早期包容手术对Perthes病自然史的改变

How does containment surgery alter the natural evolution in early stage of Perthes disease

目的观察比较Perthes病患儿早期手术治疗和保守治疗的病程演变,探讨早期手术治疗Perthes病的意义。方法收集自1997年1月至2017年12月收治的67例Perthes病患儿资料,分为手术组(35例)和保守组(32例)。手术组35例,男32例,女3例,年龄(8.3±1.0)岁(范围7.0~11.8岁),左侧21例,右侧14例;保守组32例,男24例,女8例,年龄(8.4±1.4)岁(范围7.1~12.0岁),左侧22例,右侧10例。每3个月摄取骨盆正位及蛙式位X线片,参照改良Waldenström分期评估Perthes病的病程演变,在系列观察未发现改良WaldenstromⅡb期视为跳过碎裂期。在愈合期后的骨盆正位及蛙式位X线片根据Stulburg分级评估结果,并且测量患侧与健侧干骺端宽度比值和股骨头骺高度比值。结果35例手术组进入Ⅲa期所需时间(0.58±0.33)年(范围0.1~1.5年),32例保守组(0.96±0.30)年(范围0.4~1.8年),进入修复期所需时间差异有统计学意义(t=5.259,P<0.05);手术组病程跳过碎裂期共11例(31%),保守组5例(16%),差异有统计学意义(χ^(2)=22.626,P<0.05);手术组干骺端患侧与健侧比为108.0%±6.0%(范围101%~123%),保守组115.8%±11.2%(范围101%~148%),差异有统计学意义(t=3.450,P<0.05)。手术组股骨头骺高度患侧与健侧比为82.5%±8.2%(范围61%~96%),保守组74.7%±1.3%(范围33%~92%),差异有统计学意义(t=2.921,P<0.05)。手术组改良Stulberg分级为Ⅰ类髋关节29髋,Ⅱ类髋关节6髋,Ⅲ类髋关节0髋;保守组Ⅰ类髋关节16髋,Ⅱ类髋关节10髋,Ⅲ类髋关节6髋。两者进入Ⅳ期后Stulberg分级差异有统计学意义(Z=3.386,P<0.05)。结论早期手术改变了Perthes病的自然演变,早期手术治疗缩短Perthes病碎裂期病程,使其更早进入修复期,并且有机会跳过碎裂晚期,改变其自然病程,愈合后股骨近端形态改变更接近正常。

Objective Course of evolution observed relatively early Perthes disease in children surgically treated and conservative,explore the significance of early surgical treatment of Perthes disease.Methods From January 1997 to December 2017,632 children with Perthes disease were admitted.According to the inclusion and exclusion criteria,a total of 67 children were included in this study.Surgical group:35 cases,32 males and 3 females,age ranged from 7.0 to 11.8 years,with an average 8.3±1.0 years old,21 cases on the left side and 14 cases on the right side.Conservative group:32 cases,24 males and 8 females,age ranged from 7.1 to 12.0 years old,with an average of 8.4±1.4 years old,22 cases on the left side and 10 cases on the right side.The pelvic orthosis and frog position were taken every 3 months,and the evolution of Perthes disease was evaluated by referring to the modified Waldenstrom staging.In the series of observations,no modified Waldenstrom Ⅱb stage was found to skip the fragmentation stage.After the healing period,the pelvic orthosis and frog position were evaluated according to the Stulburg classification results,and the ratio of the width of the metaphyseal end of the affected side to the contralateral side and the height of the femoral head epiphysis were measured.Results The time required to enter stage Ⅲa,surgical group:range from 0.1 to 1.5 years,with an average of 0.58±0.33 years,conservative group:range from 0.4 to 1.8 years,with an average of 0.96±0.30 years,it takes both to enter the repair phase The time difference was statistically significant(t=5.259,P<0.05);children whose disease course skipped the fragmentation stage,surgical group:11 cases(31%),conservative group:5 cases(16%),the difference is statistically significant(χ^(2)=22.626,P<0.05).The ratio of the affected side to the uninfected side of the metaphysis:surgical group:range 101%-123%,with an average of 108.0%±6.0%.Conservative group:range 101%-148%,with an average of 115.8%±11.2%.The difference in the ratio between the affected side and the healthy side of the metaphysis was statistically significant(t=3.450,P<0.05).The ratio of the affected side to the healthy side of the height of the femoral head epiphysis:surgical group:range 61%-96%,with an average of 82.5%±8.2%.Conservative group:range 33%-92%,with an average of 74.7%±1.3%.There was a statistically significant difference in the ratio of the height of the femoral head epiphysis between the affected side and the healthy side(t=2.921,P<0.05).Stulberg classification,surgical group:Type Ⅰ hip joints 29 hips,Type Ⅱ hip joints 6 hips,Type Ⅲ hips 0 hips;conservative group:Type Ⅰ hips 16 hips,Type Ⅱ hips 10 hips,Type Ⅲ hips 6 hips.There was a statistically significant difference in the Stulberg classification after the two entered stage Ⅳ(Z=3.386,P<0.05).Conclusion Early surgery changed the natural evolution of Perthes disease.Early surgical treatment shortens the fragmentation period of Perthes disease,so that it enters the repair phase ear-lier,and has the opportunity to skip the late fragmentation period and change its natural course.After healing,the morphological change of the proximal femur is closer to normal.