全髋置换术中撞击：颈部不是唯一发生的部位
Impingement Between the Metal Stem and the Ceramic Liner in Total Hip Arthroplasty: The Neck Is Not the Only Place Where Impingement Occurs
全髋关节置换术中股骨柄和陶瓷内衬的撞击：
颈部不是唯一发生撞击的部位
译者：李睿
Background: It is assumed that impingement between the ceramic liner and the stem increases the possibility of a liner fracture in total hip arthroplasty with a ceramic-on-ceramic bearing. The purpose of this study was to analyze the pattern of the impingement by evaluating the notches (U-shaped indented wear scars engraved on the stem) on radiographs to determine when and where impingement develops and to analyze the factors affecting its occurrence.
背景：当使用陶对陶界面的髋关节置换时，陶瓷内衬和股骨柄的撞击增加了陶瓷内衬碎裂的可能性。这项研究的目的是通过评估X射线片上的凹痕（股骨柄上的U形锯齿状磨损痕迹）来确定撞击的时间和部位，并分析影响撞击发生的因素，从而分析撞击的模式。
Methods: Among the primary total hip arthroplasty cases using a ceramic-on-ceramic bearing performed from November 1997 to December 2003, 244 cases of 197 patients (123 male patients and 74 female patients) that had follow-up of ≥15 years were included. All of the radiographs were examined with special regard to the notches and the cup positions.
方法：纳入自1997年11月至2003年12月，采用陶对陶界面的初次全髋关节置换病例中，随访时间≥15年的197例患者（男123例，女74例）的244髋。检查所有X线片时，特别注意了凹痕和髋臼杯的位置。
Results: Notches were detected at 77 sites of 57 cases (23.4%) for the first time between 8 months and 14.8 years after the surgical procedure. They were located on the neck or the shoulder of the stem. Shoulder notches were detected only in the cases with a short-neck head. Shoulder notches were found in 29 cases (20.0% of short-neck cases). Cup inclination was lower (p = 0.01) and anteversion was higher (p = 0.01) in the group with notches than the group without notches. There were 5 cases of ceramic head fracture. One of them experienced another ceramic liner fracture, assumed to be caused by prosthetic shoulder impingement, after the revision surgical procedure.
结果：术后8个月至14.8年内，在57例患者的77个部位首次检测到凹痕（占23.4％）。它们位于股骨柄的颈部或肩部。肩部凹痕仅在颈部较短的病例中发现。共29例发现肩部凹痕（占短颈病例的20.0％）。有凹痕组的外展角较小（p = 0.01），而前倾角较大（p = 0.01）。陶瓷头碎裂共5例。其中一例可能是由于翻修术后股骨柄肩部撞击所致，又再次出现了陶瓷内衬的碎裂。
Conclusions: The results of this study suggest that impingement between the stem and the ceramic liner occurs in a considerable proportion of patients who underwent total hip arthroplasty not only on the neck but also on the shoulder of the stem. Forceful and abrupt impingement on the stem shoulder can cause ceramic liner fracture. Impingement between the stem shoulder and the ceramic liner should be considered in designing a stem. It seems to be prudent to recommend that patients avoid squatting or sitting cross-legged on the floor as much as possible.
结论：这项研究的结果表明，全髋关节置换术后，有相当大比例的病例会有股骨柄和陶瓷内衬的撞击。而且撞击不仅发生在股骨柄的颈部，也发生在肩部。柄肩部突然强烈的撞击会导致陶瓷内衬碎裂。在设计股骨柄时，应考虑柄肩部和陶瓷内衬之间的撞击。建议患者尽可能避免深蹲或盘腿似乎是比较谨慎的做法。
文献出处：Lee S, Yoo JJ, Kim HJ. Impingement Between the Metal Stem and the Ceramic Liner in Total Hip Arthroplasty: The Neck Is Not the Only Place Where Impingement Occurs. J Bone Joint Surg Am. 2020 Dec 3. doi: 10.2106/JBJS.20.00354. Epub ahead of print. PMID: 33269897.