayed progressive osteoarthritic change and ten hips had chondrolysis of the hip joint and a collapse of the transferred acetabulum within 3 years. In the non-resection group, 15 hips showed progressive osteoarthritic change, 24 hips had no change, and 18 hips showed a decrease in the osteoarthritic stage. Conclusion Our findings demonstrated that resection of the lateral edge of the acetabulum is not a useful adjunct to the RAO procedure for the treatment of advanced coxarthrosis. No benefits in any form have been received or will be received from a commercial party related to the subject of this article.     

Dorsal root ganglion neurons with dichotomizing axons projecting to the hip joint and the knee skin in rats: possible mechanism of referred knee pain in hip joint disease

BackgroundPatients who have hip joint diseases sometimes complain of knee pain as well as hip joint area pain. However, the precise sensory innervation pattern and correlation of the sensory nerves of the hip joint and knee are unknown. The purpose of this study was to investigate dorsal root ganglion (DRG) neurons with dichotomizing axons projecting to both the hip joint and the knee skin in rats using double fluorescent labeling techniques, and to examine characteristics of the DRG neurons with dichotomizing axons using immunohistochemical staining for inflammatory neuropeptides such as calcitonin gene-related peptide (CGRP).MethodsFor 20 rats, two kinds of neurotracers, Fluor-o-Gold (FG) and 1,1′-dioctadecyl-3,3,3′,3′-tetramethyl-indocarbocyanine perchlorate (DiI), were used in the double-labeling study. FG was injected into the left hip joint, and DiI was applied to the left medial portion of knee skin. Ten days after application, bilateral DRGs were harvested and immunohistochemically stained for CGRP.ResultsDRG neurons double labeled with FG and DiI were observed only from L2 to L4 on the left side. Approximately 1.6% of all DRG neurons innervating the hip joints had other axons that extended to the medial portion of knee skin, and 35% of double-labeled neurons were CGRP positive.ConclusionsOur results showed that the double-labeled neurons had peripheral axons that dichotomized into both the hip joint and the knee skin. CGRP-positive neurons of these dichotomizing fibers may play some role in the manifestation of referred knee pain with hip joint pain.