Subtrochanteric femoral shortening osteotomy in total hip arthroplasty for high-riding developmental dislocation of the hip

A surgical technique, which uses a transverse osteotomy, for subtrochanteric femoral shortening and derotation in total hip arthroplasty for high-riding developmental dislocation of the hip is described. Anteversion is set by rotating the osteotomy fragments, and torsional stability is augmented with allograft struts and cables when indicated. Eight patients with 9 total hip arthroplasties were followed for an average of 43 months (range, 24–84 months). Good to excellent results were obtained in 87% of patients (7 of 8). Eight of 9 osteotomies (89%) demonstrated radiographic evidence of healing at an average of 5 months. One patient had an asymptomatic nonunion of the osteotomy site but still had a good overall clinical result. Another patient suffered fatigue failure of a distally ingrown porous device, which necessitated revision total hip arthroplasty 18 months after surgery. Subtrochanteric osteotomy in total hip arthroplasty for developmental dislocation of the hip allows for acetabular exposure and diaphyseal shortening while facilitating femoral derotation. Furthermore, proximal femoral bone stock is maintained and some of the potential complications of greater trochanteric osteotomy may be avoided.     

年龄因素与发育性髋关节脱位保守治疗并发股骨头缺血性坏死的相关性研究

背景：应用保守方法治疗发育性髋关节脱位（developmental dysplasia of the hip,DDH）并发股骨头缺血性坏死（avascularnecrosis of the femoral head,AVN）的风险较高,年龄因素是公认的危险因素。目前国内外均将18个月作为保守治疗与手术切开复位的分界线。目的：研究年龄因素对于应用保守方法治疗DDH并发AVN的影响,讨论DDH保守治疗的年龄选择标准。方法：2005年1月至2010年8月应用保守方法治疗DDH患儿53例（77髋）,分为3个年龄段：（1）12个月龄,25髋;（2）13～15个月龄,20髋;（3）16个月龄,32髋。前3个月每月复诊1次,之后每3个月复诊1次,应用Salter标准评判AVN。总结临床资料及影像学结果,统计分析不同年龄段保守治疗DDH并发AVN率的差异。结果：随访时间为1.1～2.2年,平均1.5年。53例（77髋）中30髋出现AVN（40.0%）,其中12个月以内患儿25髋中3髋发生AVN（12.0%）,13～15个月患儿20髋中12髋发生AVN（60.0%）,16个月以上患儿32髋中15髋发生AVN（46.9%）。结论：脱位程度、股骨头骨化核出现与否等均对保守治疗DDH并发AVN有一定的影响。12个月以上合并Ⅲ度以上脱位的DDH患儿保守治疗并发AVN的风险较高,应根据患儿本身条件制定个性化的治疗方案。     

Outcome of surgical management of developmental dysplasia of hip in children between 18 and 24 months

Background:

Developmental dysplasia of hip (DDH) is a common condition presenting to a pediatric orthopedic surgeon. There is a consensus on the surgical treatment of children with ages ranged from 18 to 24 months where majority agree on open reduction and hip spica. Open reduction was done with an additional pelvic procedure wherever required to get better results and prevent residual acetabular dysplasia (RAD) and early osteoarthritis.

Materials and Methods:

35 children with unilateral DDH were operated between 2002 and 2007 at our institute. Open reduction was performed in all using the standard anterior approach and peroperative test for hip stability was done. Nine children got an additional pelvic procedure in the form of Dega acetabuloplasty. All were followed up for a minimal period of 2 years (range 2-7 years).

Results:

No hip got redislocated. At the end of 18 months, there were seven cases of RAD with acetabular index (AI) of 35° and above. These were all from the group where open reduction alone was done.

Conclusion:

We feel that a preoperative AI of >40° and a per-operative safe-zone <20° increases the need for supplementary pelvic osteotomy in age group of 18 to 24 months because in such cases, the remodeling capacity of the acetabulum is unable to overcome the dysplasia and to form a relatively normal acetabulum.     

一期Salter截骨联合股骨近端截骨在3～8岁延迟治疗发育性髋关节脱位中的应用

[目的] 探讨应用一期Salter截骨联合股骨近端截骨在3～8岁延迟治疗发育性髋关节脱位(LDH)的临床疗效及优势.[方法] 回顾性分析本院2006年6月～2008年4月对3-8岁之前未经治疗的34例(39髋)发育性髋关节脱位患儿采用无术前牵引的一期联合手术治疗的临床资料.共34例(39髋),男5例,女29例;右髋16例,左髋17例,双髋3例;按照Tonnis分级,Ⅱ级4髋,Ⅲ级16髋,Ⅳ级19髋,术前髋臼指数平均33°(28°～42°);手术年龄平均4.5岁(3～8岁).[结果] 术后病人全部获得随访,平均随访3.5年(2.5～4年3个月),术后改善髋臼指数平均15.5°(10°～20°),1髋(2.5%)半脱位,1髋(2.5%)发生股骨头坏死征.按照Mckay临床评定标准,其中优11髋(28%),良23髋(59%),可3髋(8%),差1例(3%),优良率89%.Severin X线评定标准:优13髋(33%),良23髋(59%),可2髋(5%),差1例(3%),优良率92%.[结论] 一期联合手术无需术前牵引,能同时纠正髋关节软组织和骨性病理改变.减少术后并发症发生率,增加关节功能优良率.减少患儿痛苦及住院时间.效果优良,值得在适合的病例中推广.     

Open reduction and varus-detorsion osteotomy with femoral shortening in treatment of congenital dislocation of the hip

In this study, we clinically and radiographically evaluated open reduction with shortening of the femur in children more than 1 year old with refractory congenital dislocation of the hip. In 19 children (aged 1–4 years), 22 joints were operated on. The patients were followed-up for an average of 8.7 years (range, 2–13 years). Functional results were satisfactory in all joints, and differences in limb length were not significant. Radiographically, good results (grades I and II) were obtained in 16 of the 22 joints, according to Severin's criteria. This surgical procedure may be indispensable for treating refractory congenital dislocation of the hip in children over 1 year old. Received for publication on May 2, 1997; accepted June 3, 1998     

髂臼成形骨盆截骨术治疗幼儿发育性髋脱位的疗效

目的 探讨髂臼成形(Pemberton)骨盆截骨术治疗幼儿发育性髋脱位(DDH)的疗效.方法 对54例DDH患儿采用Pemberton骨盆截骨术治疗.记录临床随访结果和髋关节解剖结构参数.末次随访时,采用Mckay评估标准评价髋关节功能,采用Severin标准评价髋关节形态和复位情况.结果 单侧DDH患儿均获得9个月随...     

髋联合截骨术一次性重建关节结构治疗严重先天性髋关节脱位

目的 探讨髋联合截骨术一次性重建关节结构治疗严重先天性髋关节脱位的临床效果。方法 应用髋联合截骨术治疗严重先天性髋脱位患儿26例34髋并随访1～3年。结果 26例34髋中，24例32髋效果良好，髋关节功能恢复正常；合并股骨头坏死10例12髋中，治疗后11髋功能恢复正常。结论 髋联合截骨术是良好的一次性重建严重先天性髋关节脱位关节结构的方法，同时对并发股骨头坏死也有治疗效果。     

Total hip arthroplasty in developmental high dislocation of the hip

In total hip arthroplasty for developmental high dislocations, placement of the implant cup in the true acetabulum and femoral-shortening osteotomy can produce satisfactory results. We performed total hip arthroplasties in 25 high dislocated hips (22 patients) between 1992 and 2000, placing all cups in the true acetabula and using noncemented components and performing a femoral-shortening osteotomy in 22 hips. The overall complication rate was 36%. At follow-up evaluation at an average of 5 years later, patients' mean scores had improved as follows: pain, from 2.3 to 5.7; function scores, from 2.3 to 4.5; mobility scores, from 2.3 to 4.4; Harris hip scores, from 37.8 to 95. We recommend both placing the cup in the true acetabulum to maximize host-bone contact with the implant and preserve as much host bone as possible and femoral-shortening osteotomy for a lower incidence of nerve injury than with aggressive soft-tissue release.     

骨盆Salter截骨治疗发育性髋关节脱位术后渐发脱位的原因分析

目的 探讨骨盆Salter截骨治疗发育性髋关节脱位术后渐发脱位的原因.方法 采用骨盆Salter截骨治疗63例儿童发育性髋关节脱位.7例术后发生渐发脱位,分析其发生原因.结果 患儿均获得随访,时间12～89个月.术后发生渐发脱位7例中,3例因术后关节囊松弛,不能有效维持关节稳定性,通过佩带髋外展支具后髋关节恢复稳定;2...     

Safety of Fettweis squatting position in congenital dislocation of the hip: Experimental study of prevention of deformity of the femoral head and neck in pigs

The safety of the Fettweis squatting position for immobilization after reduction in congenital dislocation of the hip was evaluated in an experimental model in pigs. In seven neonatal pigs, the hips were fixed in a plaster cast for 3 h in the Fettweis squatting position after the insertion of an allogenic meniscus into the hip joint. Three to 5 months later, no obvious deformity of the femoral head or neck was noted. The results demonstrate that the squatting position is an appropriate position for immobilization after the reduction of dislocated hip joints.     

Original cementless femoral stem for dysplastic hip: clinical results of HPF stem

We designed and developed the original cementless femoral stem (HPF) adapted to femurs of developmental dysplasia of the hip (DDH). Twenty-three arthroplasties using HPF were performed in 22 cases. The average age at the operation was 48.4 years. The average follow-up period was 6 years and 10 months. The average Harris Hip Score improved from 46.3 points preoperatively to 93.4 points postoperatively. All stems were classified as bone-ingrown or stable fibrous fixation. Clinically and radiologically excellent results proved the design concept of the HPF realized good fixation in the proximal femur with deformities of DDH. The surface treatment worked well for biological fixation even in clinically difficult cases with poor bone quality and/or complicated deformity of the femur of DDH.     

全髋置换术治疗髋关节发育不良伴骨关节炎34例报告

[目的]研究全髋置换术治疗髋关节发育不良伴骨关节炎的方法及疗效。[方法]自2004年10月～2009年10月,对34例(41髋)髋关节发育不良伴骨关节炎的成年患者进行了人工全髋关节置换术,其中女性27例32髋,男性7例9髋,平均年龄5 7岁(35～76岁)。按Crowe分型,Ⅰ型16例19髋,Ⅱ型12例14髋,Ⅲ型6例8髋,术前平均Harris评分(43.5±10.5)分。[结果]手术出血量平均350 ml(200～600 ml),输血量平均230 ml(0～600ml),引流量平均200 ml(110～450 ml),手术时间平均100 min(85～130 min),术后平均Harris评分(94.5±3.2)分,较术前有明显提高(P<0.05),优良率达95%。术后平均随访4.8年(2～7年),未发现感染、无菌性松动、假体下沉、异位骨化等并发症。[结论]对于髋关节发育不良伴骨关节炎的成年患者,全髋置换术是一种较好的治疗方法。     

发育性髋关节发育不良闭合复位后影响股骨近端形态发育的因素分析

[目的]探讨闭合复位治疗发育性髋关节发育不良(developmental dysplasia of the hip,DDH)后股骨近端形态改变的发生及其影响因素。[方法]回顾分析本院2000年1月～2006年12月采取闭合复位的DDH患儿258例,其中106例(160髋)获得随访;年龄6～36个月,平均16.9个月。其中男12例,女94例,左侧脱位34例,右侧脱位18例,双侧脱位54例。脱位程度按Tnnis分型:Ⅰ型23髋,Ⅱ型81髋,Ⅲ型31髋,Ⅳ型25髋。所有患儿均随访2～11年,平均5.1年。所有患儿术前均行双下肢悬吊牵引4～24 d,平均13.4 d。全麻下行经皮长收肌腱切断、手法复位后动力蛙式石膏固定3个月,外展支具固定3个月。采用Bucholz-Ogden分型评价闭合复位后股骨近端形态改变。对DDH患儿性别、年龄、脱位程度、牵引时间、复位后固定时间、复位前骨化核出现与否、家族遗传史、胎位、复位前是否能行走等多变量进行Logistic多因素回归分析,探讨这些因素与闭合复位后股骨近端形态改变的相关性。[结果]在获得随访的160髋中有31髋发生股骨近端形态改变(19.4%),其中Bucholz-OgdenⅠ型27髋(16.9%),Ⅱ型2髋(1.25%),Ⅲ型1髋(0.625%),Ⅳ型1髋(0.625%)。经Logistic多因素回归分析,复位时患儿年龄(OR=7.006,P<0.01)、脱位程度(OR=5.116,P<0.001)、牵引时间(OR=0.261,P=0.023)及复位后固定时间(OR=3.991,P=0.03)与闭合复位后股骨近端病理形态改变存在明显相关性。而患儿性别、复位前骨化核出现与否、家族遗传史、胎位、复位前是否能行走等无明显相关性(P>0.05)。[结论]复位前的皮牵引时间14～24 d有助于减轻股骨近端形态的病理改变,复位时患儿年龄越大、脱位程度越高、复位后固定时间越长,股骨近端形态病理改变越严重。     

全髋关节置换术治疗成人发育性髋关节发育不良

目的 探讨人工全髋关节置换术(THR)在成人发育性髋关节发育不良(DDH)继发骨性关节炎中的治疗效果.方法 对26例DDH继发骨性关节炎患者行THR,其中23例中、重度骨缺损者,采用植骨修补外上方承重区骨缺损,并重建髋臼及股骨的解剖结构,合理安装假体.结果 经9个月～6年随访,患者髋关节疼痛完全消失,采用Harris关节功能评分,由术前的平均(33.8±0.7)分恢复到术后9个月时的(87.1±0.3)分.结论 DDH继发骨性关节炎采用THR是行之有效的,充分的软组织松解,重建髋臼和股骨近端的结构,假体的正确选择是手术成功的关键.     

The incidence of avascular necrosis following a cohort of treated developmental dysplasia of the hip in a single tertiary centre

PurposeAvascular necrosis (AVN) may occur following treatment for developmental dysplasia of the hip (DDH). The primary aim of this study was to identify the incidence of AVN in a cohort of patients treated for DDH. Secondary aims were to classify AVN using available classification systems, analyze the correlation between the systems and investigate their relationship with the age at diagnosis of DDH.MethodsAn 11-year retrospective study was carried out at a single tertiary centre, using data from the clinical portal (patient records database) and IMPAX (system used to store plain radiographic images). Clinical details (patient demographics and outcomes) and plain radiographic images were used to identify cases of DDH and categorize cases of AVN using available classification systems: Tonnis and Kuhlmann, Kalamchi and McEwen, Bucholz and Ogden and Salter. Severin was used to assess final clinical outcome.ResultsIn total, 405 (522 hips) cases of DDH were identified, of which 213 resolved without treatment, 93 were treated conservatively and 99 surgically. Only treated cases were included in the analysis (n = 192). AVN (45/99; 45.5%) was found to occur only postoperatively. A positive correlation was present between age at presentation and severity of AVN as classified according to Salter’s criteria (chi-squared p value < 0.01).ConclusionAVN incidence was 23.4% (45/192) and only occurred in surgically treated patients. Older age at diagnosis was associated with a higher incidence of AVN, as defined according to Salter’s criteria. The classification systems appeared to show no correlation amongst each other (p-value < 0.01).Level of evidence:III - Retrospective cohort study     

Radiological and clinical outcomes of medial approach open reduction by using two intervals in developmental dysplasia of the hip

Objective

To evaluate the midterm clinical and radiological outcomes of the medial approach using two intervals for developmental hip dysplasia (DDH).

联合术式合并异体肌腱重建圆韧带治疗小儿发育性髋关节脱位

目的探讨联合术式合并异体肌腱重建圆韧带治疗小儿发育性髋关节脱位(DDH)的手术方法及疗效。方法对48例小儿DDH患者(56髋)行软组织松解、股骨上段截骨、Salter或Pemberton髂骨截骨及异体肌腱移植、重建圆韧带术治疗,测定并对比手术前后的AI、CE角等指标,采用Severin影像学及McKay临床疗效评价标准评价疗效。结果 AI由术前36.2°~58.1°降低至11.4°~21.3°,CE角由术前-10°~-50°提高至12°~45°,差异均有统计学意义(P0.05)。患儿均获随访,时间1~4年。根据Severin X线评定标准:优30髋(53.6%),良21髋(37.5%),可5髋(8.9%)。根据McKay临床疗效评定标准:优29髋(51.8%),良20髋(35.7%),可4髋(7.1%),差3髋(5.4%)。结论联合术式结合异体肌腱重建圆韧带治疗DDH有利于提高成功率、减少并发症,但须强调联合化及个体化原则。     

Salter髂骨截骨联合股骨头圆韧带重建术治疗小儿发育性髋关节脱位

目的探讨Salter髂骨截骨联合股骨头圆韧带重建术治疗儿童发育性髋关节脱位的疗效。方法采用Salter髂骨截骨联合股骨头圆韧带重建术治疗39例(44髋)发育性髋关节脱位患儿。结果患儿均获随访,时间6～24个月。按照吉士俊等疗效评定标准进行评定:优35髋,良6髋,可3髋,优良率达93.2%。结论Salter髂骨截骨联合股骨头圆韧带重建术治疗学龄前儿童发育性髋关节脱位效果良好。     

生物型假体全髋关节置换术治疗成人髋关节发育不良继发骨关节炎的疗效评价

[目的]评价生物型假体全髋关节置换术(total hip arthroplasty,THA)治疗成人髋关节发育不良(developmental dysplasia of hip,DDH)继发骨关节炎的疗效.[方法]对2002年2月～2009年8月在本院行THA治疗的76例(102髋)髋关节发育不良继发骨关节炎患者的临床及影响学资料进行回顾性分析,其中男34例,女42例;年龄35～64岁,平均52.5岁.用Harris髋关节评分系统评价手术的临床疗效.根据骨盆平片及患髋正、侧位X线片观察髋臼、股骨假体的位置及其周围骨质变化.[结果]所有患者均获2年以上随访,平均5.3年.术后4例仍有轻度疼痛,服用非甾体类止痛药后缓解.8例存在不同程度下肢不等长(0.5 ～1.2 cm),Trendelenburg征阴性,无跛行.末次随访时Harris评分平均值(89.5±3.8)分,优46例(60髋),良20例(30髋),可10例(12髋);优良率为88.2％.末次随访时髋臼假体位置无明显移位,头臼包容性良好.30例出现异位骨化,6例出现髋臼周围骨溶解.股骨柄假体的位置无明显改变,中心固定有98髋(94.1％),柄-髓腔匹配优良率100％.4髋出现股骨侧骨溶解,8髋假体柄与股骨界面出现透亮线.所有病例均出现股骨近端骨重塑,其中Ⅰ度92髋,Ⅱ度10髋.无感染、假体松动、假体周围骨折等并发症发生.[结论]生物型假体全髋关节置换术治疗成人髋关节发育不良继发骨关节炎的疗效满意.