发育性髋关节发育不良切开复位、骨盆截骨术后再脱位的原因分析及手术治疗

Analysis of reasons and surgical treatment for failure of open reduction and pelvic osteotomy in patients with developmental hip dislocation

目的探讨发育性髋关节发育不良(DDH)切开复位、骨盆截骨术后再脱位的原因和手术治疗方法。方法回顾分析2004年1月至2016年1月北京积水潭医院小儿骨科收治的DDH切开复位、骨盆截骨术后再脱位行翻修手术的患者48例(53髋)的病历资料。其中,男7例,女41例。根据切开复位、骨盆截骨术后出现再脱位的时间,将患者分为2组,分析切开复位失败的原因。针对患者的年龄及病理变化,采用相应的治疗方案。结果翻修手术平均年龄6.1(2.8～13.5)岁。术后3个月内再脱位组32例(35髋),其中因手术未达到稳定中心复位导致去除外固定后再脱位24例(26髋),因截骨支撑物移位、碎裂、截骨端移位导致再脱位3例(3髋),因骨盆截骨后覆盖不良、髋关节复位不稳定导致去除石膏后出现半脱位2例(3髋),因股骨近端形态异常或前倾角过度矫正、复位不稳定导致去除石膏后出现半脱位2例(2髋),因术后感染导致再脱位1例(1髋);术后3个月及以上再脱位组16例(18髋),其中因髋臼成形后截骨端吸收出现半脱位或脱位7例(8髋),因髋臼外缘发育严重受损导致股骨头膨大出现半脱位6例(7髋),因骨盆Y形软骨损伤或发育异常、髋臼内壁增厚逐渐出现半脱位3例(3髋)。22例(26髋)采用再次切开复位、单独髋臼成型或髋臼成型+股骨短缩去旋转截骨治疗,16例(17髋)采用切开复位、骨盆Salter截骨内固定+股骨截骨治疗,5例(5髋)采用骨盆内移截骨治疗,3例(3髋)采用髋臼周围旋转截骨(Ganz截骨)治疗,1例(1髋)采用髋关节切开复位、股骨短缩截骨、磨臼造盖、关节囊成型(Colonna)治疗,1例(1髋)采用骨盆三联截骨+髋臼成型+股骨短缩去旋转截骨翻修手术治疗。翻修术后平均随访3.8(3.0～15.0)年,未出现再脱位的情况。末次随访时,髋关节Harris评分平均82分。结论 DDH术后再脱位是非常严重的并发症,会加大再次手术的复位难度,对关节功能及使用寿命影响极大,临床医生需加深对该病的认识,了解失败的原因,尽量避免其发生。

Objective To investigate the reasons and surgical treatment for failure of open reduction and pelvic osteotomy in patients with developmental dysplasia of the hip (DDH). Methods Retrospectively analyze 48 cases ( 53 hips ) of failed open reduction of DDH patients in Department of Pediatric Oorthopaedics, Beijing Jishuitan Hospital from January 2004 to January 2016 were performed. Seven cases were males and 41 cases were females. All patients were divided into 2 groups according to the time of re-dislocation or subluxation after the primary surgery, and the reasons for the failure of open reduction were analyzed . According to the patient's age and pathological changes, the corresponding treatment plan was adopted . Results Of the 48 cases (53 hips), the mean age of revision surgery was 6.1(2.8-13.5) years. Among them, 32 cases (35 hips) disclocated within 3 months which as a result of surgery had not reached a stable reduction or the displacement of osteotomy or some other reasons, 16 cases (18 hips) dislocated after 3 months, because of the acetabulum osteotomy side absorb, the socket gradually became shallow after the triangle cartilage damaged and some other reasons. All patients were received revision surgeries. The mean follow-up after revision was 3.8 years , and no re-dislocation occurred. The average hip Harris score was 82 in the final follow up. Conclusion Redislocation after an open reduction surgery of DDH is a very serious complication , which will increase the difficulty of reoperation and greatly affect the joint function and service life. Therefore, it is necessary to deepen the understanding of the disease, understand the reasons of failure and try to avoid it.