发育性髋关节脱位手术后再脱位原因分析及处理对策

Causes and counter-measures for relapse after open reduction for developmental dysplasia of the hip

目的探讨发育性髋关节脱位切开复位术后手术失败及再脱位原因,观察翻修手术的疗效为预防和治疗再脱位提供依据。方法回顾性收集2012年1月至2017年1月在浙江大学医学院附属儿童医院因切开复位失败后再次行翻修手术的患儿10例(10髋)作为研究对象,所有患儿首次切开复位由本院完成,分析再脱位发生的时间、手术失败再脱位原因、处理时机及对策;评价术后治疗效果和股骨头坏死发生率。结果所有病例获得随访,随访时间1～4年,平均2. 1年;发现再脱位与首次切开复位时间间隔1天至36个月,平均5. 3个月;再次手术发现2例关节粘连明显,3例关节内存在纤维组织,1例内翻的盂唇妨碍中心复位且髋臼横韧带在初次手术中没有完全松解,1例残留有圆韧带,2例关节囊破裂,4例关节囊松弛;末次随访时Mckay髋关节功能优良率30%(3/10),Severin影像学优良率为60%(6/10),术后股骨头坏死发生率70%(7/10)。结论发育性髋关节脱位切开复位失败主要与软组织松解不彻底及关节囊处理不当有关,关节内侧间隙增宽是再发脱位的危险征象,关节内粘连的松解和关节囊的剥离、修剪以及紧缩缝合对再次维持中心复位至关重要,再次脱位术后翻修并发症较多,远期随访结果较差。

Objective To explore the causes and counter-measures for relapse after open reduction for developmental dysplasia of the hip,observe the clinical effect of revision surgery and provide rationales for preventing and treating redislocation.Methods A review was conducted for 10 patients(10 hips)undergoing revision surgery between January 2012 and January 2017.All initial open reductions were completed at our hospital.Analyses were performed with regards to when and why redislocation occurred,timing of interventions and specific strategies.The function and radiographic results of the hip and the incidence rate of osteonecrosis was analyzed.Results All cases were available for the final follow-up.The average follow-up period was 2.1(1~4)years.The average time interval between redislocation and initial open reduction found was 5.3 months(1 day-36 months).After reoperation,there were joint adhesion(n=2),fibrous tissue(n=3),infolded labrum and transverse ligamentum obstructing central reduction(n=1),residual ligamentum teres(n=1),rupture of joint capsule(n=2)and relaxation of joint capsule(n=4).According to the McKay criteria at the final follow-up,3 hip(30%)achieved excellent(1 hip)and good(2 hips)clinical results.According to the Severin criteria,6 hips(60%)yielded excellent(1 hip)and good(5 hips)radiographic results.The incidence rate of avascular necrosis of femoral head was 70%.Conclusion Most cases of failed reduction for developmental dysplasia of the hip are caused by inadequate soft-tissue release and capsulorrhaphic failure.Widening of medial joint space is an ominous sign of redislocation.Releasing intra-articular adhesions and dissection of joint capsule and pruning and constricting suture are essential for maintaining central reduction.There are many potential complications of revision surgery after redislocation and the long-term follow-up outcomes remain poor.