切开复位骨盆Salter截骨术治疗发育性髋关节脱位的长期随访研究

Long term results of open reduction and Salter osteotomy for developmental dislocation of the hip in children

目的探讨早期切开复位骨盆Salter截骨术治疗发育性髋关节脱位的长期疗效及其影响因素。方法1992年9月至2002年10月接受切开复位骨盆Salter截骨术的发育性髋关节脱位患儿68例8l髋，随访至骨骼发育成熟的45例52髋纳入回顾性研究。男9例，女36例；手术时年龄1．4~5．3岁，平均2．5岁。所有患儿术前均未接受其他治疗。34例38髋术前行骨牵引。评价末次随访时改良Severin影像学及McKay临床功能情况。分析股骨头坏死发生率。分析改良severin影像学分类结果不良与股骨头坏死发生的相关性，及Ⅱ型股骨头坏死的股骨头包容情况。结果随访9．7—19．2年，平均13．5年。随访时年龄12．3~22．3岁，平均15．6岁。McKay髋关节功能评价优良率84．6％（44／52）。Severin影像学标准优良率69．2％（36／52），未发生股骨头坏死髋关节的优良率为82．8％（24／29）。23髋（44．2％，23／52）发生股骨头坏死，其中Ⅱ型16髋。年龄、性别、脱位程度、单双侧及有无过度下压均与Severin结果不良及股骨头坏死无关。股骨头坏死是severin结果为中或差的危险因素（P=0．0327）。而骨盆截骨术股骨头过度下压与严重型股骨头坏死可能有关（P=0．037）。发生Ⅱ型股骨头坏死与未发生股骨头坏死病例外侧CE角、Reimers指数的差异无统计学意义（P值分别为0．457与0．308）。结论切开复位骨盆Salter截骨治疗发育性髋关节脱位术后发生股骨头坏死的风险较高，其中以Ⅱ型最为常见，但多数不会引起进行性股骨头包容不良。骨盆截骨术中股骨头过度下压可能与严重型股骨头坏死有关。未发生股骨头坏死的病例影像学与功能结果比较满意。

Objective To retrospectively review long-term results of developmental dislocation of the hip patients treated with open reduction and Salter pelvic osteotomy, and to analyze the potential risk factors. Methods Sixty-eight developmental dislocation of the hip cases （81 hips） were treated with open reduction and Salter pelvic osteotomy from September 1992 to Octo- ber 2002, 45 eases （52 hips） were followed up to skeletal maturity. None had undergone other treatment before the key surgery. Some cases received skeleton traction before surgery. The radiographic and functional results were assessed at last follow-up. The possible relevant factors for unsatisfactory outcome were analyzed. The correlation between type Ⅱ AVN and the coverage rate of the femoral head were evaluated. Results The mean age at surgery was 2.5 years （ranged from 1.4 to 5.3 years）. At last follow-up, 44 hips （84.6%） had excellent or good functional results. 23 hips （44.2%） had avascular necrosis of varying severity, of which 16 hips were type Ⅱ. There was significant relevance between the AVN severity and the Severin classification result （P=0.018）. The ＂over correction＂ hips, that were overcorrected during surgery, were more likely to get severe type AVN （P=0.037）. There was no correlation between Type Ⅱ AVN with uncoverage according to CE angle and Reimers index （P=0.457, 0.308 respectively）. Conclusion 1） Satisfactory functional and radiographic results could be expected in developmental dislocation of the hip cases with- out AVN; 2） High risk of AVN existed in the late diagnosised hips that underwent open reduction and Salter pelvic osteotomy, type Ⅱ was the most common type; 3） Type Ⅱ AVN was not a predictor for progressive femoral head coverage deficiency; 4） ＂Over correction＂ in Salter pelvic osteotomy was related with severe type AVN which should be avoided.