3DCT辅助Dega截骨术治疗儿童发育性髋关节脱位术后再脱位

Dega osteotomy assisted with three-dimensional computed tomography for re-dislocation of developmental dysplasia of the hip in children

目的通过3DCT观察儿童发育性髋关节脱位(developmental dysplasia of the hip,DDH)骨盆截骨术后再脱位的病理改变,模拟和预判Dega截骨术的治疗效果,探讨DDH术后再脱位的个性化治疗方案。方法回顾性分析2012年7月至2017年6月采用Dega截骨术治疗的儿童DDH骨盆截骨术后再脱位27例28髋的临床资料。其中,男8例9髋,女19例19髋;再手术时患儿年龄2岁4个月至8岁,平均4岁3个月;左侧17例,右侧9例,双侧1例。Tönnis分型Ⅱ型17髋,Ⅲ型8髋,Ⅳ型3髋。20髋初次手术为Salter截骨术,1髋为Dega截骨术,3髋为"保留内板完整的Dega截骨术",4髋为Pemberton截骨术。患儿术前均行骨盆-双股骨全长CT扫描并模拟手术,据此行Dega截骨术,并同期行髋关节切开复位关节囊成形及股骨近端截骨术。比较手术前后髋臼指数和Reimer指数变化,P<0.01为差异有统计学意义。评价术后影像学结果和肢体功能恢复情况。结果27例28髋均获随访,随访时间1年6个月至3年2个月,平均2年9个月。髋臼指数由31°±8°改善至11°±4°,Reimer指数由0.78±0.21改善至0.16±0.03,再手术前与末次随访时髋臼指数和Reimer指数比较,差异均有统计学意义(P<0.01)。术前所有Shenton线均不连续,随访时均恢复连续性。所有病例均无再脱位发生。根据改良Severin分型,优19髋,良7髋,可2髋,优良率为93%(26/28)。根据改良McKay分级,优20髋,良7髋,可1髋,优良率为96%(27/28)。所有患儿术后均未出现感染、骨折和神经血管损伤等并发症。结论Dega截骨术联合髋关节切开复位关节囊成形及股骨近端截骨,治疗DDH骨盆截骨术后再脱位短期效果良好,在3DCT模拟手术的辅助下可更为精确地设计截骨方案、量化操作细节并直观判断治疗效果,值得临床推广应用。

Objective To observe the pathological changes of re-dislocation of developmental dysplasia of the hip(DDH)undergoing pelvic osteotomy in children,to predict the outcome of Dega osteotomy assisted with three-dimensional computed tomography(3DCT)simulating osteotomy and to explore the individual therapeutics for re-dislocation of DDH.Methods From July 2012 to June 2017,retrospective analysis was conducted for a total of 28 hips in 27 children with re-dislocated DDH undergoing a second Dega osteotomy.There were 9 involved hips in 8 boys and 19 involved hips in 19 girls with an average age of 51(28-96)months during the second operation.The involved side was left(n=17),right(n=9)and bilateral(n=1).According to the Tönnis classification scheme,the clinical types wereⅡ(17 hips),Ⅲ(8 hips)andⅣ(3 hips).And the procedures included Salter osteotomy(20 hips),Dega osteotomy(1 hip),Dega osteotomy with intact inner wall(3 hips)and Pemberton osteotomy(4 hips).A simulating osteotomy by 3DCT of pelvis-femurs was performed preoperatively and Dega osteotomy with open reduction plus capsuloplasty and proximal femoral osteotomy were applied simultaneously.The preoperative and postoperative changes of acetabular index and Reimer's index were compared and P<0.01 was deemed as statistically significant.Radiological findings and improvements of extremity functions were evaluated at the latest follow-up.Results 28 involved hips were followed up successfully with an average period of 33(18-38)months.Acetabular index improved from(31°±8°)to(11°±4°)and Reimer's index decreased(0.78±0.21)to(0.16±0.03)with statistically significant differences in both acetabular and Reimer's indices pre-reoperation and at the latest follow-up(P<0.01).Disrupted preoperative Shenton lines in all hips became continuous during follow-ups.No postoperative re-dislocation was seen.Based upon the modified Severin classification scheme,the outcomes were excellent(19 hips),good(7 hips)and moderate(2 hips).And the excellent-good rate was 93%(26/28);based upon the modified McKay classification scheme,the outcomes were excellent(20 hips),good(7 hips)and moderate(1 hip).And the excellent-good rate was 96%(27/28).There was no occurrence of infection,fracture or vascular/nervous injury.Conclusions With more precise designs,meticulous operations and intuitive outcomes may be achieved with an aid of 3DCT.The short-term effect of Dega osteotomy plus open reduction,capsuloplasty and proximal femoral osteotomy for re-dislocated of DDH undergoing pelvic osteotomyis is definite.And it should be further popularized clinically in children.