【作者】 李凯；

【导师】 王静成； 李小磊；

【作者基本信息】 扬州大学 ， 临床医学硕士（专业学位）， 2022， 硕士

【摘要】 背景全髋置换术(THA)目前已经在临床上普遍应用,针对于终末期髋关节患者来说,是一种显著且有效的首选手术方法。但术后并发的假体脱位对于病人和外科医生来讲,无疑是一个毁灭性的并发症。虽然其发病率相对不高,但依然是导致全髋置换术后翻修的主要因素之一,同时也是危害病人生命质量的重大并发症之一。目前对导致假体脱位的影响原因尚未得到共识,因此学术界关于诱发假体脱位的主要因素尚存在争议。目的通过回顾性研究,探索分析在全髋关节置换术后并发假体脱位的有关危险因素,并构建风险预测模型,以期为临床医师提供一个可靠的脱位风险预测工具。同时为减少术后脱位,甚至发展成反复性脱位的几率,为提高患者的生活质量提供理论基础。方法回顾性收集2013.01-2021.12在本院行初次全髋关节置换术并发假体脱位的患者,查询并收集患者的脱位情况,共收集到全髋关节置换术后脱位的患者41例,其中随访期内仅发生一次脱位的有32例,发生多次脱位的有9例,同时纳入同期行全髋关节置换术后未发生脱位患者1169例作为对照组,随访时间截止2022年4月。分析并对比了两组病人在接受治疗前的就诊原因、性别构成、年龄、BMI,基础疾病史、腰骶部疾病史、神经系统病变史,记录术中采用的麻醉方式、手术时长、髋臼杯大小、假体头直径,术后测量股骨偏心距大小、手术前后肢体长度的变化值、髋臼外展角、股骨前倾角、小转自到泪滴的垂直距离,并计算出联合前倾角、臼-头比。搜集所有可以引起术后假体脱位的相关因素纳入分析。首先使用单因素数据分析,对单因素数据分析结果中具有统计含义的危险因素纳入多因素非条件logistic回归分析,从而确定相关危险因素。随后利用R软件把有统计学含义的独立风险因素纳入,进而绘制出可反映术后脱位的风险预测模型图,来预测术后导致脱位的风险。结果本研究数据分析结果表明,在患者就诊原因、性别、慢性病史、麻醉方式、手术前后肢体长度变化值、BMI、手术时长、髋臼杯大小、小转子到泪滴的垂直距离等方面,两组数据通过分析发现,差异无统计学意义(P>0.05)。而在患者年龄、合并神经系统疾病史、腰骶部疾病史、髋臼外展角是否正常、股骨前倾角是否正常、联合前倾角是否正常、假体头直径大小、臼-头比、术后股骨偏心距等领域,两组患者之间的单因素分析结果显示,差异有统计学意义(P<0.05)。此外,对通过单因素分析中有统计学意义的变量进行多变量logistic回归分析,分析结果提示患者的年龄、合并神经系统疾病史、腰骶部疾病史、髋臼外展角是否正常、股骨前倾角是否正常、联合前倾角是否在正常及股骨假体头尺寸大小与THA术后出现假体脱位存在明显相关,差异有统计学意义(P<0.05)。基于logistic逻辑回归分析结果,将具有统计学意义的独立危险因素纳入R软件,利用RMS包建立列线图风险预测模型;校准曲线用于评价列线图模型的校准程度;发现校正曲线和理想实测曲线拟合度较高,表明预测值和理想实测值一致,同时可以通过C-index来评估校正曲线的有效性,结果显示C-index为0.943(95%CI:0.909-0.976),而校正C-index则为0.933。利用ROC分析来验证列线图模型对术后假体脱位风险的预测能力,ROC曲线下面积为0.943,ROC曲线中的最优临界值分别为0.054(0.908,0.854),这些结果表明该模型具有良好的预测性能。结论因此,患者的年龄、合并神经系统疾病史、腰骶部疾病史、髋臼外展角是否正常、股骨前倾角是否正常、联合前倾角是否在正常及股骨假体头尺寸大小都可能是造成全髋置换术后假体脱位的独立危险因素。建立的列线图模型对全髋关节置换术后发生脱位风险具有良好的预测能力,然而,这些结论需要大样本、多中心的研究支持。更多还原

【Abstract】 BackgroundTotal hip arthroplasty(THA)has been widely used in clinical practice and is a significant and effective choice for patients with end-stage hip joints.However,postoperative prosthesis dislocation is undoubtedly a devastating complication for both the patients and surgeons.It is one of the leading causes of revision after THA and a complication that can jeopardize the quality of life of patients.Unfortunately,there is no consensus on the influencing causes of prosthesis dislocation,and there is controversy about the main factors that induce dislocation of the prosthesis.ObjectiveTo explore and analyze the related risk factors of prosthetic dislocation after THA,a retrospective study was conducted and a risk prediction model was constructed,to provide a reliable tool for clinicians to predict the dislocation risk.Meanwhile,it provides a theoretical basis for reducing the chance of postoperative dislocation or developing into repeated dislocation and improving the quality of life of patients.MethodsThis study retrospectively collected 41 patients with prosthetic dislocation after the first THA in our hospital from Jan 2013 to Dec 2021,including 32 cases with only one dislocation and 9 cases with multiple dislocations during the follow-up period.1169 patients without dislocation after THA were enrolled in the control group,and the follow-up time ended in April 2022.The baseline data(including the hospital reason,gender,age,BMI,history of basic diseases,neurological disease history,and lumbosacral disease history),intraoperative indicators(including anesthesia mode,operation duration,acetabular cup size,and prosthesis head diameter),and postoperative indicators(including femoral eccentricity,acetabular abduction angle,femoral anteversion,the vertical distance from small rotation to teardrop,combined anteversion,acetabular-head ratio,and changes of femoral eccentricity and limb length before and after surgery)were compared between the two groups.All the related factors that can cause postoperative dislocation of the prosthesis were included in univariate data analysis and multivariate unconditional logistic regression analysis,to determine the related risk factors.R software is used to draw a risk prediction model to predict the risk of dislocation after THA.ResultsThe results showed that there was no significant difference between the two groups in the hospital reason,gender,chronic medical history,anesthesia method,BMI,operation time,acetabular cup size,lesser trochanter to teardrop(P>0.05).However,there was a significant difference between the two groups in the age,history of neurological disease,history of lumbosacral disease,normal acetabular abduction angle,normal femoral anteversion angle,normal combined anteversion angle,prosthetic head diameter,acetabular-to-head ratio,postoperative femoral eccentricity(P<0.05).Multivariate logistic regression analysis indicated that age,neurological disease history,lumbosacral disease history,abnormal acetabular abduction angle,abnormal femoral anteversion,abnormal combined anteversion,and femoral prosthesis head size had an obvious correlation with prosthesis dislocation after THA(P<0.05).Based on the results of logistic regression analysis,independent risk factors with statistical significance are incorporated into R software,and the risk prediction model of the nomogram is established by the RMS package.A calibration curve is used to evaluate the calibration degree of the nomogram model and found that the fitting degree between the calibration curve and the ideal measured curve is ideal,indicating that the predicted value is consistent with the ideal measured value.The validity of the calibration curve is evaluated by C-index and shows that the C-index is 0.943(95%CI:0.909-0.976)and the corrected C-index is 0.933.ROC analysis is used to verify the prediction ability of the nomogram model for postoperative prosthesis dislocation risk.The area under the ROC curve is 0.943,and the optimal critical values in the ROC curve are 0.054(0.908,0.854),respectively.These results show that this model has good prediction performance.ConclusionTherefore,the patient’s age,neurological disease history,lumbosacral disease history,abnormal acetabular abduction angle,abnormal femoral anteversion angle,abnormal combined anteversion angle,and size of femoral prosthesis head may be independent risk factors for dislocation of the prosthesis after THA.The nomogram model established in this paper can predict the dislocation risk after THA.However,a large sample and multi-center study are needed to support these conclusions.更多还原