股骨近端截骨在发育性髋关节发育不良手术治疗中的必要性研究

Surgical necessity of proximal femoral osteotomy for developmental dysplasia of the hip

目的通过比较切开复位+Dega骨盆截骨,同时行股骨近端截骨或不截骨治疗发育性髋关节发育不良(developmental dysplasia of the hip,DDH)患儿的临床及影像学结果,明确同时进行股骨近端截骨的必要性。方法回顾性收集2011年1月至2015年12月在中国医科大学附属盛京医院行切开复位+Dega骨盆截骨治疗的DDH患儿67例(80髋),以T nnisⅠ、Ⅱ、Ⅲ型DDH为研究对象,共58例67髋纳入研究。其中,股骨截骨组33例(38髋),中位手术年龄25(15~46)个月,包括男童2例,女童31例;左髋13例,右髋15例,双髋5例;股骨不截骨组25例(29髋),中位手术年龄19(6~32)个月,包括男童5例,女童20例;左髋10例,右髋11例,双髋4例。比较两组髋关节发育情况,测量指标包括髋臼指数(acetabular index,AI)、关节转子间距(articulo-trochanteric distance,ATD)、股骨头中心距离差(centre-head distance discrepancy,CHDD)、股骨头骨骺高宽指数(height-to-width index,HWI)等指标。结果中位随访时间41(24~70)个月。针对髋臼侧的形态学参数,两组AI改善程度ΔAI(术后当时-末次随访)分别为(5.3±9.2)°、(5.0±4.7)°,t=-0.183,P=0.855;两组CEA改变程度ΔCEA(术后当时-末次随访)分别为(6.2±7.7)°、(9.0±11.7)°,t=1.121,P=0.268。针对股骨近端的形态学发育情况,两组NSA改变程度ΔNSA(末次随访-术前)分别为(3.2±13.0)°、(4.7±10.1)°,t=0.518,P=0.606;两组末次随访Alsberg角分别为(76.9±7.8)°和(76.2±6.9)°,t=-0.359,P=0.721;末次随访ATD值分别为(24.0±5.3)mm和(26.8±6.0)mm,Z=-1.955,P=0.051。针对头臼关系的变化,两组单侧DDH的CHDD改变程度ΔCHDD(末次随访-术后当时)分别为(6.5±7.9)%和(3.0±7.1)%,Z=-1.594,P=0.118。针对股骨头骨骺的形态学参数,两组末次随访HWI分别为(55.7±6.7)%和(52.8±6.1)%,t=-1.855,P=0.068;单侧DDH末次随访r值分别为(1.12±0.13)和(1.19±0.15),Z=-1.790,P=0.073。两组末次随访单侧DDH的双下肢骨性长度差异(limbs length discrepancy,LLD)分别为(5.2±7.1)mm和(9.4±4.6)mm,t=2.331,P=0.024。随访患儿均无再脱位发生。按Kalamchi-MacEwen分型方法,两组AVN发生率分别为28.9%(11/38)和20.7%(6/29),χ2=0.592,P=0.442。结论行走年龄T nnisⅢ型及以下脱位的DDH在行切开复位+Dega骨盆截骨术时,无需不同时行股骨近端截骨术。

Objective To compare the clinical and radiographic outcomes of DDH patients undergoing open reduction plus Dega pelvic osteotomy with or without proximal femoral osteotomy and determine the necessity for simultaneous osteotomy of proximal femur.Methods Retrospective analysis was performed for 67 patients(80 hips)undergoing open reduction plus Dega pelvic osteotomy from January 2011 to December 2015.There were 58 children(67 hips)of T nnis typesⅠ,ⅡandⅢhips.For 33 children(38 hips)in femoral osteotomy group,there were 2 boys and 31 girls with an median operative age of 25(15-46)months.The involved side was left(n=13),right(n=15)and bilateral(n=5);For 25 patients(29 hips)in femoral non-osteotomy group,there were 5 boys and 20 girls with an median operative age of 19(6-32)months.The involved hip side was left(n=10),right(n=11)and bilateral(n=4).Compare the development of two groups,the measurements of acetabular index(AI),articulo-trochanteric distance(ATD),centre-head distance discrepancy(CHDD)and femoral epiphyseal height-to-width index(HWI)were recorded.Results All 58 patients(67 hips)were followed up for an average of 41(24-70)months.With regards to morphological parameters of acetabular side,improvement of AI(postoperative to the last follow-up)were(5.3±9.2)°and(5.0±4.7)°in osteotomy and non-osteotomy groups respectively(t=-0.183,P=0.855).Change of CEA(postoperative to the last follow-up)were(6.2±7.7)°and(9.0±11.7)°respectively(t=1.121,P=0.268).As to the morphological development of proximal femur,change of NSA(last follow-up to preoperative)were(3.2±13.0)°and(4.7±10.1)°in two groups(t=0.518,P=0.606);Alsberg angles at the last follow-up were(76.9±7.8)°and(76.2±6.9)°(t=-0.359,P=0.721);ATD values at the last follow-up(24.0±5.3)and(26.8±6.0)mm respectively(Z=-1.955,P=0.051).As to the change of CHDD(the last follow-up to postoperative)were(6.5±7.9)%and(3.0±7.1)%in two unilateral DDH groups respectively(Z=-1.594,P=0.118).As to the morphological parameters of epiphysis of femoral head,the last follow-up HWI were(55.7±6.7)%and(52.8±6.1)%respectively(t=-1.855,P=0.068).The maximal femoral head diameter ratio(r value)at the last follow-up of dislocated side and normal side were(1.12±0.13)and(1.19±0.15)in two unilateral DDH groups respectively(Z=-1.790,P=0.073).LLD at the last follow-up were(5.2±7.1)and(9.4±4.6)mm in two unilateral DDH groups respectively(t=2.331,P=0.024).No secondary dislocation occurred.According to the Kalamchi-MacEwen classification scheme,the incidence of AVN were 28.9%(11/38)and 20.7%(6/29)in two groups respectively(χ2=0.592,P=0.442).Conclusion Proximal femoral osteotomy is unnecessary when open reduction plus Dega pelvic osteotomy is performed in children of walking age with T nnis typeⅢor below hip dislocation.