髋关节发育不良保守治疗后股骨头坏死的随访研究

[目的]总结采用保守治疗6 ～36个月龄髋关节发育不良(DDH)的随访结果,回顾分析在该治疗模式下发生股骨头缺血坏死(AVN)的相关因素.[方法]随访2007年12月～2009年12月在本院采用双侧内收肌松解、手法闭合复位、石膏外固定方法治疗有完整资料的6～ 36个月龄DDH患儿,治疗结果的评价采用周永德、吉士俊的方法,根据影像学表现和Bucholz-Ogden分型标准进行AVN评价.[结果]63例101髋获得随访,随访时间为2.25～4.25年,平均3.2年.优良率为80.2％,13髋发生AVN,发生率为12.8％,3髋发生再脱位,发生率为2.9％.[结论]采用内收肌松解、手法闭合复位、屈髋90°～ 120°外展位外固定是治疗6～36个月DDH一种良好方法,AVN的发生与患儿的脱位程度、股骨头骨化中心发育情况有关.     

发育性髋关节脱位的早期手术治疗

[目的]总结12～18个月龄发育性髋关节脱位(developmental dislocation of the hip,DDH)患儿手术治疗的临床和影像学方面的结果,研究早期手术治疗的可行性。[方法]回顾性分析本院在2004～2006年年龄为12～18个月发育性髋关节脱位患儿采用手术治疗的59例72髋临床资料,其中男8例,女51例,左侧27例,右侧19例,双侧13例。手术方式:切开复位加Salter骨盆截骨53髋;切开复位加Pemberton骨盆截骨19髋。[结果]平均随访50个月,术后按改良的McKay标准进行临床评估;按Severin标准进行放射学评估;按Salter标准诊断有无股骨头缺血性坏死。SeverinX射线评分优良率为94.4%,McKay临床评估优良率为93%。按Salter标准有2髋(2.8%)发生股骨头缺血性坏死(avascular necrosis of the femoral head,AVN)。[结论]不必过分强调小年龄DDH患儿的保守治疗,放宽手术指征,早期手术治疗是可行的。     

小儿发育性髋关节脱位的关节镜下治疗

[目的]探讨关节镜在小儿发育性髋关节脱位（DDH）治疗中的应用价值。[方法]所有患儿经理学检查、X线及螺旋CT诊断为DDH,并一部分为闭合复位再脱位,另一部分为难复位。将所有病人随机分两组：一组经关节镜治疗,21例,男7例,女14例,左侧14髋,右侧12髋,共26髋;年龄6～30个月,平均17.4个月。另一组为对照组,经Ferguson手术,25例,男8例,女17例,左侧16髋,右侧13髋,共29髋;年龄8～32个月,平均18.9个月。两组均清除妨碍复位的因素并使关节成形,复位石膏外固定10个月。[结果]按周永德评分标准,关节镜治疗组：优10髋,良11髋,中3髋,差2髋。Ferguson手术组：优11髋,良10髋,中7髋,差1髋。两组间各级比较,统计学无显著性差异（P〉0.05）。[结论]关节镜在直视下观察并清除妨碍股骨头复位的因素,成形关节。此项技术,在一定条件下是可采纳的微创治疗DDH方法。     

非手术方法治疗婴幼儿发育性髋脱位的疗效分析

[目的]评估应用内收肌切断、手法闭合复位、改良蛙式石膏固定方法治疗6～36个月婴幼儿发育性髋脱位的价值与适应证.[方法]随访1995年1月～2001年12月有完整资料的6～36个月DDH患儿193例282髋,根据开始治疗时间分为6～12个月、13～24个月和25～36个月3组,按照复位前髋臼指数和脱位程度进行分类,比较不同髋臼指数、脱位程度与治疗结果的关系.最后随访时间为5.5～11.5年,平均8年.[结果]根据1993年全国小儿髋关节会议通过的周永德发育性髋脱位疗效评价标准,本文239髋复位满意,优良率为84.8%,其中6～12个月组优良率为88.9%,13～24个月组和25～36个月优良率分别为85.3%、80.4%,3个年龄段优良结果相比无统计学差异(P＞0.05);治疗前所有病例AI均大于30°,其中30°～35°组和36°～40°组的优良率分别为90.9%、87.6%,而＞40°组的优良率为74.1%,前两组间优良率比较无显著性差异(P＞0.05),而与＞40°组比较差异则有统计学意义(P＜0.05);复位前Ⅰ度、Ⅱ度、Ⅲ度脱位的远期优良率分别为86.5%、84.9%、82.5%,3组统计学检验无显著性差异(P＞0.05),共10髋发生股骨头缺血性坏死,复位前脱位程度均为Ⅲ度.[结论]内收肌切断、手法闭合复位、改良蛙式石膏固定方法对6～36个月DDH患儿是一种有效的治疗方法,3岁以下开始治疗年龄对优良率的影响不大;复位前AI值小于40°优良率高;脱位程度对治疗优良率影响不大,但＞2 cm的高度脱位是并发股骨头缺血性坏死的因素之一.     

发育性髋脱位保守治疗方法和影响因素概述

发育性髋脱位（developmentaldislocationofthehip,DDH）治疗方法多样,多数学者认为其病理改变是继发的,髋臼发育不良和股骨近端变化是继发于髋关节脱位的结果。DDH的髋臼、股骨头颈、关节囊形态变化随着患儿年龄增长、负重增多而加重,如果能在早期发现本病并给予及时的治疗,将会有效地阻止畸形发生,提高患儿远期生活质量,所以保守治疗受到了越来越多的人关注。保守治疗是婴幼儿DDH的一种有效治疗方法,特别是对于年龄小、早期发现的患儿,其效果优良,避免了手术所造成的广泛创伤和严重并发症。     

改良蛙式石膏固定治疗发育性髋脱位

目的总结用改良蛙式石膏固定方法治疗发育性髋脱位（DDH）的临床经验。方法采用内收肌切断、手法闭合复位、改良蛙式石膏固定方法治疗DDH患儿193例282髋,对患儿的临床资料进行回顾性分析。结果193例均获得随访,时间5年6个月～11年6个月,平均（8±3.2）年。参照周永德等发育性髋脱位疗效评价标准,239髋复位满意,远期优良率为84.8%。根据Salter评价标准,有10例发生股骨头缺血性坏死。结论改良蛙式石膏固定方法治疗DDH具有操作简单、住院时间缩短等优点,是一种有效的方法。固定后护理很重要。     

大龄儿童发育性髋关节脱位的手术治疗

年龄超过7岁的发育性髋关节脱位（developmental dislocation of the hip,DDH）患儿保守治疗后往往会出现再脱位、股骨头缺血性坏死、关节僵硬等并发症。因此,对于大龄DDH患儿多采用手术治疗。2000年3月-2009年8月,我科对12例大龄DDH患儿采用手术治疗,术后结合短期合理的石膏外固定,并加强复位术后分阶段的功能锻炼,取得良好效果。     

18～36个月发育性髋脱位闭合复位的远期疗效评价

[目的]评估内收肌切断、手法闭合复位、改良蛙式石膏固定方法治疗18~36个月婴幼儿发育性髋脱位(developmental dislocation of hip,DDH)的远期效果。[方法]随访1993年1月~2001年12月在本院采用内收肌切断、手法闭合复位、改良蛙式石膏固定方法治疗有完整资料的18~36个月DDH患儿156例232髋,其中Ⅰ度77髋,Ⅱ度95髋,Ⅲ度60髋,随访时间为5.5~14.5年,平均9.2年,并对全部病例进行影像学检查和髋关节功能评价。[结果]根据周永德发育性髋脱位疗效评价标准,本文195髋复位满意,优良率为84.05%,9例发生股骨头坏死;术前平均髋臼指数(AI):复位成功髋(35.34°±5.95°),失败髋(44.51°±5.32°),成功髋复位前AI均数明显小于失败髋均数;Ⅰ度优良率为84.41%,Ⅱ度优良率为85.21%,Ⅲ度优良率为81.67%。[结论]内收肌切断、手法闭合复位、改良蛙式石膏固定方法对18~36个月DDH患儿是一种有效的治疗方法,复位前AI值的大小对于DDH保守治疗方法的选择和远期疗效评估具有一定的指导意义,而脱位程度不是能否采用手法复位的标准。     

发育性髋脱位闭合复位治疗后股骨头骨骺坏死

闭合手法复位是治疗婴幼儿发育性髋脱位(developmental dysplasia of the hip,DDH)的常用方法,但是治疗后最常见的并发症之一就是股骨头骨骺缺血性坏死(简称头坏死,avascular Becrosis,AVN).它严重影响髋关节的发育,其远期效果不佳,甚至造成终身残疾.自从1910年Legg,Calve, Penlles报告儿童股骨AVN以来,许多学者也相继报告了DDH治疗中的类似现象,AVN被认为是由股骨头血供障碍所致.近年来,在治疗DDH中发生AVN的原因方面已取得了较为一致的意见,认为该病由股骨头与髋臼之间压力增加所致.     

开放复位加股骨短缩术治疗小儿发育性髋关节脱位的临床研究

目的探讨开放复位加股骨短缩术治疗小儿发育性髋关节脱位（DDH）的临床疗效。方法回顾性分析本组11例（11髋）DDH患儿采用开放复位、股骨短缩术加Salter截骨术式治疗。其中男2例,女9例;左侧7例,右侧4例。患儿手术时年龄为2岁8个月～5岁3个月,平均3．5岁。按Tsnnis系统分级：Ⅲ度2例,Ⅳ度9例。术前患肢缩短1．5～3．5cm,平均2．4cm。结果患儿随访时间1～6年,平均2．8年。股骨颈前倾角术前测量30°～50°,术中皆矫正至20°左右。术前髋臼指数35°～55°,术后矫正至17°～32°。术中股骨截骨长度1．0～2．5cm,平均1．6cm。McKay评分,优7髋,良4髋。股骨头缺血性坏死1例。结论对2～6岁之间的高脱位DDH患儿,开放复位术中发现复位困难或复位后压应力大时应行股骨截骨短缩术。     

Perthes' disease or late avascular necrosis after developmental dislocation of the hip? 10 children followed for 6-35 years

We studied 10 patients treated because of late avascular necrosis (AVN) mimicking Legg-Calvé-Perthes' disease (LCPD) after developmental dislocation of the hip (DDH). DDH was recognized late at an average age of 5.4 months and in all children it was treated without surgery. In 4 children, the treatment was complicated by mild AVN of the femoral head, which had disappeared before 3 years of age. The first clinical signs of LCPD were noted at a mean age of 5.8 years. They all had Catterall's type III or IV of LCPD. The course was typical of LCPD. 8 children were operated on at mean age of 7.4 (5-12) years. In 7 of them, subtrochanteric derotation-varisation osteotomy of the femur with shortening combined mainly with Dega's pelvic osteotomy was done. The operative treatment resulted in a concentric position of the femoral head and good coverage of the acetabulum. Follow-ups were done at 10 (6-35) years. Shortened femoral neck and trochanteric overgrowth occurred in 4 operated hips. According to the Stulberg classification, 2 hips were classified as type I, 1 as I/II, 5 as II/I as II/III and 1 as IV. We conclude that LCPD mimicking late AVN can occur in hips treated because of developmental dislocation.     

Outcome of 881 total hip arthroplasties in 747 patients 21 years or younger: data from the Nordic Arthroplasty Register Association (NARA) 1995–2016

We studied 10 patients treated because of late avascular necrosis (AVN) mimicking Legg-CalvéPerthes' disease (LCPD) after developmental dislocation of the hip (DDH). DDH was recognized late at an average age of 5.4 months and in all children it was treated without surgery. In 4 children, the treatment was complicated by mild AVN of the femoral head, which had disappeared before 3 years of age. The first clinical signs of LCPD were noted at a mean age of 5.8 years. They all had Catterall's type III or IV of LCPD. The course was typical of LCPD. 8 children were operated on at mean age of 7.4 (5-12) years. In 7 of them, subtrochanteric derotation-varisation osteotomy of the femur with shortening combined mainly with Dega's pelvic osteotomy was done. The operative treatment resulted in a concentric position of the femoral head and good coverage of the acetabulum. Follow-ups were done at 10 (6-35) years. Shortened femoral neck and trochanteric overgrowth occurred in 4 operated hips. According to the Stulberg classification, 2 hips were classified as type I, 1 as I/II, 5 as II, 1 as II/III and 1 as IV. We conclude that LCPD mimicking late AVN can occur in hips treated because of developmental dislocation.     

带血管腓骨移植治疗股骨头坏死后股骨头塌陷的危险因素

目的通过回顾性分析带血管腓骨移植(FVFG)治疗股骨头坏死(AVN)的随访资料,探讨FVFG术后股骨头塌陷的高危时间窗和危险因素,为临床进一步优化FVFG术后随访和康复锻炼计划提供可靠依据。 方法筛选2006年1月至2012年12月在上海市第六人民医院行FVFG治疗的AVN病例共307髋。入组标准：①年龄18～55岁;②AVN Ficat-Arlet Ⅱ～Ⅲ期;③按计划进行随访且抵达随访终点。排除标准：①术后继发感染、排异等严重并发症;②未按计划随访、随访资料不全或抵达随访终点前失访。记录入组病例的年龄、性别、AVN诱因、AVN单双侧、AVN分期及术后股骨头有无塌陷并对以上数据采用单因素和多因素Logistic回归分析FVFG术后股骨头塌陷进展的危险因素。 结果共收集215例307髋病例,平均随访时间(51±26)个月,其中股骨头塌陷未进展率为84.7%(260髋),股骨头塌陷进展率为15.3%(47髋)。股骨头塌陷发生在术后3～24月,其中25%发生在术后3月内,50%在术后6月内,75%在术后15月内。单因素和多因素Logistic回归分析提示,年龄≥ 40岁(P＝0.021)和Ficat-Arlet Ⅲ期AVN(P＝0.003)是FVFG术后股骨头塌陷进展的危险因素。 结论FVFG是一种有效的AVN保髋治疗方法。术后15月内是FVFG术后股骨头塌陷的高危时间窗,年龄较大和Ficat-Arlet Ⅲ期是其风险因素;此类病人在FVFG术后应缩短随访时间间隔,减轻锻炼强度。     

Long-term outcome of Ludloff’s medial approach for open reduction of developmental dislocation of the hip in relation to the age at operation

We reviewed long-term outcomes after open reduction by the medial approach for developmental dislocation of the hip (DDH). Forty-five hips in 43 patients with more than ten years of follow-up were assessed clinically and radiologically. The mean age at surgery was 14.0 (range 6–31) months, and the follow-up period ranged from ten to 28 years (mean 16.4 years). We compared the good (18 hips) and poor groups (27 hips) as classified by the Severin classification. The mean age at surgery was significantly older in the poor group than the good group (17.1 and 9.4 months, respectively, P < 0.001). Thirteen (29%) of 45 hips had avascular necrosis (AVN) of the femoral head. The mean age at surgery was significantly older in the patients with AVN than without AVN (20.0 and 11.6 months, respectively, P < 0.001). Another approach, such as the wide exposure method, should be selected for DDH with increased age at operation.     

Does the vascular development of the femoral head correlate with the incidence of avascular necrosis of the proximal femoral epiphysis in children with developmental dysplasia of the hip treated by closed reduction?

PurposeThe purpose of this study was to identify the correlation between the vascular development of the femoral head and avascular necrosis (AVN) in patients with developmental dysplasia of the hip (DDH) treated by closed reduction (CR).MethodsWe retrospectively reviewed 78 patients with DDH treated by CR (83 hips). The vascular maturity, number of vessels and perfusion changes of the femoral head were assessed on perfusion MRI (pMRI) before and after CR.ResultsThe number of vessels (mean 4.2 sd 1.4) of the femoral head and the ratio (36.1%) of mature vessels (type III) on the dislocated side were significantly less than those at contralateral side (mean 6.0 sd 1.2; 82.2%) (p < 0.001). Of the included 83 hips, 39 hips (61.5%) showed decreased perfusion of the femoral head, including partial decreased (Class B, 47.0%) and global decreased (Class C, 14.5%), at the dislocated side, which was significantly more than those at contralateral side (0.0%) (p < 0.001). In total, 32 out of 83 hips (38.5%) developed AVN. The rate of AVN with Class A (18.8%) which perfusion of the femoral head was normal (unchanged or enhanced) was significantly less than those with Class C (66.7%) (p = 0.006).ConclusionThe vascular development and perfusion changes of the femoral head on the dislocated side are significantly worse than those at contralateral side. Immature vascularity of the femoral head before CR and poor perfusion of the femoral head after CR may be risk factors for AVN in patients with DDH.Level of evidenceIII     

应用改良Pemberton骨盆截骨术治疗6岁以上发育性髋关节发育不良患儿的中期随访结果

目的探讨应用改良Pemberton骨盆截骨术治疗6岁以上发育性髋关节发育不良(DDH)患儿的中期疗效。方法对2001年1月至2017年12月内蒙古医科大学第二附属医院小儿骨科采用改良Pemberton骨盆截骨术联合或不联合股骨转子下旋转短缩截骨术一期手术治疗的DDH患儿60例(74髋)的临床资料进行回顾性分析。其中男22例,女38例;手术时年龄(8.20±2.56)(6~15)岁。左侧20例,右侧26例,双侧14例。术前Tonnis分级Ⅱ级38髋(51.35%),Ⅲ级10髋(13.51%),Ⅳ级26髋(35.14%)。联合应用股骨转子下旋转短缩截骨52例(61髋),未联合应用股骨转子下旋转短缩截骨8例(13髋)。初次治疗50例(64髋),残余畸形治疗10例(10髋)。依照年龄将全部患者分为6岁≤年龄<8岁组和年龄≥8岁组。采集术前Tonnis分级和髋臼指数(AI)以及末次随访AI、中心边缘角(CE)和股骨头缺血坏死(AVN)发生情况并进行比较;采用McKay临床评定标准和Severin影像学评定标准分别对术后患者髋关节功能和放射学结果进行评估。采用χ2检验,单因素筛选及多因素logistic回归模型对数据进行统计学分析。P<0.05为差异有统计学意义。结果全部患者均获得随访,随访时间为(5.86±3.63)(2~17)年。术前AI=(37.18±10.67)°;末次随访AI=(14.11±5.76)°,CEA=(38.59±11.46)°。术后Severin评价优良率为71.6%,McKay评价优良率为74.3%;AVN发生率为18.9%(12例,14髋)。2个年龄组患者McKay评分和Severin评分差异均无统计学意义(P=0.135,0.129)。是否出现AVN(均P<0.001)和术前Tonnis分级(P=0.002,<0.001)是影响术后McKay和Severin评分的主要因素。结论改良Pemberton骨盆截骨术是治疗6岁以上DDH患儿有效安全的手术方式;发生AVN和术前Tonnis分级较高是影响预后的独立危险因素。     

Avascular necrosis rate in early reduction after failed Pavlik harness treatment of developmental dysplasia of the hip

Our hypothesis is that hips with developmental dysplasia (DDH), which fail Pavlik harness treatment and are reduced within 3 months of age, have a low rate of avascular necrosis (AVN). Inclusion criteria are as follows: diagnosis of DDH within 2 months of birth, failure of reduction or stabilization by Pavlik harness treatment, surgical reduction of the hip advised to be performed within 3 months of age, and follow-up for Salter criteria of AVN. Twenty-one consecutive cases (35 hips) met the inclusion criteria. Nineteen cases (31 hips) were initially reduced within 3 months of age, and none of these cases developed AVN. After Pavlik harness failure, initial closed reduction was achieved in 33 (94%) of 35 hips, and open reduction required in 2 (6%) of 35 hips. At latest follow-up, one (3%) of 35 hips had AVN. At the time of reporting, 1 (3%) of the 35 hips has required an additional procedure (Pemberton osteotomy) for residual dysplasia. There were 2 outlier cases (4 hips) in which the parents delayed the reduction and 1 case developed unilateral AVN, which was reduced after the proximal femoral ossification center developed at 7 months of age. The data presented in the current study support our hypothesis.     

Adolescents after pemberton's osteotomy for developmental dysplasia of the hip displayed greater joint loading than healthy controls in affected and unaffected limbs during gait

Patients after reduced developmental dysplasia of the hip (DDH) are at higher than normal risk of developing avascular necrosis (AVN) of the femoral head and degenerative hip osteoarthritis (OA) that are closely related to abnormal loadings. We aimed to determine the lower limb loadings in adolescents after Pemberton's osteotomy for unilateral DDH. Eleven females (age: 10.6 ± 1.0 years), who had received Pemberton's osteotomy for unilateral DDH at 1.6 ± 0.5 years of age, and 12 age‐matched healthy controls were studied using gait analysis. Compared to the normal controls, the patients were displayed greater peak axial forces at the hip, knee, and ankle in both limbs, with greater loading rates in the ground reaction force (GRF) and at the hips (p < 0.05 for all comparisons). The increased rates of repetitive loading around heel strike in both hips suggest that patients treated for unilateral DDH using Pemberton's osteotomy may be at higher risk of premature hip OA. The increased axial forces at the affected hip may be a contributing factor to the development of AVN of the femoral head in these patients, especially when incomplete coverage, insufficient congruency, and/or damaged articular surfaces remain after the osteotomy. Therefore, monitoring the loading condition at the hip is necessary for a more accurate assessment of the risk of developing joint pathology in patients after reduced DDH. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: 1034–1041, 2011     

螺旋CT三维重建在儿童发育性髋关节脱位 治疗中的应用

目的：通过术前术后对髋关节前倾角及髋臼壁发育情况的观察,探讨螺旋CT三维重建技术在儿童发育性髋关节脱位（DDH）治疗中的应用价值。方法：2003年6月至2007年6月,发育性髋关节脱位53例（61髋）,男12例,女41例;左侧34例,右侧11例,双侧8例;年龄3-16岁,平均5．6岁。行双侧髋关节螺旋CT三维重建检查,测量前倾角（FNA）及髋臼壁的发育情况,与术中所见比较。采用Pemberton或Chiari骨盆截骨及股骨近端旋转截骨治疗,术后复查三维CT,测量FNA,观察新髋臼的情况,与术前进行比较。结果：53例患髋前倾角均增大,最大90°,最小35。,平均（45．6±11．4）°。正常45髋前倾角为（23．5±10．2）°。髋臼各壁不同程度发育不良,与术中所见符合。术后前倾角较术前明显降低,前倾角平均（15．6±5．8）°。髋臼对股骨头包容明显改善。结论：髋关节螺旋CT三维重建技术可以全面显示髋关节的病理形态,精确地测量FNA,对术者选择适当的治疗方案具有重要的指导意义,术后能更直观地判断手术效果。评估预后。     

成人发育性髋关节脱位股骨解剖参数测量

目的分析成人发育性髋关节脱位患者股骨髓腔解剖形态参数变化,为临床手术治疗提供理论基础。方法收集DDH病例43例53髋,其中女31例,男12例。采用Crowe分型,其中Ⅰ型20髋（37.7%）、Ⅱ型19髋（35.8%）、Ⅲ型7髋（13.2%）、Ⅳ型7髋（13.2%）。Ⅰ、Ⅱ、Ⅲ、Ⅳ型分别对应Ⅰ、Ⅱ、Ⅲ、Ⅳ组。分别进行下肢全长DR影像学（正侧位）及股骨CT三维重建检查并与正常对照组比较。结果 DDH各组间患者股骨形态相似,股骨峡部平均位于小粗隆下115 mm处。DDH组股骨髓腔宽度明显小于对照组。DDH组髓腔张开指数相似,多表现为锥形髓腔。DDH组股骨头中心高度明显低于对照组。DDH组II型、Ⅲ型、Ⅳ型颈干角和对照组相比明显增大。所有DDH组与对照组相比前倾角变大。结论发育性髋关节脱位患者其股骨髓腔形态变异较大,尤其是CroweⅢ、Ⅳ患者。