重度股骨头骺滑脱的手术治疗

The surgical treatment of severe slipped capital femoral epiphysis

目的探讨重度股骨头骺滑脱的手术治疗。方法回顾性分析2006年1月至2014年12月北京积水潭医院小儿骨科手术治疗并获得随访的重度股骨头骺滑脱患者45例。其中男37例，女8例；平均年龄11．9岁（7-18岁）；非稳定型15例，稳定型30例；急性6例，慢性26例，慢性病程急性发作13例。根据术前患者病程的长短、影像学表现和术者对手术方法的熟悉程度，采取了不同的手术治疗方法。切开复位空心钉固定11例（包括牵引无效之后的切开复位4例），牵引后空心钉固定21例，直接空心钉固定13例。平均随访33．4（18～75）个月。随访时X线观察股骨头骺的转归和固定情况，并根据Harris髋关节评分对髋关节功能进行评估。结果末次随访时，所有患者均可无需拄拐行走，Harris髋关节评分为86—100分，平均96．1分。在切开复位加空心钉固定的11例中，x线显示4例出现股骨头缺血坏死，2例术后出现半脱位，经过治疗后，半脱位得以恢复。在非切开复位空心钉固定的34例中，10例出现凸轮畸形，2例出现股骨头缺血坏死，2例出现牵引处的皮肤激惹。所有病例均未出现滑脱加重、软骨溶解。结论重度股骨头骺滑脱的治疗充满挑战，非切开复位空心钉固定出现股骨头缺血坏死的风险相对较低，但是残余畸形可能需要进一步治疗。切开复位空心钉固定能恢复股骨头颈的正常解剖形态，但是出现并发症的风险较高，需要较长的学习曲线。

Objective To evaluate the results of surgical treatment of severe slipped capital femoral epiphysis （SCFE）. Methods From Jan 2006 to Dec 2014, 45 cases of severe SCFE,all surgically treated, were retrospectively analyzed. There were 8 females and 37 males. The average age of patients was 11.9 years （from 7 to 18 years） old. Fifteen cases were unstable and 30 cases were stable. Six cases were acute, 26 cases were chronic and 13 cases were acute on chronic. Different surgical methods were chosen according to the chro- nicity of SCFE, the X-ray presence and the surgeon＇s preference. Eleven cases were treated with open reduction and screw fixation through either Smith-Peterson approach or surgical hip dislocation approach, while 21 cases were treated with screw fixation after traction, and other 13 cases were treated with screw fixation directly. The mean follow-up period was 33.4 months （range, 18 to 75 months）. X-ray films were taken to assess the fixa- tion. The Harris hip score was used to assess the function of hip. Results At the time of the last follow-up, all patients were able to walk without crutches. The mean Harris hip score was 96.1 （range, 86 to 100）. In the 11 cases with open reduction, X-ray showed osteonecrosis in 4 cases （2 in Smith-Peterson approach and 2 in surgical hip dislocation approach）, and subluxation in 2 cases（ in surgical hip dislocation approach）. The sub- luxation cases were reduced after treatment. In the 34 cases with non-open reduction, X-ray showed cam de- formity in 10 cases, osteonecrosis in 2 cases and skin irritation at the traction pin site in 2 cases. There was no slip aggravation and chondrolysis. Conclusion The treatment of severe SCFE is challenging. The risk of osteo- necrosis in cases with non-open reduction is lower, and the secondary deformity need to be treated in the future. Treatment with open reduction could restore the normal anatomy of the femoral head and neck, but it has a higher risk of complication, and requires a longer learning curve.