儿童臀肌挛缩致骨盆倾斜的手术治疗

Operative management for children with pelvic obliquity caused by gluteal muscle contracture

目的探讨儿童臀肌挛缩致骨盆倾斜的发生机制、手术方法和治疗效果.方法对36例臀肌挛缩致骨盆倾斜患儿术前检查均发现有双下肢不等长,假性长肢侧髋关节内收明显受限,骨盆前后位X线片示骨盆倾斜角5°～28°,平均15.5°;术中除松解挛缩的臀大肌及其筋膜外,探查发现髋关节外展肌明显挛缩,予以彻底松解.结果36例臀肌挛缩致骨盆倾斜患儿术中发现除假性长肢侧髂胫束、臀大肌筋膜及前外侧肌纤维纤维化挛缩外,髋关节外展肌明显挛缩,其中仅臀中肌挛缩者5例(13.9%),仅臀小肌挛缩者21例(58.3%),臀中、小肌均有挛缩者10例(27.8%).手术松解挛缩的臀中肌和/或臀小肌以及髂胫束、臀大肌筋膜及前外侧肌纤维,恢复假性长肢侧髋关节内收功能和双下肢等长.随访32例,平均随访3.5年.27例完全矫正;5例髋关节内收轻度受限,其中3例仍有轻度骨盆倾斜,患肢长0.5～1.5 cm.无一例出现髋关节外展肌力减弱.骨盆前后位X线片显示29例术后骨盆倾斜完全消失,3例骨盆倾斜角残留5°～10°.结论儿童髋关节外展肌挛缩是臀肌挛缩导致骨盆倾斜的主要原因,尤以臀小肌挛缩发生率高,且位置隐蔽.对臀肌挛缩伴有骨盆倾斜者,手术中应注意探查髋关节外展肌,对挛缩明显的予以彻底松解.

Objective To explore the pathogenesis, operation and long-term results of pelvic obliquity secondary to gluteal muscle contracture in children. Methods Clinical data from 36 children with pelvic obliquity secondary to gluteal muscle contracture were retrospectively analyzed. All of them presented with inequality of lower limb, restriction of coxa addueta, false long leg and inclination of pelvis on anteroposterior radiograph （range from 5° to 28°, mean 15.5°）. The contractive gluteal muscles included gluteus maximus, and/or gluteus medius and/or gluteus minimus were completely released by operations. Results All patients suffered from the adductor contracture： 5 cases with gluteus medius contracture （ 13.89% ）, 21 cases with gluteus minimus contraeture （58.33% ）, and 10 cases with gluteus medius and gluteus minimus contracture （27.78% ）. Thirty-two cases were followed up for an average of 3.5 years. Among them,27 cases obtained complete correction, 5 cases including 3 cases which still showed light pelvic obliquity had mild restriction of adduction. No attenuation of abductor strength was noted in these children. Pelvic obliquity disappeared in 29 cases as demonstration by radiographical examination. Conclusions Abductor contracxure of the hip, especially gluteus minimus,is primary factor that results in pelvic obliquity in children with gluteal muscle contracture. It is necessary to release the abductor contraction to get the satisfactory results in these patients.