髋臼骨折后的全髋关节置换术

随着对髋臼骨折的认识以及手术技术和内固定设计的发展，髋臼骨折的治疗预后也不断改善。但是，创伤性关节炎仍然是髋臼骨折的一个远期并发症。目前认为，关节面残留的不连续性是创伤后关节炎并导致治疗失败的主要原因。另外，髋关节脱位，软骨撞击损伤，股骨头缺血性坏死等也是导致创伤性关节炎的重要因素（图16-20至图16-22）。

图16-20　髋臼骨折内固定术后全髋置换术

A．男性，28岁，左髋臼骨折伴髋关节后脱位；B．切开复位内固定术后；C．术后16个月，股骨头坏死；D．全髋关节置换术后

图16-21　左髋臼骨折术后创伤性关节炎，全髋关节术中股骨干骨折

图16-22　女性46岁，左髋臼骨折合并股骨颈骨折，保守治疗失败。使用金属加强网笼自体股骨头颗粒植骨重建髋臼，骨水泥髋臼杯，非骨水泥股骨柄全髋关节置换

髋关节创伤后关节炎的治疗方法主要包括髋关节融合和全髋关节置换术。由于髋臼骨折多发生在活跃的年轻患者中，髋关节融合通常不能被接受，并且，髋关节融合术后的腰椎退变，同侧膝关节以及对侧髋关节的退变也是医生必须考虑的因素。因此，全髋关节置换术成为了髋关节创伤后关节炎的主要治疗手段。然而，所有的临床研究均指出这是一项技术要求较高的手术。由于这类患者中，大多数均存在髋臼骨量缺损，严重的瘢痕形成，残留内固定，骨盆解剖畸形，骨不连以及异位骨化等问题，使得手术变得极具挑战性。尽管许多文献报道髋臼骨折后全髋关节置换的临床结果令人满意，但结果一般较退行性髋关节疾病患者的全髋关节置换差。

1．手术适应证

（1）髋臼骨折后出现严重创伤性关节炎。

（2）保守治疗失败。

2．禁忌证

（1）髋关节部位活动性感染。

（2）髋关节无疼痛。

3．病理特征　髋臼骨折后，尤其是伴有髋关节脱位的病例，通常存在较大的骨缺损并且骨折块间存在瘢痕组织和骨痂及异位骨化。经过手术治疗的病例，多有严重的瘢痕组织，髋关节周围软组织挛缩严重，并且有内固定的残留，这些都为手术带来较大的困难。

4．技术难点

（1）手术显露：由于越来越多的髋臼骨折患者采用切开复位内固定手术治疗，手术的显露通常会带来一定的难度。手术入路通常使用后入路，这样可以较大范围显露髋臼后方，对于后方异位骨化严重，髋关节僵直的病例，可能需要采用前后联合入路进行软组织松解。对于存在骨折骨不连的病例，必须充分暴露骨折段，清理瘢痕组织，骨折断端间植骨以获得骨折愈合。

（2）髋臼的固定：由于髋臼骨折或经手术治疗，髋臼的骨量和质量均较普通的髋臼差，一般采用非骨水泥固定髋臼假体，必要时需要使用多孔髋臼以增加髋臼的初期稳定性。除非使用打压植骨技术，一般不使用骨水泥固定髋臼。

髋臼骨折后的处理对全髋关节置换术的影响，学术界的观点并不一致。A.Veil-Picard等认为对于髋臼骨折的治疗不影响关节置换手术的成功率。Romness和Lewallen认为，髋臼骨折后的骨缺损和髋臼的解剖畸形程度与手术的难度相关，并可能会影响髋臼假体的生存率。因此建议对于有移位的髋臼骨折均采用切开复位内固定以恢复髋臼的解剖和骨量，为以后的全髋关节置换提供良好的调节。与之相反，Willem Schreurs则认为内固定对于全髋关节手术操作来说会增加难度。手术瘢痕挛缩和粘连，异位骨化的形成以及内固定的取出等均会增加手术的时间和复杂程度，同时，由于切开复位内固定术需要较大范围剥离髋臼周围的软组织，造成骨坏死，不利于髋臼的重建。我们认为，手术骨折复位内固定对于髋臼解剖的恢复和骨量的恢复仍然是至关重要的。但是，应当尽可能减少骨块的剥离和内固定的金属，在当前的情况下，尽可能采用导航技术间接复位微创内固定的方法，不但可以使患者能迅速康复，减少骨折血供的破坏，对于全髋关节补救手术也是十分有利的。

5．关节置换手术时是否必须取出内固定　学术界也有不同的观点。我们认为，如果内固定不妨碍髋臼的安放和固定，可以保留内固定。理由是保留内固定一方面可以缩短手术时间，减少因为取内固定而带来的创伤，同时，内固定的存在，也有助于髋臼假体初期稳定性的建立，尤其是在使用非骨水泥压配技术和需要植骨的患者中（图16-23和图16-24）。

6．感染的发生　文献报告髋臼骨折内固定术后进行全髋关节置换术的感染发生率高于普通全髋关节置换术。Bucholtz等报告髋臼骨折内固定术后感染的发生率高达20%。Tile等认为这与内固定术后存在低度骨髓炎有关。因此建议所有髋臼骨折内固定后创伤性关节炎患者，在全髋关节置换术前进行髋关节穿刺培养，排除潜在的低度感染。我们报道的病例中有一例深部感染患者中，全髋关节置换术前的血沉和C反应蛋白均正常，术中的冷冻切片提示感染可能（多核细胞5～10个/HP），术中进行了清创并取出所有内固定。但使用了股骨头进行髋臼后壁缺损的植骨，这可能是导致深部感染的原因（图16-25）。

图16-23　髋臼螺钉穿入髋臼，影响髋臼的安装，必须取出

图16-24　髋臼骨折内固定术后股骨头坏死伴创伤性关节炎，术中保留内固定，使用异体颗粒骨植骨填充骨缺损

图16-25　术后感染病例

A．髋臼骨折术后1年，髋关节脱位，创伤性关节炎；B．全髋关节术后，使用自体股骨头重建髋臼缺损；C．术后3周伤口愈合不良，出现窦道，脓性分泌物；D．进行了彻底清创，缺损区域使用抗生素骨水泥加强；E、F．术后1年随访，伤口愈合良好，无感染复发，Harris评分85分

7．骨缺损的处理　不同的作者对于骨缺损的处理使用不同的方法，Daniel Berry报告使用非骨水泥髋臼加上自体颗粒骨和结构植骨，34例髋关节至少10年随访，只有2例因为髋臼松动导致翻修。Willem Schreurs等使用打压植骨骨水泥髋臼假体，同样取得良好的临床结果。20例髋臼骨折术后髋关节置换手术的10年髋臼假体生存率达到100%，15年假体生存率80%。我们的病例中，对于骨缺损的病例均采用了结构植骨和颗粒植骨技术，（图16-26和图16-27）这样手术比较简单，使用的材料来源容易，不增加手术的时间和成本，同样也能获得较好的疗效。当然，结构植骨从本质上是没有生物活性的，仅能起到初期支撑的作用，如果缺损较多的情况，自体股骨头可能骨量不够，同时也存在自体骨感染的危险。

总之，对于年轻的生活要求较高的患者，全髋关节置换术仍然是一种有效的治疗手段，但是与骨关节炎患者相比，髋臼骨折后全髋关节置换手术是一种复杂而高风险手术。

图16-26　髋臼骨折伴脱位，保守治疗失败，全髋关节置换，使用自体股骨头结构植骨重建髋臼

图16-27　男性51岁，陈旧性髋臼骨折脱位20年，创伤性关节炎

A．术前X线片显示右侧髋臼骨折伴髋关节脱位，继发创伤性关节炎；B．CT显示髋臼后壁缺损；C．术中使用自体股骨头重建髋臼后壁，植入髋臼；D．术后X线片

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