幼儿发育性髋脱位髋臼前倾的三维CT研究

[目的]利用髋关节的三维CT影像,来探讨3岁以下幼儿发育性髋关节脱位(developmentaldislocationofthehip,DDH)髋臼前倾角(Acetabularanteversion,AA)的改变。[方法]对44例3岁以下单侧DDH患儿的3DCT影像资料进行分析,正常侧髋作为对照,测量髋臼的前倾角。[结果]正常侧髋臼AA为(10·0±4·7)°,脱位侧为(18·1±4·5)°,P<0·01。按年龄分组,正常侧髋臼AA:小于18个月组为(9·2±4·3)°,大于等于18个月组为(10·6±4·9)°,P=0·34。脱位侧髋臼AA:小于18个月组为(16·2±4·5)°,大于等于18个月组为(19·2±4·1)°,P=0·03。[结论]三维CT能清晰地显示幼儿DDH髋臼的形态。脱位后,髋臼前倾角明显增加,且脱位时间越长,髋臼前倾越明显。了解髋臼的前倾情况,对DDH的治疗具有重要意义。     

Pemberton髋臼成形术治疗发育性髋关节脱位

目的：探讨分析Pemberton髋臼成形术在发育性髋脱位的治疗上具有哪些优势。方法：采用Pemberton髋臼成形术治疗儿童发育性髋脱位106例116髋,男19例29髋,女87例87髋。左侧46髋,右侧50髋,双侧20髋。年龄18个月～13岁,平均7岁3个月,其中18个月～6岁99髋,7～13岁17髋。116髋均采用Pemberton髋臼成形术或内收肌、髂腰肌切断加Pemberton髋臼成形术加转子下股骨短缩、旋转截骨术。95髋单纯行Pemberton髋臼成形术,余21髋行全套手术。双侧髋脱位患儿均先做一侧,1年后再做另一侧,同时将第1次手术股骨内固定钢板取除。结果：病例随访时间2～10年,平均6年。按照Mullerh和Seddon标准进行功能评定,优67髋,良34髋,可10髋,差5髋,优良率87%。结论：Pemberton髋臼成形术适用于多个年龄段的儿童发育性髋脱位患者,疗效肯定,在发育性髋脱位的治疗中占有重要地位。     

前倾角在治疗发育性髋关节脱位中的地位

目的 :说明在治疗发育性髋关节脱位中矫正前倾角的必要性。方法 :1 990～ 1 999年我院采用各种手术方法治疗了发育性髋关节脱位 1 1 5例 ,术中发现前倾角最大的为 90°,最小的为 45°,平均为 70°。其中 1 1 0例在处理髋臼的同时进行了前倾角的矫正 ,保留前倾角在 1 0°～ 30°之间 ,平均矫正 45°。结果 :仅 75例病人有 2～ 5年不等的随访资料。效果良好者 62例 ;不良者为 1 3例 ;有外旋步态者 1 7例。结论 :前倾角的矫正可有效的减少头骺与髋臼之间的扭矩 ,更加有利于髋臼的再塑形 ,使髋关节更加吻合、稳定 ,应得到足够的重视。     

3D-CT初步分析发育性髋臼发育不良患儿髋臼前倾的原因

[目的]观察发育性髋臼发育不良患儿病变髋是否存在髋臼过度前倾,并分析髋臼前倾的原因.[方法]回顾性收集50例单髋脱位患儿和30例正常对照组髋关节的3D-CT影像学资料.病例组:男11例,女39例;年龄6～ 60个月,平均18个月.左侧髋脱位29例,右侧髋脱位21例.对照组:男16例,女14例;年龄7～48个月,平均20个月.所有实验对象均测量髋臼前倾角(AA)、坐骨旋转角(IA)、耻骨旋转角(PA)、耻骨相对长度(PRL)和坐骨相对距离(IRD),统计学分析对比病例组和对照组上述指标是否存在统计学差异.[结果]正常对照组左侧髋和右侧髋的AA、IA、PA、PRL和IRD差别均无统计学意义(P＞0.05).单髋脱位患儿脱位侧髋和未受累侧髋的PA差别无统计学意义(P＞0.05).脱位侧髋的PRL值小于未受累侧髋,差异有统计学意义(P＜0.05).脱位侧髋的AA、IA和IRD均大于未受累侧髋,差异有统计学意义(P＜0.05).无论是在脱位侧髋还在未受累侧髋,IA均与AA和IRD呈正相关.[结论]发育性髋臼发育不良患儿髋臼过度前倾是普遍存在的,除了髋臼前壁缺陷外,患儿脱位侧髋的坐骨外侧旋转引起坐骨外侧移位也是髋臼发生过度前倾的原因之一.     

先天性髋脱位髋臼前倾角的CT测量

目的 探讨先天性髋脱位髋臼前倾角的变化。方法 对18例先天性单侧髋脱位患儿作CT检查，比较其侧与健侧的髋臼前倾角；18例患儿均做手术切开复位，对其中6例患儿术后半年作CT随访，比较其手术前后髋臼前倾角的变化。结果 患侧的髋臼倾角与健侧比较，差异无显著性。手术可改变髋臼前倾角，部分会至异常范围。结论 先天性髋脱位的髋臼前倾角与正常相似，在手术复位过程中髋臼前倾角会有改变。     

发育性髋关节发育不良髋臼形态变化的MRI分析

目的通过MRI定量分析,探讨发育性髋关节发育不良(DDH)患者髋臼形态的病理变化特点。方法笔者自2011-05—2015-03对53例(106髋)发育性髋关节发育不良患者进行MRI扫描检查,选取69髋为试验组,选取30例(30髋)双侧髋关节完全正常儿童为对照组,测量对照组及试验组髋关节的骨性髋臼指数(BAI)、软骨髋臼指数(CAI)、前骨性髋臼指数(ABAI)、前软骨性髋臼指数(ACAI)、后骨性髋臼指数(PBAI)、后软骨性髋臼指数(PCAI)、骨性髋臼前倾角(BAAV)、软骨性髋臼前倾角(CAAV),分析年龄与髋关节MRI测量指数的相关性、各组间MRI测量指数的差异及相关性特点。结果对照组年龄与BAI(r=-0.715)、CAI(r=-0.597)存在负相关;试验组BAI、CAI、ABAI、ACAI、BAAV、CAAV与对照组比较差异有统计学意义(P0.05),其中BAI、CAI在试验组亚组中Ⅱ度、Ⅲ度与Ⅰ度之间差异有统计学意义(P0.05),ABAI仅在试验组亚组Ⅰ度与Ⅲ度之间差异有统计学意义(P0.05),ACAI、BAAV与CAAV在试验组诸亚组之间差异无统计学意义;试验组(r=0.384)及对照组(r=0.551)的BAI与CAI之间存在正相关。结论 MRI可以有效评价髋臼形态改变;髋臼软骨相对年龄变化更为稳定,评价髋关节形态更为准确;DDH患者髋臼骨性及软骨性缺损主要位于髋臼外上缘及前缘,软骨性改变与骨性改变相关而非完全同步。     

发育性髋关节脱位术后再脱位的原因分析与翻修策略

[目的]分析手术治疗发育性髋关节脱位术后再脱位的原因,探讨减少和避免再脱位的对策。[方法]2011年7月～2015年7月,本院经手术治疗发育性髋关节脱位术后再脱位患儿31例(31髋),男9例,女22例,初次手术年龄20个月～10岁1个月,平均(31.21±10.33)个月。对所有患儿进行3D CT影像检查,综合分析再脱位原因。针对具体病理进行翻修术,包括切开复位Salter截骨16髋,其中同时行股骨短缩手术者12髋;切开复位加Pemberton截骨13髋,其中同时行股骨短缩手术者11髋;切开复位加Chiari截骨者2髋。对翻修手术的效果进行临床与影像分析。[结果]再脱位原因包括:11髋内收肌紧张,8髋髂腰肌未切断,7髋关节囊内盂唇内翻,6髋内侧关节囊未彻底松解,11髋臼底脂肪纤维组织填充;10髋髋臼指数45°,2髋后方骨质缺损。13髋股骨头缺血性坏死,4髋严重变形伴短颈,5髋颈干角160°,7髋股骨颈前倾角40°。31例(31髋)再手术复位成功率100%。随访25～72个月,平均(35.33±11.24)个月,末次随访时根据Mckay临床评估标准,优25髋,良4髋,可2髋,优良率93.55%。影像检查显示中心性复位29例,残留髋臼发育不良1例,新发生股骨头坏死1例。[结论]手术治疗发育性髋关节脱位术后再脱位的主要原因包括:术中关节囊及周围软组织处理不当、手术指征及术式掌握不当、手术操作不规范及年龄等因素。只有遵循个体化的治疗原则,获得术中股骨头与髋臼稳定的同心圆复位,才能避免再次脱位的发生。     

髋臼成形术并股骨近端旋转截骨治疗小儿发育性髋关节脱位

目的：评估髋臼成形术并股骨近端旋转截骨治疗发育性髋关节脱位的临床效果。方法：本组患儿48例,男12例,女36例,年龄2．6—8．5岁,平均5．4岁。采用S—P切口,切开关节囊,清理真臼内软组织,复位股骨头;股骨近端旋转截骨,纠正前倾角;髋臼缘上方沿关节囊附着点行弧形截骨,髂骨块植入截骨处,增加股骨头的包容。结果：48例患儿经1．6-5．6年的随访,按照周永德先天性髋脱位疗效评定标准,优32例,良16例,可3例,差4例,手术优良率为86．8％。结论：髋臼成形术并股骨近端旋转截骨是治疗小儿发育性髋关节脱位的一种较为有效的方法。     

髋臼Y形软骨损伤对髋关节发育影响的实验研究

目的探讨“Y”形软骨损伤后骨骺早闭对髋关节发育的影响。方法选用10只4~5周龄大白兔,切除、破坏右侧髋臼部分“Y”形软骨,左侧髋关节不行处理,作为对照。X线动态观察双侧髋关节发育状况,术后12周处死动物,进行形态学及组织学观察。结果手术侧术后3周“Y”形软骨均出现骨骺早闭,髋臼内壁增厚、髋臼变浅;术后6~9周髋臼浅且形态不规则,4例出现半脱位;术后12周全部出现关节发育不良,50%的髋关节发生半脱位。形态学观察见髋臼变浅,内壁厚度增加,股骨头增大、变扁,关节软骨失去光泽,部分缺失。HE染色见髋臼及股骨头软骨层变薄,软骨细胞排列紊乱,骺板扭曲、变薄。对照侧各髋关节形态结构正常。手术侧各期臼头指数、相对髋臼指数及臼壁厚度与对照侧相比差异均有显著性意义(P<0.05)。手术侧术后12周臼头指数及相对髋臼指数与术后第2d相比差异有非常显著性意义(P<0.01)。结论“Y”形软骨损伤可导致骨桥形成、骨骺早闭,使髋臼内壁增厚、髋臼变浅,继而引发髋关节发育不良和半脱位。     

发育性髋关节脱位闭合复位后髋臼发育的研究

目的 通过回顾性研究,观察闭合复位治疗发育性髋关节脱位的临床疗效,动态分析闭合复位后髋臼发育的特点.方法 2002年1月-2005年12月,采用闭合复位治疗100例单侧发育性髋关节脱位患儿.男18例,女82例;年龄7～36个月,平均19.4个月.左侧68例,右侧32例.髋关节脱位按Zionts等方法分度,Ⅰ度15例,Ⅱ度50例,Ⅲ度26例,Ⅳ度9例.治疗时行内收肌切断与牵引74例,直接闭合复位26例.按四级功能评价标准判定临床疗效;于复位前、复位后第3、6、9和12个月动态测量患、健侧髋关节的髋臼指数(acetabular index,AI)和髋臼深度与宽度比值[acetabular index of depth to width,AI(D/W)],并进行相关比较.结果 治疗12个月功能恢复总优良率达88.00%.复位后12个月,患侧AI由治疗前(37.17±2.17).下降至(27.02 ±3.54).,AI(D/W)由22.06%±1.65%增长至29.80%±3.56%,各时间点比较差异均有统计学意义(P<0.01);患侧AI下降幅度、AI(D/W)增长幅度明显快于健侧(P<0.01).复位后1～3个月、10～12个月AI分别为(3.22±1.42).和(3.41±2.03). 9 AI(D/W)分别为2.69%±1.83%和2.33%±1.13%,明显快于其他时间段(P<0.01);各时间段患侧AI下降幅度、AI(D/W)增长幅度均明显快于同期健侧(P<0.01).复位后12个月,7～12月龄、13～18月龄A1分别为(13.71±396).和(11.48±4.15).,AI(D/W)分别为9.95%±3.81%和8.28%±3.58%,明显快于其他年龄段患儿(P<0.05);各年龄段患侧AJ、AI(D/W)变化速度均明显快于健侧(P<0.01).结论 闭合复位治疗发育性髋关节脱位操作简便,治疗效果良好,在治疗后12个月内,患侧髋臼发育速度明显快于健侧;患侧髋臼的发育高峰期在复位后1～3个月和10～12个月;患儿年龄<18个月为闭合复位治疗发育性髋关节脱位的最佳时期.     

Three dimensional-CT evaluation of femoral neck anteversion, acetabular anteversion and combined anteversion in unilateral DDH in an early walking age group

Purpose

At present, the indications for femoral derotational osteotomy remain controversial due to the inconsistent findings in femoral neck anteversion in developmental dysplasia of the hip (DDH). Moreover, combined anteversion is not assessed in unilateral DDH using three dimensional-CT. Therefore, the purposes of our study were to observe whether the femoral neck anteversion (FA), acetabular anteversion (AA) and combined anteversion (CA) on the dislocated hips were universally presented in unilateral DDH according to the classification system of Tönnis.

Methods

Sixty-two patients with unilateral dislocation of hip were involved in the study, including 54 females and eight males with a mean age of 21.63 months (range, 18–48 months). The FA, AA and CA were measured and compared between the dislocated hips and the unaffected hips.

Results

Although no significant difference was observed in FA between the dislocated hips and the unaffected hips (P = 0.067, 0.132, respectively) in Tönnis II and III type, FA was obviously increased on the dislocated hips compared with the unaffected hips in Tönnis IV type. Increased AA on the dislocated hips was a universal finding in Tönnis II, III and IV types. Meanwhile, a wide safe range of CA from 24° to 62° was demonstrated on the unaffected hips.

Conclusion

Femoral derotational osteotomy seems not to be necessary in Tönnis II and III types in unilateral DDH. Femoral derotational osteotomy should be considered in DDH, especially in Tönnis IV type, if the CA is still above 62° and the hip joints present instability in operation after abnormal acetabular anteversion, acetabular index and acetabular coverage of the femoral head are recovered to normal range through pelvic osteotomy.     

Femoral neck anteversion, acetabular anteversion and combined anteversion in the normal Indian adult population: A computed tomographic study

Background:

Abnormal femoral neck anteversion (FNA) and/or acetabulum anteversion (AA) have long been implicated in the etiogenesis of hip osteoarthritis (OA), developmental dysplasia of the hip (DDH), and impingement, instability and wear in total hip arthroplasty (THA). Since studies on the Indian population are sparse on this topic, the purpose of this study was to report the normal values of FNA, AA and the combined anteversion (CA= FNA+ AA) in Indian adults.

Materials and Methods:

FNA, AA and CA were prospectively measured in 172 normal hips in 86 Indian adults using standardized computed tomographic (CT) methods and this data was compared with the established Western values.

Results:

The median values and interquartile ranges were 8° (6.5-10.0°) for FNA, 19° (16.0-22.0°) for AA and 27° (23.5-30.0°) for CA. AA and CA values were significantly (P<0.05) lower in males, and there was also a trend towards lower FNA in males. Although a negative correlation was observed between the FNA and AA, this was not strong and may not be clinically relevant.

Conclusion:

When compared with the Western data, the FNA values were 3-12° lower and the CA values were 3-5° lower in Indian adults. The AA values were comparable, but were skewed towards the higher side. Further studies are needed to assess the clinical relevance of our basic science data in pathogenesis of OA, and to validate it in relation to hip surgeries like corrective osteotomies and THA.     

髋臼假体前倾角的临床意义及其二维影像测量

髋臼假体前倾角(ACA)是全髋关节置换术(THA)髋臼假体的方向参数之一,对THA手术效果存在显著影响,是THA术中控制及术后评估的重要指标。ACA并非新的概念,但近年来相关研究的深入更新了对ACA临床意义的认识:一方面,ACA的概念混淆和误用降低了众多既往文献的参考价值;另一方面,对于ACA的理想值,长期沿用的"安全区"标准逐渐受到临床证据质疑;新的研究不再孤立地考虑髋臼方向,而是整体分析髋臼方向与周围力学结构来探索ACA的理想值。ACA的影像测量有助于评估手术效果,具有重要的临床和科研意义;但ACA在临床常规的X线片上无法直接测量。针对这一难题,1970年代以来研究者提出了多种间接测算方法,然而现有方法均未能同时突破依赖主观估计和操作复杂这两种局限性,还需改进以便于临床应用。本文回顾既往文献,对ACA的临床意义及其二维影像测量作一综述,以厘清ACA的概念,增补其临床意义的新认识,并总结在常规X线片上测量ACA的各种方法,从而为THA的临床与研究提供参考。     

髋臼前倾角研究进展

髋臼前倾角和外展角为全髋关节置换术(THA)中评估髋臼假体位置,术后随访假体位置的两个重要参数。髋臼前倾角的测量目前仍无统一标准。该文就近期文献中髋臼前倾角的定义、测量时骨盆参考平面、各种测量方法、髋臼角安全范围等作一综述。     

Computed tomography measurement of acetabular cup anteversion and retroversion in total hip arthroplasty.

In a clinical study conducted between March 1983 and July 1987, computed tomography of the hip was employed with specially designed software in 20 patients after 23 total hip arthroplasties (THAs). Three patients had bilateral THAs. Computed tomography was performed in the routine manner, except that the image was reconstructed utilizing software that eliminated the metallic artifacts. The angle of the acetabular cup is determined on a display console. The cursor is turned on, one pole of the cup is marked, and when the second moving cursor is positioned on the opposite pole, the angle is shown and measured on the console. This technique has been indispensable for accurate measurement of the angle of inclination of the acetabular cup and in treatment planning in patients with a dislocating total hip prosthesis.     

Radiographic calculation of anteversion in acetabular prostheses

The position of the acetabular prosthesis is critical for preventing dislocation following total hip arthroplasty. The reliability of a mathematical model for radiographically calculated acetabular cup version was examined. A porous-coated anatomic acetabular prosthesis was mounted in a mold. Anteroposterior radiographs were taken with the cup in five different positions of anteversion. These were reviewed by five orthopaedic surgeons, and measurements were taken from each radiograph. From these measurements, the mathematically derived degree of version was calculated. The results were examined for accuracy and intraobserver reliability. It was concluded that intraobserver reliability was very good and that the accuracy was within a clinically acceptable range. This technique could be useful in studying the “safe zone” for acetabular prostheses.     

Quantification and visualization of the influence of pelvic tilt upon measurement of acetabular inclination and anteversion

AIM: The indication of acetabular inclination and anteversion not only depends on definition but also on a correctly aligned patient. Determination of anteversion and inclination according to Sven-Johannsson and Visser were simulated with 3D calculations. The influence of pelvic tilt in relation to the frontal plane was evaluated and visualized. METHOD: With 3D calculations of planar X-ray photographs for artificial hip cups the normal vector of the acetabular cup was used to calculate anteversion and inclination. RESULTS: The main axis of the projected acetabular rim is equally suited to determine the cup orientation as the normal vector of the cup plane. Pelvic tilt of about 10 degrees causes measuring errors of about 8 degrees when measured with conventionally used techniques. CONCLUSION: For the correct determination of cup orientation pelvic tilt in relation to the frontal plane has to be accounted for.