改良腘绳肌后置术治疗痉挛型脑瘫膝关节屈曲挛缩畸形

The analysis of modified hamstring post surgery for the treatment of spastic cerebral palsy with knee flexion deformity

目的 探讨改良腘绳肌后置术治疗痉挛型脑瘫膝关节屈曲挛缩畸形的临床疗效.方法 选取30例痉挛型脑瘫膝关节屈曲挛缩畸形患者随机分为传统手术组（15例,采用传统腘绳肌后置术）和改良手术组（15例,采用改良腘绳肌后置术,即将半腱肌后置于腓肠肌内侧头起点处）,两组患者软组织松解术后均联合应用Ilizarov外固定支架牵伸矫正膝关节屈曲挛缩畸形.自软组织松解术后第7天开始调整牵伸外固定支架,每次撑开约0.2°,3次/d;直至屈曲挛缩畸形矫正至过伸10°位并维持3周,期间每2周摄X线片测量膝关节屈曲挛缩度数;拆除Ilizarov外固定支架后,佩戴下肢膝关节铰链支具至少3个月,至膝关节行走功能满意后去除.临床疗效评价采用Dimeglio标准,对关节疼痛指数、行走功能指数、屈膝畸形程度及关节活动范围进行评分.结果 30例患者（60膝）膝关节屈曲挛缩畸形经Ilizarov外固定支架牵伸治疗后矫正至膝关节伸直0°～-5°,均达到预期矫正效果;拆除Ilizarov外固定支架后60膝关节活动度均接近正常,屈曲100°～135°,伸0°～10°.去除膝关节铰链支具后直立位屈膝角度-1.2°～13.3°,平均7.32°±3.41°;其中4例（8膝）出现屈膝角度10°～15°的复发.临床疗效采用Dimeglio标准,在关节疼痛、行走功能、膝关节屈曲畸形程度及关节活动范围方面,两组患者手术前后的差异均有统计学意义,表明两种术式的矫形效果均良好.两组患者术后疗效在关节疼痛、膝关节屈曲畸形程度及关节活动范围方面的差异均无统计学意义,在行走功能方面的差异有统计学意义,表明改良手术组在行走功能方面明显优于传统手术组.结论 采用改良腘绳肌后置术联合Ilizarov外固定支架牵伸治疗痉挛型脑瘫膝关节屈曲挛缩畸形,在改善患者行走功能方面较传统术式疗效更好,且能简化手术切口,减少创伤,是一种有效的治疗方法.

Objective To explore the curative effect of knee flexion deformity on spastic cerebral palsy treatment method.Methods All of 30 patients with spastic cerebral and knee flexion deformity were randomly divided into two groups：traditional operation group and modified operation group,using the commonly used operation （In 15 cases,with traditional hamstring post surgery） and） modified operation （In 15 cases,with modified hamstring post surgery）,two groups of patients were treated with Ilizarov external fixation drafting device in the correction of knee flexion deformity after soft tissue release.Adjustment began 7 days after the soft tissue release operation of external fixation,and stretched approximately 0.2 degrees each time,3 times/d,until knee flexion deformity was corrected to hyperextension for 10 degree and maintained for 3 weeks,and the flexion contracture degree of knee joint was measured every 2 weeks;then the Ilizarov external fixation drafting device was removed.Then wear a walking straight leg brace for more than 3 months,until the knee walking function is good.Clinical evaluation included the joint pain index,walking function index,knee flexion deformity degree and range of joint motion score of Dimeglio standard.Results Flexion contracture deformity of knee joint in 30 cases （60 knees） was corrected when Ilizarov external fixator was removed,knee extension to 0 degrees-5 degrees.The two groups of patients had the knee flexion angle range of-1.2 degrees to 13.3 degrees,with an average of （7.32°±3.41°） after removed of the walking straight leg brace,in which 4 cases （8 joints） got recurrent deformity of 10°-15° at the time of removing of the walking straight leg brace.Knee activity significantly was improved at the end of treatment.60 cases of knee joint activity were close to normal,with flexion of 100 degrees to 135 degrees,extension of 0 degrees to 10 degrees.Two groups of patients were statistically significantly improved before and after surgery.Curative effect comparison：The walking function index of the modified operation group was obviously superior to that of the traditional operation group,there was significant statistical difference.There were no statistically significant differences in pain index,knee flexion,and range of joint motion.Conclusion For the treatment of flexion deformity of the knee joint in spastic cerebral palsy,traditional surgery using the semitendinosus and gracilis,post and semimembranosus lysis,combined with the Ilizarov draft external fixation could improve the walking function of the patients,simplify the surgical incision and reduce trauma.As a result,modified hamstring post surgery is an ideal,effective treatment method.