双侧分别行髋臼周围截骨和全髋关节置换术后的功能比较

doi:10.3877/cma.j.issn.1674-134X.2022.04.005

目的

探讨双侧分别接受髋臼周围截骨术(PAO)和全髋关节置换术(THA)的发育性髋关节发育不良(DDH)患者术后自评关节功能的差异及对手术倾向的影响。

方法

回顾性分析解放军总医院第四医学中心关节外科2010年6月至2017年5月双侧髋关节一侧行PAO治疗对侧行THA治疗的患者，纳入标准为术前诊断为双侧DDH，且同一名患者双侧髋关节术前DDH分型相同，患者仅接受单纯PAO手术和THA手术。采用方差分析比较手术时间，术中出血量和围手术期并发症等手术相关数据，采用独立样本t检验比较术后早期和1年后随访视觉疼痛评分、髋关节Harris功能评分、患者自我功能评分(简化国际髋关节评分问卷量表)和手术倾向性。

结果

共有12例患者(24髋)纳入研究，其中男性2例，女性10例，首次手术平均年龄为(35±4)岁，两次手术间隔(17±11)月。术后3个月THA侧Harris髋关节评分明显改善(t＝－15.222，P<0.001)，PAO侧则较术前下降(t＝3.927，P＝0.001)，至术后1年随访双侧髋关节Harris评分差异无统计学意义(t＝1.156，P>0.05)，患者自我功能评价差异有统计学意义(t＝3.550，P＝0.002)。PAO术后患者关节疼痛持续时间较长，使用拐杖非负重活动时间较THA长。PAO侧髋关节共出现3例并发症，THA侧出现1例。早期随访THA侧满意度(58.3%)高于PAO侧(41.7%)，但差异无统计学意义(χ²＝0.667，P>0.05)；至末次随访患者对两种术式的满意度相同。手术倾向性方面，所有患者在末次随访时倾向接受PAO手术。

结论

PAO和THA在功能改善和疼痛缓解方面均可获得满意的疗效，术后1年以上随访患者更倾向接受PAO。此研究结果对年轻症状型DDH患者的治疗方案选择有一定的参考意义。

关键词: 发育性髋关节发育不良, 截骨术, 关节成形术

Objective

To investigate the difference of self-evaluated joint function and the effect on the tendency of operation choice in DDH patients who bilaterally receive periacetabular osteotomy (PAO) and total hip replacement (THA) respectively.

Methods

A retrospectively analysis was carried out on the patients with DDH who underwent bilateral PAO and THA in the joint surgery department of the Fourth Medical Center of PLA General Hospital from June 2010 to May 2017. Inclusion criteria: preoperative diagnosis of bilateral DDH, the patient had the same DDH classification of both sides. The patients who underwent surgeries other than PAO and THA were excluded. The medical records and imaging data were reviewed. The operation related data such as operation time, intraoperative bleeding volume and perioperative complications were compared use on-way ANOVA. The hip Harris score, patient-reported function score (iHOT-12)and operation tendency at early and last follow-up were also compared use independent t test.

Results

Overall 12 patients (24 hips) were included in this study, among which were two males and 10 females, the age at the first operation time were (35±4) years, with the interval between the two operations (17±11) months. The Harris score was significantly improved (t=-15.222 P<0.001) in THA side, but the scone of the PAO side decreased (t=3.927 P=0.001) compared with the preoperative data at three months follow-up. There was no statistically significant difference of the postoperative Harris score of both sides after follow-up more than one year (t=1.156 P=0.264). There was statistically significant difference in the patient-reported function score between the two sides (t=3.550 P=0.002). The duration of joint pain after PAO was longer, and the time of non-loadbearing activity with crutches was longer than THA patients. There were three cases have complications in PAO side and only one case in THA side. The satisfaction rate of THA side was higher (58.3%) than that of the PAO side (41.7%) at the early follow-up, the difference was not statistically significant(χ²=0.667, P>0.05). The patient satisfaction results of the two procedures were the same at the last follow-up. All the patients tended to chose PAO surgery at the last follow-up.

Conclusions

PAO and THA both produce comparable improvement in function and pain one year after surgery. The patients are satisfied with bilateral surgery but more incline to receive PAO. These findings may be important in the decision making process in middle aged patients with symptomatic acetabular dysplasia.

Key words: Developmental dysplasia of the hip, Osteotomy, Arthroplasty

表1 患者两侧手术相关数据比较(±s)

手术侧	例数	术时年龄(岁)	BMI(kg/m²)	手术时间(min)	术中出血量(ml)	出院时Hgb(g/L)	住院天数(d)	住院费用(万元)
PAO	12	34.3±8.7	25.3±3.8	103.3±13.7	533.3±176.2	74.1±7.2	13.8±2.2	4.9±1.3
THA	12	34.3±10.3	25.9±3.4	69.8±10.6	145.8±62.0	79.5±10.4	11.6±1.4	7.0±0.5
t值		0.000	－0.410	6.692	7.185	－1.487	2.954	－5.143
P值		>0.05	>0.05	<0.001	<0.001	>0.05	0.007	<0.001

表1 患者两侧手术相关数据比较(±s)

手术侧	例数	术时年龄(岁)	BMI(kg/m²)	手术时间(min)	术中出血量(ml)	出院时Hgb(g/L)	住院天数(d)	住院费用(万元)
PAO	12	34.3±8.7	25.3±3.8	103.3±13.7	533.3±176.2	74.1±7.2	13.8±2.2	4.9±1.3
THA	12	34.3±10.3	25.9±3.4	69.8±10.6	145.8±62.0	79.5±10.4	11.6±1.4	7.0±0.5
t值		0.000	－0.410	6.692	7.185	－1.487	2.954	－5.143
P值		>0.05	>0.05	<0.001	<0.001	>0.05	0.007	<0.001

表2 患者两侧手术髋关节功能相关数据比较　(±s)

手术侧	例数	VAS评分			F值	P值
手术侧	例数	术前	术后3个月	术后1年	F值	P值
PAO	12	28.8±5.5	30.3±5.6	9.0±5.3^ab	67.576	<0.001
THA	12	68.1±9.8	20.0±4.7^a	9.2±6.3^ab	215.188	<0.001
t值		－12.116	4.910	－0.070
P值		<0.001	<0.001	>0.05
手术侧	例数	Harris评分			F值	P值
手术侧	例数	术前	术后3个月	术后1年	F值	P值
PAO	12	87.3±3.8	80.5±4.7^a	93.3±2.9^ab	36.636	<0.001
THA	12	48.1±5.8	86.3±5.8^a	91.8±3.4^a	212.123	<0.001
t值		19.522	－2.672	1.156
P值		<0.001	<0.014	>0.05
手术侧	例数	iHOT-12评分			F值	P值
手术侧	例数	术前	术后1年		F值	P值
PAO	12	44.7±4.3	73.6±4.3^a	－	－17.297	<0.001
THA	12	37.2±3.6	68.6±2.4^a	－	－23.961	<0.001
t值		4.657	3.550	－
P值		<0.001	0.002	－

表2 患者两侧手术髋关节功能相关数据比较　(±s)

手术侧	例数	VAS评分			F值	P值
手术侧	例数	术前	术后3个月	术后1年	F值	P值
PAO	12	28.8±5.5	30.3±5.6	9.0±5.3^ab	67.576	<0.001
THA	12	68.1±9.8	20.0±4.7^a	9.2±6.3^ab	215.188	<0.001
t值		－12.116	4.910	－0.070
P值		<0.001	<0.001	>0.05
手术侧	例数	Harris评分			F值	P值
手术侧	例数	术前	术后3个月	术后1年	F值	P值
PAO	12	87.3±3.8	80.5±4.7^a	93.3±2.9^ab	36.636	<0.001
THA	12	48.1±5.8	86.3±5.8^a	91.8±3.4^a	212.123	<0.001
t值		19.522	－2.672	1.156
P值		<0.001	<0.014	>0.05
手术侧	例数	iHOT-12评分			F值	P值
手术侧	例数	术前	术后1年		F值	P值
PAO	12	44.7±4.3	73.6±4.3^a	－	－17.297	<0.001
THA	12	37.2±3.6	68.6±2.4^a	－	－23.961	<0.001
t值		4.657	3.550	－
P值		<0.001	0.002	－

图1 典型病例患者双侧髋关节手术前后X线片。图A为患者术前站立位骨盆正位X线片，左髋关节T?nnis 2期，右髋关节T?nnis 0期；图B右侧髋臼周围截骨术后23个月随访X线片，右髋关节外侧中心角正为25°，T?nnis角矫正为0°，左髋关节T?nnis分期加重至3期；图C为患者右髋内固定取出左髋关节置换术后12个月随访X线片，右髋截骨后矫正角度未见丢失，T?nnis 0期，左髋假体位置良好未见松动迹象

图2 术后并发症患者骨盆正位X线片。图A示右髋截骨术后耻骨上支不愈合；图B示左髋THA术中股骨距骨折给予钢丝固定

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Functional outcomes comparison following simultaneously bilateral periacetabular osteotomy and total hip arthroplasty

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Functional outcomes comparison following simultaneously bilateral periacetabular osteotomy and total hip arthroplasty