股骨近端外展截骨治疗儿童股骨颈骨折不愈合

Efficacy of valgus intertrochanteric osteotomy for nonunion of femoral neck fractures in children

目的探讨股骨近端外展截骨治疗儿童股骨颈骨折不愈合的治疗效果。方法回顾性分析北京积水潭医院小儿骨科2003年1月至2018年1月间收治的股骨颈骨折不愈合19例患儿的临床资料。其中,男13例,女6例;年龄(10.0±3.0)岁。术前已经过1~2次手术治疗15例;因多发创伤后漏诊2例;经长期牵引、外固定保守治疗后骨折仍不愈合2例。合并股骨头缺血坏死15例。记录患儿骨折分型、治疗经过、术中操作、术后愈合时间及并发症,并对手术前后股骨颈干角、Pauwel角变化进行对比分析。结果全部19例患儿经股骨近端外展截骨治疗后均达到骨折愈合。合并骨质缺损4例,采用自体或异体骨移植治疗。术后愈合时间为(8.2±2.4)个月。本组术前颈干角和Pauwel角分别为110.3°±18.8°和56.4°±12.0°,术后颈干角和Pauwel角分别为142.3°±12.6°和25.3°±5.9°,组间比较,颈干角差异有统计学意义(P<0.05)。相关性检验显示,年龄(外展截骨手术时)与骨折不愈合无显著相关,而Garden分型和Delbet分型均与骨折不愈合相关(P=0.039和0.001)。术后发生下肢机械轴外移5例,1例采用股骨远端外侧骺阻滞治疗,其余4例观察;内固定断裂1例,再次手术治疗;切口浅表感染1例,换药后愈合。双下肢不等长15例,未行进一步治疗。股骨近端骨骺早闭8例、股骨颈短颈畸形4例、继发股骨头骺滑脱2例,随访至股骨近端骨骺闭合未进一步加重,未行进一步治疗。继发髋臼发育不良2例,目前随访观察中。结论儿童股骨颈骨折不愈合治疗困难,并发症多。股骨近端外展截骨可以改变骨折线应力方向,增加骨折端压应力,有效治疗儿童股骨颈骨折不愈合。

Objective To explore the efficacy of valgus intertrochanteric osteotomy(VITO)for femoral neck fracture nonunion in children.Methods Clinical data were retrospectively analyzed of 19 children of nonunion of femoral neck fracture from January 2003 to January 2018.There were 13 boys and 6 girls with an age range of(10.0±3.0)years.Two cases were misdiagnosed after multiple trauma.Fracture nonunion occurred after conservative measures of long-term traction and external fixation(n=2).Ischemia necrosis of femoral head was reported(n=15).The preoperative changes of femoral neck-shaft angle(NSA)and Pauwel angle were compared.Fracture classification,treatment duration,intraoperative operation,postoperative healing time and complications were recorded.Results All fractures healed after VITO.Four children of bone defect underwent autograft or allograft.The postoperative healing time was(8.2±2.4)months.Preoperative NSA and Pauwel angle were(110.3°±18.8°)and(56.4°±12.0°)and postoperative NSA and Pauwel angle(142.3°±12.6°)and(25.3°±5.9°).The inter-group difference of NSA was statistically significant(P<0.05).Correlation tests indicated that age(during valgus osteotomy)was insignificantly associated with nonunion while both Garden and Delbet classifications associated with nonunion(P=0.039&0.001).Postoperative complications included mechanical axle displacement of lower extremity(n=5).One case underwent distal lateral femoral epiphysis block while the remainders were passively observed.One case of internal fixation rupture underwent re-operation.One case of wound infection healed after dressing change.Fifteen cases of unequal length of lower extremity were not further treated.There were premature closure of proximal femoral epiphysis(n=8)and short-neck deformity of femoral neck(n=4).Two cases of slipped capital femoral epiphysis were followed up until proximal closure without further worsening and no treatment was offered.Two cases of acetabular dysplasia were tracked.Conclusion Treatment is difficult for nonunion of femoral neck fracture in children.And VITO changes the stress direction of fracture line so as to treat bone non-union of femoral neck effectively.