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放射学评估

时间:2023-03-15 理论教育 版权反馈
【摘要】:髋关节的前后位及侧位应当包括假体全长。髋关节外旋将导致所摄X线片反应的关节偏心距缩短、颈干角的加大。如果患者髋关节内外旋受限,可以在半卧位摄片,以获得垂直于股骨颈的投射。如果临床测量和放射学测量差距较大,或者患者髋关节或者膝关节有明显的挛缩畸形可能影响下肢长度准确测量时,可采用CT协助确定肢体的长度差异。具体内容在本章第二节“人工关节置换术后疼痛关节的评估”介绍。

标准的术前放射学评估包括四个位置:以耻骨为中心的骨盆前后位(图14-16),患侧髋关节的前后位,蛙式位,侧位(图14-17)。

髋关节的前后位及侧位应当包括假体全长。骨水泥全髋假体的X线片应包括最远端的骨水泥塞。如果使用的是长柄股骨假体,摄片的长度应包括整个股骨。在任何情况下,摄片范围都应当包含整个股骨假体及周围骨水泥以及假体尾端以远至少2~3倍股骨直径距离的股骨长度。如果曾经发生过股骨骨折,术中截骨,或者股骨其他特殊异常,手术考虑使用长柄假体翻修时,需要拍摄股骨全长正侧位片。

摄髋关节前后位片时,球管应垂直于桌面,聚焦中心位于大粗隆顶端水平髂前上棘的内侧2英寸处。髋关节外旋将导致所摄X线片反应的关节偏心距缩短、颈干角的加大。为避免这一点,摄髋关节前后位片时,下肢应内旋15°~20°。如果患者髋关节内外旋受限,可以在半卧位摄片,以获得垂直于股骨颈的投射。

侧位的X线摄片也应当包含假体全长和完全的骨水泥包壳,股骨前弓也应在侧位片上准确显示。常用的侧位摄片有两种。一种为蛙式位,又称Lowenstein侧位(图14-18)。拍摄时,患者卧床,身体向患侧倾斜,患侧髋膝关节屈曲,髋膝踝关节接触桌面,以小粗隆为中心垂直于股骨近端投射。这种方法的优点是重复性好,能很好显示股骨干的前弓,但对股骨颈的前倾显示不佳。

另一种侧位片为shoot-through侧位(图14-19),又称为Daneulius-Miller modification of Lorenz方法。拍摄时患者仰卧,患侧髋关节伸直,对侧髋膝关节屈曲。球管置于对侧肢体下,于桌面平行同时与身体轴线成45°,以患侧股骨头为投照中心。髋臼假体前倾角在此位置时显示最佳。

如果同侧肢体进行过人工膝关节置换,摄片时要将膝关节包括在内,手术要考虑膝关节假体对髋关节假体的选择所造成的影响。对于骨盆、髋臼骨折和髋臼骨缺损严重的患者,Judet位摄片有助于评估前柱和后柱的完整性以及骨缺损的程度。除了髋臼的Judet位摄片外,复杂髋臼畸形或缺损还需要CT平扫以及三维影像重建帮助判断病情严重程度。

图14-16 骨盆前后位

图14-17 髋关节正位片及shoot-through侧位片

图14-18 Lowenstein侧位的拍摄体位

图14-19 shoot-through侧位的拍摄体位

有了X线片以后,术者首先应对现有假体的类型,位线,假体的松动程度,骨水泥壳的质量等作出判断,患侧股骨骨溶解的程度,应力遮蔽引起的骨萎缩,异位骨化,粗隆有无骨折,髓腔直径,髋关节偏心距,下肢长度等更应仔细评估。髋关节周围的骨折内固定器材的部位、种类应该明确,以便准备相应取出器械。应注意异位骨化的程度,严重的异位骨化(如3~4级)可能影响关节的暴露和活动。异位骨化骨组织通常形成于髋外展肌深面,有时可能需要行大粗隆截骨暴露异位骨化骨组织。异位骨化的预防可采用放疗或口服药物的方法。骨水泥翻修可口服吲哚美辛,对于使用非骨水泥假体的患者通常采用术后放疗,放疗时应用注意遮挡假体置入的部位。

X线片上的下肢长度差异通过测量坐骨结节连线与大粗隆顶点的距离予以确定。X线测量出的下肢长度差异可与体检测得的长度差异相比较。如果临床测量和放射学测量差距较大,或者患者髋关节或者膝关节有明显的挛缩畸形可能影响下肢长度准确测量时,可采用CT协助确定肢体的长度差异。

手术医生应首先从X线片明确假体的情况并确定是否需要取出假体。从病史中获得的假体资料需与X线片影像互相比对。术者可能需联系产品供应商以获取特殊的取出器械。位置良好的非骨水泥髋臼未出现松动,仅有内衬磨损,单纯更换内衬即可完成手术。这时,手术医生需要了解如何在不损坏臼杯的扣锁机制的情况下取出内衬,并准备相应的更换内衬。如果臼杯锁扣机制受损,那么即使其固定也很牢固,也需要翻修髋臼假体,而不能仅更换内衬。这时另一种选择是保留金属臼杯,在其内置入用骨水泥固定的全聚乙烯髋臼。在股骨假体固定完好,仅需更换股骨头时,术中要准备同一型号不同颈长的股骨头,不同厂商之间的股骨头假体不能互相替代,即使是同一个厂商的不同股骨假体颈锥度也有不同,因此术前一定要询问制造商有关信息。

组配型髋臼假体若有固定螺钉,需要供应商提供匹配的螺丝刀取出。很多非骨水泥股骨假体在假体肩部设计有带螺纹的连接孔,准备相应的拔出器械能降低假体取出的难度。

了解股骨假体表面涂层分布范围非常重要。如广泛涂层假体在假体柄部都可有骨长入。当X线片显示股骨假体柄部牢固固定时,应考虑采用延长的粗隆截骨技术,截骨需延伸至涂层最远端的位置。

从X线片判断,骨水泥股骨假体松动有3种形态:松动;高度可能松动;可能松动。具体内容在本章第二节“人工关节置换术后疼痛关节的评估”介绍。Gruen描述了骨水泥假体柄失败的四种模式:活塞运动;以柄内侧中部为枢轴的旋转运动;以股骨距为枢轴的旋转运动;悬臂样弯曲疲劳。这些情况可以在系列随访的X线片上得以体现。无菌性松动常产生骨水泥-骨界面透亮线,随着松动的进展,可在假体周围出现扇贝样骨质吸收区,髓腔重新塑形,髓腔内新生皮质骨样结构。

非骨水泥股骨假体的松动判断更为困难,在本章第二节“人工关节置换术后疼痛关节的评估”有详细介绍。在系列随访X线片上见假体移位是假体不稳定的表现。在近端涂层的股骨假体中,原本与髓腔内皮质紧密接触的远端柄周围出现空隙意味着不稳定。在假体柄无表面涂层部位周围产生的硬化骨并不说明假体松动,尤其在近端多孔表面涂层设计的股骨假体中更是如此。假体的多孔表面的颗粒脱落说明假体存在与骨组织的相对运动,也是明确的假体松动表现。

当假体不能得到坚实固定的时候,在假体尾端的髓腔内可能自发形成骨性基座来为假体提供垂直稳定性。一方面,骨长入良好,完全稳定的假体柄很少会产生骨基座;另一方面,在一个有明确骨长入证据的假体远端出现的骨基座并不表示假体松动。只有当假体尾端与骨基座之间出现反应性透亮线时,我们需怀疑假体松动。

应力遮蔽是非骨水泥假体固定可靠的表现,骨萎缩常发生在骨长入区域的近端。当远端固定假体或者锥形柄假体在股骨峡部固定时,应力直接向股骨远端传递,可出现股骨距萎缩。非骨水泥股骨假体多孔表面产生的生物学连接限制了聚乙烯颗粒向远端髓腔的迁移,因此早期的溶骨反应通常发生在Gruen1区和7区。

骨水泥髋臼假体的松动常常发生在髋臼骨水泥-骨界面。骨水泥髋臼假体的骨水泥-骨界面间形成的纤维组织层为磨损颗粒的播散提供了通道,从而导致骨水泥髋臼在放射学检查时表现为线型溶骨,因此骨水泥髋臼假体表面的透亮线与假体松动相关(图14-20)。按照Delee和Charnley描述的3分区原则,在Hodgkinson的一项200例骨水泥髋臼假体的研究中,若连续透亮线侵袭3个区域,有94%的髋臼被术中证明是松动的;如果透亮线只占2个区域,有74%的假体是松动的;若只有1个区域存在透亮线,则只有7%的髋臼假体出现松动。X线片显示臼杯移位是假体松动的明确证据。

图14-20 骨水泥髋臼松动表现为线型溶骨,透亮线均匀

明确提示非骨水泥髋臼假体松动的放射学征象有髋臼假体位移,螺钉断裂,假体断裂,多孔表面颗粒脱落。非骨水泥髋臼假体周围出现的透亮线并不一定说明假体松动。

非骨水泥髋臼出现骨溶解并不说明假体松动。关节活动过程中产生的聚乙烯磨损颗粒可顺着螺钉孔扩散,引起溶骨反应,系列X线片可见从局灶向周围逐渐扩大的溶骨区域,只要假体表面还有足够维持稳定的骨长入区域存在,假体就不一定松动。扣锁机制失败引起的内衬脱位可导致股骨头与髋臼金属臼杯的直接摩擦。在严重的情况下,由于磨损的金属颗粒沉积在关节内,导致X线片上可以看见关节囊的轮廓,就是所谓的气泡征。

感染患者的放射学诊断敏感性很差,约半数的感染患者X线片表现正常。感染的放射学表现包括花边状的骨膜反应,髋臼软骨下骨硬化区消失,少数有溶骨改变。

当前述的工作都完成后,接下来就是要精确评估并确定骨缺损的程度。骨缺损的程度直接影响翻修手术方案的确定和翻修假体的选择。很多临床医生根据自己的经验提出了很多的骨缺损分类方法,本书有专门章节介绍。完美的分类方法应该既能准确反应骨缺损的状况,又能准确地指导手术方案的确定。一旦确定手术方案,随后应该通过模板测量决定最终置入的假体类型、型号及假体置入位置。

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