Hardt Sebastian, Hube Robert, Perka Carsten
Musculoskeletal Surgery Centre, Charité - University Medicine Berlin.
Orthopaedic Surgery, OCM Clinic Munich.
Z Orthop Unfall. 2020 Apr;158(2):170-183. doi: 10.1055/a-0946-2750. Epub 2020 Mar 4.
Total hip arthroplasty in patients with high hip dislocation is a surgically demanding procedure. This is due to the congenital disorder of hip maturation and the resulting anatomical features. The aim of the arthroplasty is implantation of the cup prosthesis in the original centre of rotation, at the same time correcting femoral deformities and reducing the hip joint.
The indications include advanced osteoarthritis in the secondary acetabulum, existing instability, severe contractures and secondary changes in adjacent joints.
The contraindications include cerebrospinal dysfunction with impaired coordination, muscular dystrophies, overt metabolic bone disorders and complete or nearly complete absence of muscles that stabilise the hip/hip-stabilising musculature.
The operation is preferably performed through an anterolateral approach with the patient supine or through a posterolateral approach with the patient on his side. Sparing the pelvitrochanteric muscles is crucial for the functional outcome. Exposure of the original acetabulum is essential for correct and secure placement of the cup component. We perform planned shortening femoral osteotomy above an increase in length of more than 3.0 cm in patients without previous surgery and depending on the operative findings in previously operated patients. As a rule of thumb, the bone fragment to be removed should be approximately 60% of the distance between the planned and the preoperative position of the trochanter tip. Additional fixation is necessary only in the absence of primary stability between the parts of the femur divided by the osteotomy.
In these patients, the postoperative management is determined individually depending on the stability of the prosthetic cup fixation, bone quality, rotational stability of the stem in both segments of the femur after the osteotomy, existing soft tissue contractures and the resulting postoperative leg length difference.
The most frequent complications are nerve injuries, femoral fractures, malpositioning of the components, absence of integration of the components (usually due to inadequate primary stability), joint instability due to damage to the pelvitrochanteric muscles and therefore an increased risk of dislocation, pseudarthrosis of the femoral osteotomy and increased perioperative blood loss due to the prolonged operation time.
The currently published results show that subtrochanteric shortening osteotomy in patients with high hip dislocation with anatomic reconstruction of the original centre of rotation delivers good functional results with insignificantly increased 10-year loosening rates compared with standard management of primary hip osteoarthritis.
对于髋关节高位脱位患者，全髋关节置换术是一项对手术要求很高的操作。这是由于髋关节发育的先天性疾病以及由此产生的解剖特征所致。关节置换术的目的是将髋臼假体植入原始旋转中心，同时矫正股骨畸形并复位髋关节。
适应症包括继发性髋臼的晚期骨关节炎、现有不稳定、严重挛缩以及相邻关节的继发性改变。
禁忌症包括伴有协调功能受损的脑脊髓功能障碍、肌肉萎缩症、明显的代谢性骨病以及稳定髋关节的肌肉完全或几乎完全缺失。
手术最好通过患者仰卧位的前外侧入路或患者侧卧位的后外侧入路进行。保留骨盆转子周围肌肉对功能结果至关重要。暴露原始髋臼对于正确且安全地放置髋臼组件至关重要。对于既往未接受过手术的患者，若股骨长度增加超过3.0厘米，我们会进行计划性缩短股骨截骨术；对于既往接受过手术的患者，则根据手术中的发现进行操作。一般来说，要切除的骨块应约为大转子尖计划位置与术前位置之间距离的60%。仅在截骨分开的股骨部分之间缺乏初始稳定性时才需要额外固定。
在这些患者中，术后管理会根据髋臼假体固定的稳定性、骨质、截骨术后股骨两段中假体柄的旋转稳定性、现有的软组织挛缩以及由此导致的术后腿长差异进行个体化确定。
最常见的并发症是神经损伤、股骨骨折、组件位置不当、组件未融合（通常由于初始稳定性不足）、因骨盆转子周围肌肉损伤导致的关节不稳定以及因此脱位风险增加、股骨截骨处假关节形成以及由于手术时间延长导致的围手术期失血增加。
目前已发表的结果表明，对于髋关节高位脱位患者，通过解剖重建原始旋转中心并进行转子下缩短截骨术，与原发性髋关节骨关节炎的标准治疗相比，能带来良好的功能结果，10年松动率虽有小幅增加但不显著。
