髋臼周围截骨术中与术后早期并发症分析

Analysis of intraoperative and early postoperative complications of Bernese periacetabular osteotomy

目的通过回顾性研究观察髋臼周围截骨手术中与手术后3个月内的早期并发症,分析原因及提出预防措施。方法对2012年1月至2014年12月在解放军总医院第一附属医院关节外科行单纯髋臼周围截骨术(PAO)治疗的CroweⅠ型髋关节发育不良(DDH)患者,排除PAO手术同时行髋关节外科脱位、股骨近端截骨或股骨头缩小成形术等其他手术的患者。共有274例患者(325髋),平均年龄为(28.9±8.0)岁,其中男性41例(47髋),女性233例(278髋);左髋109例,右髋114例,双髋51例102髋。平均随访时间(12.8±9.3)个月。对患者的病历与影像学资料做回顾性研究。每例患者常规拍摄术前和术后骨盆站立正位、双髋外展内旋功能位及65°假斜位X线片,通过Uni Sight系统测量手术前和手术后髋臼的外侧中心边缘角(LCEA)、前侧CE角(ACEA)与髋臼指数(AI)的变化。观察术中与手术后3个月内出现的早期并发症。采用SPSS 19.0统计软件行配对t检验比较术前和术后LCEA、AI、ACEA。以P<0.05为差异有统计学意义。结果所有患者截骨术后股骨头覆盖均得到改善,术前LCEA为(8.5±8.9)°,术后LCEA为(32.5±6.7)°,手术前后差异有统计学意义(t=-146.6,P<0.01)。术前AI为(26.8±10.4)°,术后AI为(6.7±2.6)°,手术前后差异有统计学意义(t=42.7,P<0.01)。术前ACEA为(2.5±12.1)°,术后ACEA为(29.0±5.6)°,差异有统计学意义(t=-65.5,P<0.01)。术后发生股外侧皮神经损伤30例、股神经损伤2例、坐骨神经损伤2例、股静脉损伤1例、臀上动脉损伤1例、切口愈合不良4例、深部感染1例、关节内截骨致四边体开放4例、后柱不连续28例、耻骨下支应力骨折17例。结论髋臼周围截骨术操作复杂,手术风险较高,对术者技术要求很严格,可能出现多种并发症;通过严格手术技术训练、个体化处理细节,可以减少术后并发症的发生。

Objective To retrospectively study the intra-operative complications and early post-operative complications three months after the operation in Bernese periaeetabular osteotomy （PAO） , and to discuss the causes and precautions. Methods A retrospectively analysis was carried out on the patients with Crowe [ developmental dysplasia of the hip （DDH） who underwent PAO in the joint surgery department of the First Affiliated Hospital of PLA General Hospital from Jan 2012 to Dec 2014. The patients who underwent surgeries other than PAO at the same time were excluded. Overall 274 patients （ 325 hips） were included in this study, among which were 41 males （47 hips） , 233 females （ 278 hips） , 109 cases in left hip, 114 cases in right hip, and 102 cases in bilateral hips; the average age was （29±8 ） years. The mean follow-up time was （13 ± 9） months. Routine radiography included pre- and post- operative standing pelvic anteroposterior view, hip function view and false profile view. The lateral centeredge angle （LCEA） , acetabular index （AI） and anterior center-edge angle （ACEA） were measured by UniSight system. Intra-operative and post-operative complications three months after the surgery were observed and recorded. Pre- and post-operative LCEA, AI, and ACEA were compared by SPSS 19.0 using paired t test. Statistical significance was defined as P 〈 0. 05. Results The femoral head coverage improved in all the patients. LCEA improved from pre-operative （ 8.5± 8.9 ） ° to post-operative （ 32. 5 ± 6. 7） °, （t = - 146. 6, P 〈 0. 01 ）. AI improved from pre-operative （26. 8 ± 10.4） ° to post-operative （6. 7±2. 6） ° （t =42. 7, P 〈0. 01 ）. ACEA improved from pre-operative （2. 5 ± 12. 1 ） ° to post-operative （29. 0±5.6） ° （ t = - 65.5, P 〈 0. 01 ）. Complications included 30 cases of lateral femoral cutaneous nerve injury, two cases of femoral nerve injury, two cases of sciatic nerve injury, one case of femoral vein injury, one case of superior gluteal artery injury, four cases of poor wound healing, one case of deep infection, four cases of intra-articular fracture causing opening of the trapezoid, and 28 cases of the posterior column discontinuity. Fifteen cases had stress fracture of the inferior pubic branch. Conclusion PAO is a complicated, risky and technique-demanding procedure with a long learning curve, so serious complications may be encountered which can be reduced by strict surgical training and individualized management.