Flecher X, Argenson J N, Parratte S, Ryembault E, Aubaniac J M
Service de Chirurgie Orthopédique, CHU Sud, Hôpital Sainte-Marguerite, 270, boulevard Sainte-Marguerite, BP 29, 13274 Marseille Cedex 09.
Rev Chir Orthop Reparatrice Appar Mot. 2006 Jun;92(4):332-42. doi: 10.1016/s0035-1040(06)75763-4.
Arthroplasty in developmental dysplasia of the hip joint raises technical problems related to the anatomy and age of the young patient. The purpose of this work was to report results obtained with a custom-designed cementless stem.
This study included 257 hips reviewed at mean 82 months (range 43-162 months). Mean patient age was 55 years (17-78), mean weight 67 kg (42-118), and mean height 164 cm (147-190). A standard imaging protocol was performed for all patients: AP pelvis in reclining position, AP and lateral views of healthy and pathological hip, AP view of entire lower limb in standing position, computed tomography of lower limb. La position of the greater trochanter and the lengthening necessary was determined from the preoperative films. Stem integration and migration as well as osteolysis were studied postoperatively. Femoral anteversion and the anteroposterior diameter of the paleoacetabulum were measured on the superposed computed tomographic images. Surgery was performed via a Watson-Jones approach to insert a noncemented cup hooked in the obturator foramen and implanted in the paleoacetabulum. The femur endomedullary cavity was prepared with a ream having the form of the definitive stem and the prosthetic neck was custom fit to match the desired lever arm and anteversion.
The series included 174 cases of dysplasia and 83 dislocations, 39% stage 1, 30% stage 2, 14% stage 3 and 17% stage 4. Mean lengthening was 39 mm. The mean helitorsion was 28 +/- 16 degrees and the mean anteroposterior diameter of the acetabulum was 51 mm. On average, the alpha correction in the prosthetic neck was -13.4 degrees (-71 degrees to +37 degrees). The Postel-Merle-d'Aubigné score improved from 10.4 points preoperatively to 16.7 points at last follow-up. Postoperative x-rays showed signs of osteointegration in 88% of cases, osteolysis in 5% and one case of stem impaction. Ten hips (3.9%) required revision for replacement (7 for an aseptic problem and 3 for sepsis). Survival was 94.7% at 13 years.
This study confirmed the anatomic modifications observed in patients with developmental hip dysplasia and the surgical problems they cause. There was no correlation between the degree of dislocation and the degree of helitorsion which is difficult to assess without a preoperative computed tomography. The survival rate at 13 years is encouraging in this population. The intramedullary portion of the cementless stem must be adapted to the dimensions of the femoral canal which decrease with increasing dislocation.
髋关节发育不良的关节成形术会引发与年轻患者解剖结构和年龄相关的技术问题。本研究旨在报告使用定制设计的非骨水泥型股骨柄所取得的结果。
本研究纳入了257例髋关节，平均随访82个月（范围43 - 162个月）。患者平均年龄55岁（17 - 78岁），平均体重67千克（42 - 118千克），平均身高164厘米（147 - 190厘米）。对所有患者均执行标准成像方案：仰卧位前后位骨盆片、健侧和患侧髋关节的前后位及侧位片、站立位全下肢前后位片、下肢计算机断层扫描。根据术前X线片确定大转子的位置及所需延长长度。术后研究股骨柄的整合与移位以及骨溶解情况。在叠加的计算机断层扫描图像上测量股骨前倾角和髋臼前后径。手术通过Watson-Jones入路进行，以插入一个钩在闭孔内的非骨水泥髋臼杯并植入髋臼。股骨骨髓腔用与最终股骨柄形状相同的扩髓器进行准备，假体颈部定制以匹配所需的力臂和前倾角。
该系列包括174例发育不良和83例脱位病例，39%为1期，30%为2期，14%为3期，17%为4期。平均延长长度为39毫米。平均螺旋扭转角为28±16度，髋臼平均前后径为51毫米。假体颈部的平均α角矫正为 - 13.4度（ - 71度至 + 37度）。Postel-Merle-d'Aubigné评分从术前的10.4分提高到末次随访时的16.7分。术后X线片显示88%的病例有骨整合迹象，5%有骨溶解，1例股骨柄撞击。10例髋关节（3.9%）需要翻修置换（7例因无菌性问题，3例因感染）。13年时的生存率为94.7%。
本研究证实了在发育性髋关节发育不良患者中观察到的解剖学改变及其引发的手术问题。脱位程度与螺旋扭转角之间无相关性，若无术前计算机断层扫描则难以评估。该人群13年的生存率令人鼓舞。非骨水泥股骨柄的髓内部分必须适应随脱位程度增加而减小的股骨髓腔尺寸。
