3DCT辅助Dega截骨术治疗脑瘫患儿髋关节脱位的短期疗效分析

目的 通过3DCT模拟手术预测治疗效果,探讨Dega截骨术在脑瘫患儿髋关节脱位治疗中的应用和短期疗效.方法 收治8例发生髋关节脱位的脑瘫患儿共11髋,其中4髋半脱位,7髋完全脱位;手术时平均年龄为7岁8个月,术前均行骨盆-双股骨全长3DCT扫描并模拟手术,据此行Dega截骨术;评价手术前后肢体功能、步态的改善和髋关节发育状况;评价术后髋臼覆盖的变化和头臼的形态学匹配.结果 术后平均随访24个月.手术时Y形软骨未闭的7例9髋,髋臼指数(AI)术前(38±7)°,术后(12±6)°,平均减少26°;手术时Y形软骨闭合的1例2髋,Sharp角术前平均(51±1)°,术后(45±2)°,平均减少6°;所有患儿中心边缘角(CEA)术前(-9±18)°,术后(20±6)°,平均增加29°;股骨头偏移百分比(MP)术前(63±22)％,术后(19±6)％,平均改善44％;手术前后AI、CEA和MP的差异有统计学意义(P＜0.01).术前所有患儿Shenton线均不连续,术后均恢复连续性.根据改良Severin影像学分类,Ⅰ型4髋(36％)为优,Ⅱ型5髋(45％)为良,Ⅲ型2髋(18％)为可,优良率82％.手术时Y形软骨未闭合的7例9髋头臼形态匹配良好,关节包容满意;手术时Y形软骨已闭合的1例2髋头臼匹配良好无半脱位,但残留关节包容不良.术前GMFCS分级Ⅱ、Ⅲ、Ⅳ级各2、3、3例,术后评级Ⅰ、Ⅱ、Ⅲ级各1、4、3例.其中1例手术前后均为Ⅲ级,但其髋关节术前伸直、外展受限明显,术后活动范围已接近正常;1例手术前后均为Ⅱ级,但髋关节活动较前好转,跛行改善明显,步态趋于稳定.全部8例11髋术后髋关节功能改善满意,步态均较术前稳定.结论 3DCT可以直接观察脑瘫患儿髋关节脱位的骨性病理改变并模拟手术以指导截骨操作,以之辅助Dega截骨术治疗Y形软骨闭合前的脑瘫患儿髋关节脱位,短期效果良好,影像学及关节功能均改善满意;但用于Y形软骨闭合后的病例,尚需充足的数据以评价其疗效.

Short-term outcomes of 3DCT-assisted Dega osteotomy for hip displacement in children with cerebral palsy

Objective To explore the short-term outcomes of 3DCT-assisted Dega osteotomy for hip displacement in children with cerebral palsy.Methods A total of 8 children with cerebral palsy (11 hips) were treated.And the involved hips were displaced (7 hips) or subluxated (4 hips).Each of 8 children underwent a simulating osteotomy by 3DCT of pelvis-femurs pre-operation with an average age of 7 years and 8 months at the time of surgery.Dega osteotomy was performed to each hip as respective pre-operative simulation.Gait,limb function and development of hip were evaluated pre and post-operation.The improvement of acetabular coverage post-operation and morphology matching of femoral head to acetabulum were also evaluated.Results The average follow up period was 24 months.The mean AI of 9 hips in 7 patients with unclosed triangular cartilages improved from(38 ± 7)° to(12 ± 6)° with an average of 26° and mean AI of Sharp's angle of another 2 hips in 1 patient with closed triangular cartilages improved from (51 ± 1)°to (45 ± 2)° with an average of 6°;mean CEA improved from(-9 ± 18)° to (20 ± 6) ° with an average of 29° and mean MP improved from(63 ± 22) ％ to (19± 6)％ with an average of 44％.The changes of AI,CEA and MP were analyzed pre-and post-operation and all differences were statistically significant (P＜0.01).All Shenton lines were disrupted pre-operation and became continuous post-operation.Modified Severin classification was applied for evaluating the radiographic improvement:4 hips (36％) of type Ⅰ as excellent,5 hips (45％) of type Ⅱ as good and 2 hips (18％) of type Ⅲ as moderate.And the excellent-good rate was 82％.Morphology matching of femoral head to acetabulum were obtained in 9 hips of 7 patients with unclosed triangular cartilages in operation with favorable containments.Insufficient containments were obtained in the other 2 hips of 1 patient with closed triangular cartilages despite the matched morphologies of femoral head to acetabulum and undisplaced joints.The GMFCS classification of Ⅱ,Ⅲ,Ⅳ pre-operation was of 2,3,3 patients respectively and improved to Ⅰ,Ⅱ,Ⅲ of 1,4,3 patients respectively.And 1/8 children was marked Ⅲ pre-and post-operation with range of motivation (ROM) almost normal post-operation.Another one was marked Ⅱ pre-and post-operation with developments of ROM of hip involved and stabilization of gait.Satisfactory functional improvements and more stable gaits were obtained in all 11 hips.Conclusions Osseous pathological changes of hip displacement may be observed visually in children with cerebral palsy.And simulating osteotomy is demonstrated through 3DCT.Good short-term outcomes can be obtained in hips with unclosed triangular cartilages with satisfactory functional improvements and radiographic performances through Dega osteotomyo But adequate data are still needed for evaluating the outcomes of Dega osteotomy for displaced hips with closed triangular cartilages.