股骨头缩小成形术治疗大头髋或扁平髋畸形的早期疗效

Primary outcomes of femoral head reduction osteotomy for coxa magna or coxa plana

目的探讨股骨头缩小成形术治疗青少年大头髋或扁平髋畸形的有效性与安令性。方法2012年6月至2015年9月应用股骨头缩小成形术治疗青少年发育性大头髋畸形（coxa magna）或扁平髋畸形（coxa plana）患者12例13髋，男6例7髋，女6例6髋；年龄10-25岁，平均18．1岁。6髋为多发骨骺发育不良，7髋为Legg-Calve-Perthes病后遗扁平髋畸形。采用髋关节外科脱位入路及支持带软组织瓣延长技术，9髋行髋臼周周旋转截骨术＋股骨颈相对延长＋股骨头缩小成形术、4髋行髋臼周围旋转截骨术＋股骨颈相对延长＋股骨头缩小成形＋股骨近端去旋转截骨术。均行标准的术后康复锻炼计划。观察术后并发症、髋关节活动度、步态情况，测量股骨头圆形指数、髋关节外侧CE角、股骨头覆盖率等X线指标，采用Harris髋关节评分、iHOT评分对髋关节功能进行评估，以疼痛VAS评分评估手术前后的疼痛状态。结果术后随访12-45个月，平均28．8个月。所有患者股骨头截骨处及其他截骨部位均愈合，愈合时间3-7个月，平均3．7个月。9例跛行患者的步态均有明显改善。Harris髋关节评分由术前（81.08±12．36）分提高至未次随访的（88．38±8．96）分，差异有统计学意义（t=2．41，P=0．033）。iHOT评分由术前（51．90±15．07）分提高至未次随访的（67．69±8．70）分，差异有统计学意义（t=3．63，P=0．003）。疼痛VAS评分由术前（4．46±2．37）分降低至末次随访的（1．23±0．93）分，差异有统计学意义（t=4．25，P=0．001）.髋关节活动度术前264．62°±32．05°，末次随访时255．00°±40．31°，差异无统计学意义（t=0．89，P=0．391）。骨盆正位X线片上股骨头圆形指数由术前71．08％±10．32％升高至术后81．22％±8．61％，差异有统计学意义（t=7．17，P=0．000）；股骨头覆盖率由术前48．79％±11．85％增加至术后87．46％±10．44％，差异有统计学意义（t=8．56，P=0．000）；髋关节外侧CE角由术前-1.82°±16．57°增加至术后36．02°±7．72°，差异有统计学意义（t=10．52，P=0．000）。髋65°假斜位X线片上股骨头圆形指数术前78．96％±10．39％，术后80．36％±8．42％，差异无统计学意义（t=0．411，P=1．688）。1例出现股骨头外上部分局部坏死，随访3年坏死无进展。无一例患者因股骨头坏死、骨关节炎、髋部疼痛、骨不愈合而接受关节置换或再次翻修手术。结论应用股骨头缩小成形术矫正股骨头大头或扁平畸形，能修复股骨头圆度、有效改善步态、缓解疼痛症状、提高髋关节功能，方法安全有效，近期疗效满意。

Objective To investigate the elinical efficiency and safety of femoral head reduetion osteotomy for young pa- tients with coxa magna or coxa plana. Methods Between June 2012 and September 2015, the elinical characteristics of 12 pa- tients （13 hips） with coxa magna or coxa plana who underwent femoral head reduction osteotomy were analyzed retrospectively. There were 6 males （7 hips） and 6 females （6 hips） with average age 18.1 years （range, 10-25 years）. The etiology of the femoral head deformity was multiple epiphyseal dysplasia in 6 hips and Legg-Calve-Perthes sequela in 7 hips. The head reduction osteoto- my was conducted through the surgical hip dislocation approach combined with extended retinacular soft-tissue flap extencting technique. ALl patients underwent simuhaneous periaeetabular osteotomy and relative lengthening of the femoral neck, of which four also underwent proximal femur derotational osteotomy. All patients received the standardized rehabilitation proceAures. The postoperative complications, gaits, the range of motion （ROM） of the hip, Harris hip seores, iHOT scores amt VAS were analyzedpostoperatively. In addition, the lateral center-edge （LCE） angle, sphericity index and coverage rate of femoral head were assessed as well. Results The average follow-up duration was 28.8 months （range, 12-45 months）. All patients achieved osteotomy heal- ing of the femoral head and greater trochanter with average healing time 3.7 months （range, 3-7 months）. Nine of 12 patients had significant gaits improvement. The Harris hip scores （81.08± 12.36 vs. 88.38±8.96, t=2.41, P=0.033）, iHOT score （51.9＋± 15.07 vs. 67.69±8.70, t=3.63, P=0.003）, LCE angle （-1.82°± 16.57° vs. 36.02°±7.72°, t=10.52, P=0.000）, sphericity index of anteropos- terior pelvic radiographs （71.08%± 10.32% vs. 81.22%± 8.61%, t=7.17, P=0.000） and the coverage index （48.79%± 11.85% vs. 87.46%±10.44%, t=8.56, P=0.000） were all significantly improved when compared to those preoperatively. The VAS score （4.46± 2.37 vs. 1.23±0.93, t=4.25, P=0.001） was significantly decreased when compared with that preoperatively. However, for the sphe- ricity index of 65° false profile （78.96%±10.39% vs. 80.36%±8.42%, t=0.411, P=0.688） and the average hip ROM （264.62°±32.05° vs. 255.00°±40.31°, t=0.89, P=0.391）, they did not achieve statistical significant difference. One case of femoral head ne- crosis site was localized at the lateral-superior part of femoral head, and there was no progression after 3 years follow-up. Moreover, no revision or total hip arthroplasty were observed due to other complications （osteoarthritis, hip pain or non-union）. Conclusion The femoral head reduction osteotomy can correct deformity, improve femoral head sphericity, relieve pain and improve gaits and hip function. This procedure leads to satisfied clinical outcomes for patients with coxa magna or coxa plana in early follow-up.