四合一联合手术治疗Crawford Ⅳ型儿童先天性胫骨假关节的疗效分析

Four-in-one surgery for treatment of CrawfordⅣcongenital pseudarthrosis of the tibia in children

目的探讨采用四合一联合手术治疗CrawfordⅣ型儿童先天性胫骨假关节(CPT)的疗效。方法回顾性分析2013年1月至2017年12月期间在湖南省儿童医院骨科治疗的86例CrawfordⅣ型CPT患儿的临床资料。男47例,女39例;手术时年龄(40.7±9.7)个月。其中63例合并神经纤维瘤病1型。均采用四合一联合手术治疗,即胫骨假关节及其周围错构瘤样组织切除、胫骨髓内棒内固定、包裹式自体髂骨植骨及Ilizarov外固定支架固定。记录患儿骨愈合情况、术后并发症情况及随访结果。结果所有患儿术后获(80.1±12.4)个月随访。本组患儿的初期骨愈合率为96.5%(83/86),初期骨愈合时间为(4.8±0.7)个月。末次随访时再骨折患儿20例,双侧下肢不等长15例(其中患侧胫骨长5例,健侧胫骨长10例),胫骨近端外翻10例,踝外翻12例,胫骨远端骺板骨桥9例,Ilizarov外固定支架针道感染10例,胫骨骨髓炎2例。踝关节僵硬35例,胫骨髓内棒偏离胫骨髓腔中央60例(其中20例突出胫骨骨皮质,行髓内棒取出)。末次随访时骨骼发育成熟患儿15例,骨骼发育未成熟71例。结论四合一联合手术治疗CrawfordⅣ型儿童CPT的初期骨愈合率高,疗效确切,但术后并发症仍较多,后期仍需继续改进。

Objective To explore the clinical efficacy of 4-in-1 surgery in the treatment of CrawfordⅣcongenital pseudarthrosis of the tibia(CPT)in children.Methods A retrospective study was conducted to analyze the clinical data of 86 patients with CrawfordⅣCPT who had been treated by 4-in-1 surgery at Orthopedic Department,Hunan Children's Hospital from January 2013 to December 2017.There were 47 boys and 39 girls,with an age of(40.7±9.7)months at the time of surgery.Of them,63 were complicated with type I neurofibromatosis.The 4-in-1 surgery consisted of resection of the tibial pseudarthrosis and surrounding hamartoma-like tissue,internal fixation with tibial intramedullary rod,grafting with wrapped autologous iliac bone,and Ilizarov external fixation.Their bone union,postoperative complications,and follow-up results were recorded.Results The mean postoperative follow-up time was(80.1±12.4)months for this cohort.The initial bone union rate was 96.5%(83/86),and the initial bone union time(4.8±0.7)months.The last follow-up revealed 20 re-fractures,15 cases of leg length discrepancy(longer tibia on the affected side in 5 ones and longer tibia on the healthy side in 10 ones),10 cases of proximal tibial valgus,12 cases of ankle valgus,9 cases of bone bridge formation of the distal tibial epiphyseal plate,10 cases of Ilizarov pin infection,and 2 cases of tibial osteomyelitis.Ankle stiffness occurred in 35 cases,and deviation of the tibial intramedullary rod from the center of the tibial medullary cavity in 60 cases,of which the intramedullary rod had to be removed in 20 because the rod protruded the tibial bone cortex.At the last follow-up,there were 15 cases of skeletal maturity and 71 cases of immature skeleton.Conclusions In the treatment of CrawfordⅣCPT in children,the 4-in-1 surgery can lead to a high rate of initial bone union and definite primary clinical efficacy,but further improvements are necessary because postoperative complications are numerous.