【作者】 王强；

【导师】 许树柴；

【作者基本信息】 广州中医药大学 ， 中医骨伤科学， 2012， 硕士

【摘要】 目前随着人工髋关节假体设计的日益完善,手术技术的日臻成熟,人工全髋关节置换(Total Hip Arthroplasty, THA)已成为治疗老年人髋部病变的常用方法,并且取得了良好的手术效果,明显提高了老年患者的生活质量。但同时也产生了不少的并发症,其中人工全髋关节置换术后脱位是仅次于无菌性松动的第二大并发症。因此,如何减少老年患者初次全髋置换术后脱位的风险因素,正确的进行全髋关节置换术后脱位的中西医结合围手术期治疗是临床骨科仍需要解决的问题。目的：探讨65岁及以上老年人因为髋部骨折(股骨颈骨折、粗隆间骨折)、AVN (avascular necrosis,股骨头缺血性坏死)、髋关节骨性关节炎、DDH (development dysplasia of hip joint,发育性髋关节不良)、强直性脊柱炎等原因,而采用人工全髋关节置换术,对术后出现脱位患者,进行脱位原因分析、中医证候的流行病学情况调查。通过对广东省中医院骨科老年初次人工全髋关节置换置换术后脱位原因的分析、脱位后中医证候的调查研究,明确危险因素,提出相应的中西医结合预防措施,为进一步提高老年患者的围手术期安全性、术后良好的效果、减轻患者负担提供保证。方法：本研究主要采用回顾性及前瞻性临床试验研究方法,研究了广州中医药大学附属第二医院(即广东省中医院)2009年1月至2012年1月中西医结合治疗65-100岁老年初次全髋关节置换术患者的基本信息资料,手术治疗的基本信息,其中要进行引起脱位的风险因素的统计比较、术后的中医证候频数统计。计数资料采用X2检验,计量资料采用独立样本t检验,所有数据采用SPSS17.0统计软件进行检验,P＜0.05作为有统计学意义标准。结果：本研究共收集65岁及以上因髋部骨折(股骨颈骨折、粗隆间骨折)、股骨头缺血性坏死(AVN)、髋关节骨性关节炎、DDH、强直性脊柱炎等患者,而进行初次人工全髋关节置换置换术患者共581例,术后脱位25例,脱位率4.3%,采用传统手法复位治疗18例,其中2例行切开复位,因反复脱位、假体位置严重不良再次手术治疗7例。脱位患者中髋臼侧为水泥型的共15例,占60%,生物型10例,占40%。本研究中,青年老年人组(65-74岁)共388例,脱位12例,脱位率3.09%；中老年老年人组(75-89岁)共190例,脱位13例,脱位率6.84%;老年老年人组(90岁及以上)共3例,脱位0例。SA (American Society of Anesthesiologists)(1-2)级患者共369例,脱位11例,脱位率2.98%；ASA(3-4)级患者共212例,脱位14例,脱位率6.60%。脱位组髋臼外展角平均55.1°,最小值为48.8°,最大值66.2。(与公认的最佳髋臼假体外展位置45。、髋臼假体外展最大安全区域50。相比)。09年THA共196例,脱位人数10例,脱位率5.1%；10年THA共208例,脱位人数11例,脱位率5.28%；11年THA共177例,脱位人数4例,脱位率2.26%。以上数据组之间差异有统计学意义(P＜0.05)。男性患者212例,脱位10例,脱位率4.72%；女性患者369例,脱位15例,脱位率4.07%。脱位组前倾角平均度16.4°,最小值10.5°,最大值26.2°(与公认最佳髋臼假体前倾角15。相比)。不同股骨头假体直径22mm、26mm、28mmm、32mm、36mm分组,脱位率分别为6.67%、5.88%、4.49%、3.14%、3.66%。脱位组与非脱位皆进行关节囊修复(其中70例患者根据关节囊不同的修复方式采取前瞻性研究,并进行脱位率比较)、手术入路采用后外侧入路。以上数据分组之间无明显统计学差异(P＞0.05)。0.05)。老年初次全髋置换术后脱位患者的中医证候分布：气虚血瘀证共13例,约占52.0%,瘀积化热证共7例,占28.0%,气滞血瘀证5例,占20%。结论：在我们的研究中,过大的髋臼外展角及早期的护理不当,是老年患者脱位的主要原因,同时由于老年患者年龄增大,身体机能降低,常合多种并发症,手术耐受性差而且由于术前、术后卧床时间相对年轻患者较长等因素还可使身体状况恶化,脱位的风险进一步增高。因此,术前充分的准备,术中假体位置的准确安放、髋关节旋转中心的良好重建、周围软组织的充分修复,术后早期软枕维持患肢外展中立位,准确而又积极的康复锻炼,正确的中医药辨证施治,是减轻患者髋部疼痛、恢复髋关节功能、提高患者生活质量的重要条件。医生应掌握老年人工全髋关节置换置换术后导致脱位的风险因素,采取预防性医疗,准确合理的中医药辨证施治,可减少术后医疗纠纷的风险,达到良好的术后效果。更多还原

【Abstract】 ObjectiveTo investigate the syndromes of Traditional Chinese Medicine and the reasons of the primary Total Hip Arthroplasty (THA) in elderly patient (≥65years), who suffered from hip frctures、AVN(avascular necrosis of femoral head)、osteroarthritis of hip joints、DDH (development dysplasia of hip joint)、 AS(ankylosing spondylitis). To clear and definite the risk factors and prevent the dislocation after the THA operation, thanks to this investigation.MethodsAn retrospective and prospective data of the elderly aged65years and over who received primary THA operation between Jan2009and Jan2012were reviewed. The date comes from The The Second Affiliated Hospital of Guangzhou Traditional Chinese Medicine University(Guangdong Traditional Chinese Medicine Hospital), which includes the basic information of the patients and the operation, the multiple comparsion of the the dislocation and TCM symptoms. Enumeration data used X" test, measurement data used Independent sample matching t test. All the data should be tested by SPSS17.0. The standard of the statistics is P<0.05.ResultsThe quantity of the hip fracture、AVN、osteroarthritis of hip joint、 DDH、AS are581cases,25cases(4.5%) in dislocation after operation, Con-serative measurements for16cases,2open reduction, operation for7cases. Acetabulum prothesis of cement is15(60%), cementless for10(40%).In this study group, There are388cases in Youth older age groups (65-74years), include12dislocated cases (3.09%), Middle older age groups (75-89years) includes190cases,13dislocated cases (6.84%), Old older age groups (≥90years) includes3cases,0dislocated cases (0%). There are11dislocated patients (2.98%) in369cases with American Society of Anesthesiologists (ASA)1-2grade,14(6.14%) dislocated patients in212with (ASA)3-4grade. Acetabular outreach Angle is54.7°, minimum value is48.8°, maximum value66.2°.The number of THA is196cases, and10(5.1%) for dislocation,5.28%in2010,2.26%in2011. There are statistical significance in the data set above.212cases are male, including10dislocated cases(4.72%);female369cases,15dislocated cases(4.07%). Acetabular anteversion Angle is16.9°, minimum value is10.5°, maximum value26.2°.The different diameter of femoral head is22mm、26mm、28mm、32mm、36mm, dislocation rate of them are6.67%、5.88%、4.49%、3.14%、3.66%respectively. There are no statistical significance in the acetabular abduction degrees and anteversion degrees between dislocated group and non dislocated group. All the patiens in the operation suffered from hip joint capsule repair、postlateral approach. There are no statistical significance in the data set above.The epidemiological survey on sydromes of TCM:There are13cases (52.0%) in qi defficiency and blood stasis syndrome,7cases(28.0%)with the syndrome of aeeumulating blood stasis generating internal heat,5cases (20.0%) with the syndromes of Qi-stagnaneyand bloodstasis.ConclusionOld patients are almost suffer from preoperative comorbidities、more surgical risk because of older age and low immunity. So, there are more compli-cations after THA than the younger, the most one is dislocation after operation. The positive treatments including,full preparation before opera-tion, prosthesis position in the center of the hip, accurate reconstruction of the soft tissue around hip joint during perioperative period and elaborate nursing, play very impotant part in sugry. In addition, the right of Chinese medicine treats dialectical is also included. These actions could reduce the risk of the operation, and improve the quality of life after operation.更多还原