髋臼周围截骨术治疗临界发育性髋关节发育不良的疗效

The effects of periacetabular osteotomy in the treatment of borderline developmental dysplasia of the hip

目的探讨髋臼周围截骨术(periacetabular osteotomy,PAO)治疗临界发育性髋关节发育不良(developmental dysplasia of the hip,DDH)的疗效。方法回顾性分析2011年1月至2018年1月行PAO治疗的外侧中心边缘角(lateral center-edge angle,LCEA)为18°~25°且随访超过2年的DDH患者33例(18°≤LCEA<25°组);根据患者性别、年龄、体质指数和随访时间按1∶2的比例匹配对照组:0°≤LCEA<10°组66例,10°≤LCEA<18°组66例。比较三组患者术前及末次随访的LCEA、前中心边缘角(anterior center-edge angle,ACEA)、臼顶倾斜角(Tönnis角)、股骨头外移指数、股骨头骨骺臼顶(femoro-epiphyseal acetabular roof,FEAR)指数、股骨前倾角、西安大略和麦克马斯特大学(West Ontario and McMaster University,WOMAC)骨关节炎指数和国际髋关节结果工具(international hip outcome tool,iHOT-12)评分。结果术前18°≤LCEA<25°组33例中3例(9.1%)的LCEA为唯一的影像学特征提示髋臼发育不良而其他参数在正常范围内;ACEA<20°者17例(51.5%)、Tönnis角>10°者24例(72.7%)、ACEA<20°且Tönnis角>10°者12例(36.4%)。18°≤LCEA<25°组后壁征阳性率(72.7%)低于10°≤LCEA<18°组(77.3%)和0°≤LCEA<10°组(90.9%),差异有统计学意义(χ^(2)=6.417,P=0.040);18°≤LCEA<25°组交叉征阳性率(27.3%)和坐骨棘征阳性率(48.5%)高于10°≤LCEA<18°组(分别为10.6%和18.2%)和0°≤LCEA<10°组(分别为9.1%和13.6%),差异有统计学意义(χ^(2)=7.002,P=0.030;χ^(2)=16.497,P<0.001);18°≤LCEA<25°组FEAR指数(3.7±8.0)低于10°≤LCEA<18°组(4.3±7.9)和0°≤LCEA<10°组(11.0±8.8),差异有统计学意义(F=12.703,P<0.001)。术后18°≤LCEA<25°组LCEA由20.4°±1.8°提高至37.8°±7.1°、ACEA由18.3°±7.8°提高至36.3°±6.3°、Tönnis角由12.7°±6.2°降低至-5.6°±9.2°、股骨头外移指数由22.9%±6.7%降低至10.7%±12.2%、WOMAC评分由(20.1±13.4)分降低至(6.0±6.3)分、iHOT-12评分由(50.2±19.9)分提高至(90.0±13.7)分,手术前后的差异均有统计学意义(P<0.05)。末次随访时18°≤LCEA<25°组WOMAC评分小于10°≤LCEA<18°组的(9.3±9.6)分和0°≤LCEA<10°组的(12.0±16.0)分,差异有统计学意义(F=6.515,P=0.002);iHOT-12评分大于10°≤LCEA<18°组的(77.7±17.3)分和0°≤LCEA<10°组的(78.1±20.5)分,差异有统计学意义(F=15.833,P<0.001)。结论在超过2年的随访中,PAO能够显著改善临界DDH患者的股骨头骨性覆盖和髋关节功能。术前应重视对髋臼不同影像学指标的综合评价,更好地制订术前规划。

Objective To investigate the effects of periacetabular osteotomy(PAO)in treating borderline developmental dysplasia of the hip(DDH).Methods The patients with borderline DDH[lateral center-edge angle(LCEA):18°-25°)who received PAO with follow-up duration for more than 2 years from January 2011 to January 2018 in our hospital were retrospectively analyzed.The patients in the control group were matched on a 1∶2 ratio based on gender,age,body mass index(BMI)and follow-up duration.There were 66 patients in the 0°≤LCEA<10°group and 66 patients in the 10°≤LCEA<18°group.The LCEA,anterior center-edge angle(ACEA),Tönnis angle,femoral head extrusion index,femoro-epiphyseal acetabular roof(FEAR)index,femoral anteversion angle,West Ontario and McMaster University(WOMAC)index and International Hip Outcome Tool(iHOT-12)were compared among the three groups before operation and the last follow-up.Results In the preoperative 18°≤LCEA<25°group,three of 33 patients(9.1%)had LCEA,because the only imaging feature suggested acetabular dysplasia,while other parameters were evaluated within the normal range.There were 17 patients with ACEA<20°(51.5%),24 patients(72.7%)with Tönnis angle>10°,12 patients(36.4%)with ACEA<20°and Tönnis angle>10°.The positive rate of posterior wall signs in the 18°≤LCEA<25°group(72.7%)was lower than that in the 10°≤LCEA<18°group(77.3%)and the 0°≤LCEA<10°group(90.9%)with statistically significant difference(χ^(2)=6.417,P=0.040)at preoperation.The positive rate of cross sign(27.3%)and ischial spine sign(48.5%)in the 18°≤LCEA<25°group were higher than those in the 10°≤LCEA<18°group(10.6%and 18.2%,respectively,χ^(2)=7.002,P=0.030)and the 0°≤LCEA<10°groups(9.1%and 13.6%,respectively,χ^(2)=16.497,P<0.001).The FEAR index in the 18°≤LCEA<25°group(3.7±8.0)lower than that in the 10°≤LCEA<18°group(4.3±7.9)and the 0°≤LCEA<10°group(11.0±8.8)with significant difference(F=12.703,P<0.001).In the 18°≤LCEA<25°group,postoperative LCEA increased from 20.4°±1.8°to 37.8°±7.1°,ACEA increased from 18.3°±7.8°to 36.3°±6.3°.Tönnis angle decreased from 12.7°±6.2°to-5.6°±9.2°,the femoral head extrusion index decreased from 22.9%±6.7%to 10.7%±12.2%,the WOMAC index decreased from 20.1±13.4 to 6.0±6.3,and the iHOT-12 score increased from 50.2±19.9 to 90.0±13.7.The above difference before and after surgery was statistically significant(P<0.05).At the last follow-up,the WOMAC score in the 18°≤LCEA<25°group was 6.0±6.3,wich was less than 10°≤LCEA<18°group(9.3±9.6)and 0°≤LCEA<10°group(12.0±16.0)(F=6.515,P=0.002).The iHOT-12 score in the 18°≤LCEA<25°group was 90.0±13.7,which was greater than 10°≤LCEA<18°group(77.7±17.3)and 0°≤LCEA<10°group(78.1±20.5)(F=15.833,P<0.001).Conclusion After 2 years follow-up,PAO significantly improved bone coverage of femoral head and hip function in patients with borderline DDH.Before surgery,we should pay attention to the comprehensive evaluation of different radiological parameters of the acetabulum,to make better preoperative planning.