全髋置换术治疗髋关节发育不良

目的探讨全髋置换术治疗髋关节发育不良(DDH)的手术方法并评价其临床疗效。方法12例DDH患者根据Crowe分型:Ⅰ型2例,Ⅱ型4例,Ⅲ型4例,Ⅳ型2例。全部采用B iom et全髋假体置换。髋臼假体均为生物型固定,股骨假体除2例骨水泥固定,其余为生物型固定。3例髋臼重建利用自体股骨头于髋臼前外方植骨造盖,9例于真臼水平将髋臼内移;3例股骨重建于转子下截骨短缩并纠正前倾;Ⅲ、Ⅳ型DDH行关节周围软组织松解。结果患者术后均未出现坐骨神经麻痹、下肢深静脉栓塞、切口感染及早期人工关节脱位等并发症。肢体延长最多4.8 cm,平均2.8 cm。随访6个月~2年,Harris髋关节评分由术前平均40.7分提高到84.5分,未发生人工关节脱位或假体松动。结论对有症状的DDH或强烈要求改善步态的年轻患者,全髋置换术是一种有效的治疗方法。     

Developmental dysplasia of the hip (DDH): diagnosis and treatment

This article describes the definition, investigation, imaging and treatment of developmental dysplasia of the hip (DDH). There is controversy in what constitutes physiological or pathological DDH. The results of hip screening programmes are disappointing. DDH may be diagnosed by clinical, sonographic or radiological means. The clinical diagnosis is confirmed by sonographic imaging (in the first months of life). Late presenting pathological DDH (>6 months of age) is usually diagnosed by an X-ray(s) of the pelvis. The majority of pathological DDH cases are female and unilateral, with the left hip joint being involved more commonly. Dysplasia, subluxation and dislocation of the hip joint may be associated with the development of premature osteoarthrosis in adults. The majority of neonatal hip joint instabilities and sonographic hip dysplasia spontaneously resolve without treatment. Persistent hip joint instability is initially treated with bracing/splintage, the majority resolving without further additional treatment. Some early presenting probable irreducible hip dislocations can be treated by manipulation under anaesthetic, hip arthrography plus the application of a hip spica. If this procedure fails, if it is not technically possible or if the dislocation presents ‘late’, more invasive surgery with open reduction of the hip joint and reconstructive surgery to the pelvis or femur may be necessary.     

Prevalence of trochlear dysplasia in infants evaluated for developmental dysplasia of the hip

PurposeThe purpose of this study was to define the incidence of trochlear dysplasia in an infant cohort being screened for developmental dysplasia of the hip (DDH).MethodsNewborns screened for DDH that were evaluated with ultrasound for the presence of trochlear dysplasia were retrospectively reviewed. The sulcus angle and trochlear depth were measured. Based on previous work, trochlear dysplasia was defined as a sulcus angle of > 159°. Our newborn cohort was then analyzed to identify potential risk factors for trochlear dysplasia.ResultsA total of 383 knees in 196 infants were studied. In total, 52% were referred for breech intrauterine positioning and 21% were ultimately diagnosed with DDH and had treatment initiated with a Pavlik harness. Of the entire cohort, 8% of knees were deemed to have trochlear dysplasia. Breech patients were found to have a flatter sulcus angle than those that were not breech (149.5° (sd 7.2°) versus 147.9° (sd 7.5°); p = 0.028). Similarly, a shallower trochlear depth was identified in breech patients versus non-breech patients (1.6 mm (sd 0.4) versus 1.8 mm (sd 0.4); p = 0.019). Those with trochlear dysplasia (as defined by sulcus angle > 159°) did show a smaller alpha angle (i.e. more dysplastic hip) as compared with those without trochlear dysplasia (59.2° (sd 10.2°) versus 65.9° (sd 7.5°); p < 0.001). Hips with DDH were 2.4-times more likely to have knees with trochlear dysplasia (95% confidence interval 1.1 to 5.3).ConclusionUltrasound screening of newborn knees reveals that trochlear dysplasia is relatively common in breech babies with DDH.Level of EvidenceIII     

广州市区新生儿及6个月内婴儿发育性髋关节发育不良患病率的超声筛查

目的研究广东省广州市新生儿及小于6月婴儿发育性髋关节发育不良(DDH)患病率情况,以指导临床治疗和预防。方法 2015年8月至2017年8月,Graf超声对广州市9766(19532髋)名新生儿及小于6月婴儿进行DDH普查。结果检出可疑髋关节1370个,占7.01%,异常髋关节(DDH)18个,占0.09%,其中女婴DDH髋检出13个(0.13%),男性5个(0.05%),女性DDH患病率明显高于男性(P0.05)。臀位产婴儿DDH检出率0.35%,明显高于非臀位产婴儿DDH髋检出率0.08%(P0.05)。有家族史的DDH检出率为0.22%,明显高于无家族史的DDH检出率0.07%(P0.05),体检髋关节可疑者DDH检出率为0.2%,明显高于体检髋关节为正常者DDH检出率。结论广州市新生儿及小于6月婴儿DDH患病率为0.09%,女性、臀位产、家族史的DDH发病率高,应重点监控。     

全髋置换术治疗成人髋臼发育不良伴骨性关节炎

目的 探讨全髋关节置换术治疗髋臼发育不良(DDH)伴髋关节骨性关节炎的手术疗效.方法 对11例(12髋)因DDH致髋关节骨性关节炎患者行全髋关节置换术.根据Zionts分级,Ⅰ度7髋,Ⅱ度5髋.术前Harris评分28～63(48.1±9.4)分.结果 11例均获随访,时间6个月～6年.术后Harris评分为82～98(88.6±7.6)分.1例术后3年X线片示人工臼与植骨块间有透亮线,余患者人工臼位置均无移位、松动.有2例患肢轻度跛行,无疼痛,可以长距离行走.结论 全髋置换术解除患者症状,改善关节功能,提高生活质量,是一种行之有效的治疗方法.手术成功的关键在于加深髋臼、内移髋关节活动中心及适当植骨.     

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。     

Developmental dysplasia of the hip in the newborn: A systematic review

Developmental dysplasia of the hip (DDH) denotes a wide spectrum of conditions ranging from subtle acetabular dysplasia to irreducible hip dislocations. Clinical diagnostic tests complement ultrasound imaging in allowing diagnosis, classification and monitoring of this condition. Classification systems relate to the alpha and beta angles in addition to the dynamic coverage index (DCI). Screening programmes for DDH show considerable geographic variation; certain risk factors have been identified which necessitate ultrasound assessment of the newborn. The treatment of DDH has undergone significant evolution, but the current gold standard is still the Pavlik harness. Duration of Pavlik harness treatment has been reported to range from 3 to 9.3 mo. The beta angle, DCI and the superior/lateral femoral head displacement can be assessed via ultrasound to estimate the likelihood of success. Success rates of between 7% and 99% have been reported when using the harness to treat DDH. Avascular necrosis remains the most devastating complication of harness usage with a reported rate of between 0% and 28%. Alternative non-surgical treatment methods used for DDH include devices proposed by LeDamany, Frejka, Lorenz and Ortolani. The Rosen splint and Wagner stocking have also been used for DDH treatment. Surgical treatment for DDH comprises open reduction alongside a combination of femoral or pelvic osteotomies. Femoral osteotomies are carried out in cases of excessive anteversion or valgus deformity of the femoral neck. The two principal pelvic osteotomies most commonly performed are the Salter osteotomy and Pemberton acetabuloplasty. Serious surgical complications include epiphyseal damage, sciatic nerve damage and femoral neck fracture.     

全髋关节置换术治疗成人髋关节发育不良

目的 探讨全髋关节置换术(THA)治疗成人髋关节发育不良的临床疗效.方法 采用THA治疗45例髋关节发育不良患者(50髋).记录术后感染、髋关节脱位、假体松动、神经损伤情况,末次随访时采用Harris评分评定髋关节功能.结果 患者均获得随访,时间2～65(24.1±16.0)个月.术后无感染、髋关节脱位、神经损伤等并发...     

Pavlik吊带治疗婴幼儿发育性髋关节发育不良的经验

目的探讨Pavlik吊带治疗6个月内婴幼儿发育性髋关节发育不良(DDH)的治疗效果。方法 2015年8月至2017年8月,Graf超声对广州市新生儿及小于6月婴儿进行DDH普查,检出异常髋关节(DDH)18个,其中女婴DDH髋检出13个,男性5个。根据Graf超声诊断发育性髋关节发育不良(DDH)的病理分型,9髋为Ⅱb型,6髋为Ⅱc型,2髋为Ⅲ型,1髋为Ⅳ型。均采用Pavlik吊带治疗,间隔2周复诊1次,超声检查观察髋关节发育变化。吊带治疗时间6~20周,随访时间3~18个月,平均8个月。结果 17髋经Pavlik吊带治疗后,经超声和X线片检查,相关指标达到正常,确认治愈。1髋在经Pavlik治疗过程中,经超声检查后,相关指标改善明显,58°α角60°。全部患儿均无股骨头无菌性坏死等并发症。结论 Pavlik吊带对于Graf II型患儿治愈率高,而对于GrafⅢ、Ⅳ型患儿,Pavlik吊带治愈率降低,部分患儿需要进一步的后续治疗。超声检查可达到动态观察Pavlik吊带治疗效果的目的。早期超声检查为发育性髋关节发育不良(DDH)能早期得到Pavlik吊带治疗提供了可能,对减少患儿远期遗留畸形和降低治疗过程中并发症发生率有重要意义。     

Developmental dysplasia of the hip: A special pathology

Developmental dysplasia of the hip (DDH) is one of the most common congenital disorders in childhood. Its diverse pathological changes require different treatments and result in different outcomes. Although many studies have been conducted on DDH, some special pathology is still unrecognized. We here presented a rare case of a one-year and eleven-month old girl with DDH; a half-free intra-articular osteocartilaginous tissue was found in her right hip joint. X-ray, computer assisted tomography (CT) and magnetic resonance imaging (MRI) were performed to evaluate the pathological changes. MRI revealed some positive findings. The patient experienced open reduction and histopathological examination of the small tissue. Through gross anatomy it is a half-free intra-articular osteocartilaginous tissue, which can fully match a fossa observed at the femoral head. Histopathological examination found that the tissue was composed of collagenous fiber and cartilage-like tissue. Interestingly, we found the expression of type I collagen according to immunohistochemical analysis, which indicated that the cartilage-like tissue was formed due to laceration of the articular cartilage. This kind of disorder should be included as one of the pathologies of DDH. The most possible origin of this tissue is the femoral head which we speculate may have been fractured before.     

人工全髋关节置换治疗成人髋关节发育不良

目的探讨成人髋关节发育不良(DDH)行人工全髋关节置换(THA)的手术方法及早期疗效。方法对21例成人DDH继发骨关节炎患者(22髋)行生物型THA。髋关节脱位按Crowe分型:Ⅰ型15髋,Ⅱ型和Ⅲ型共6髋,Ⅳ型1髋。髋臼重建方式中采用真臼加深内移15髋,结构性植骨4髋,旋转中心上移3髋。1髋CroweⅣ型行转子下短缩截骨。结果患者均获得随访,时间6~24个月。无假体周围感染、假体不稳及松动。X线片显示结构性植骨无塌陷,转子下截骨部位愈合良好。髋关节功能Harris评分:术前30~53(38.6±5.6)分,术后76~94(84.2±6.8)分。结论 THA治疗成人DDH早期疗效满意,与普通THA相比,DDH的THA技术要求高,操作较复杂。     

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.     

发育性髋关节发育不良早期诊断的研究进展

发育性髋关节发育不良（DDH）是儿童骨科最常见的髋部疾患,早期诊断意义重大。先前,DDH的诊断主要依靠体格检查、骨盆平片。但因体格检查对DDH的检出率不高,小婴儿髋关节有大量对X线不显影的软骨成分,X线检查也不易判断,造成大量新生儿、婴幼儿被漏诊或误诊。近年来,这方面的工作也得到了越来越多的国内外学者的重视,髋关节超声检查的广泛应用显著提高了DDH的早期诊断率,最近MRI在DDH诊断的研究和应用也逐渐展开。综述体格检查,X线、CT、MRI、超声等影像检查在DDH早期诊断中的研究进展和应用价值。     

Evaluation of the hip center in total hip arthroplasty for old developmental dysplasia

We describe the problems with positioning the hip center according to the severity of dislocation in 97 cementless total hip arthroplasty for developmental dysplasia of the hip. The mean location of the hip center from the interteardrop was 30.4 +/- 8.7 mm horizontally and 23.4 +/- 5.4 mm vertically. The presence of a limp correlated with a superior placement of the cup. Four cups were revised, 2 of which with a significant high hip center. The survival rate of the acetabular component was 95% at 12 years. Craniopodal repositioning was easy in class 1. In class 2, the cup was the largest. In class 3, the greatest variations of the hip center were found. In class 4, the smallest implants were necessary for positioning in the true acetabulum.     

不同程度髋关节发育不良继发骨性关节炎的全髋关节置换术疗效分析

[目的]探讨全髋关节置换术治疗髋关节发育不良继发骨性关节炎的术后效果及髋关节发育不良的严重程度对于术疗效的影响.[方法]对47例(55髋)髋关节发育不良继发骨性关节炎的患者进行全髋关节置换术.其中Crowe Ⅰ型23髋;Ⅱ型19髋;Ⅲ/Ⅳ型共13髋.术前应用影像学方法评估髋臼和股骨的形态学变化,术中髋臼重建在真臼位置,逐渐扩大股骨髓腔,选用细而直的股骨假体.术前和术后对术侧髋关节行Harris髋关节评分.[结果]Ⅰ、Ⅱ和Ⅲ/Ⅳ型患者Harris髋关节评分分别由术前的50.7±7.6、44.9±6.2和41.1±8.2增加到术后的90.6±3.7、87.3±4.5和82.7±7.3,和术前比较有显著性差异(P＜0.05).Harris髋关节评分分级显示,Ⅰ、Ⅱ和Ⅲ/Ⅳ型髋关节术后分级在良以上的关节分别占本组髋关节的100%、100%和69%,优分别为70%、53%和31%.随访23～81个月,平均45个月,关节假体稳定,关节功能正常.[结论]全髋关节置换术是治疗髋关节发育不良继发骨性关节炎的有效方法,Crowe Ⅰ和Ⅱ型患者术后效果优于Ⅲ/Ⅳ型.     

Paediatric hip ultrasound: uncertainties in examination and choice of treatment

PurposeIn Germany, neonates undergo hip sonography examination using the Graf method during the routine U3 screening examination, performed by consultant physicians four to five weeks after birth, and are referred to specialized orthopaedic departments if there are any uncertainties. This study evaluated the quality of sonographic screening in the outpatient sector and the treatment requirements of referred children. MethodsWe performed a retrospective analysis of the patient data of 384 neonates collected in consultations performed between April 2016 and April 2019. ResultsIn total, 74% (n = 284) of neonates presented a hip type Ia/b. Treatment (abduction brace or Fettweis cast) was required in 32% (n = 122) of cases. The treatment duration was significantly correlated with age at first presentation (Pearson’s r = 0.678; p = 0.001). The treatment duration for patients aged > 200 days old at first presentation was twice as long as those aged 100 days at first presentation. Patients with public health insurance require referral by a consultant. Developmental dysplasia of the hip as referral diagnosis could not be confirmed in control examination in 64% (n = 132) of cases. Of the public health insured children, 97% (n = 200) were referred through a consultant paediatrician. ConclusionWe identified deficits in performing and interpreting the Graf method of ultrasound examination. A total of 64% of referred pathological hips turned out to be physiological configurations in our control examination. The future goal should be to increase anatomical knowledge of the newborn hip and ensure the correct use of Graf ultrasound method. Advanced training courses are recommended and necessary. Level of evidenceIV     

Selective ultrasound screening is inadequate to identify patients who present with symptomatic adult acetabular dysplasia

Purpose

One goal of neonatal screening for developmental dysplasia of the hip (DDH) is the prevention of late surgery. However, the majority of patients with acetabular dysplasia at skeletal maturity are not diagnosed with DDH during infancy. Selective ultrasound screening may identify patients with neonatal hip instability, but may be ineffective for the prevention of dysplasia presenting in adulthood. The purpose of this study is to identify the prevalence of risk factors for DDH that would have warranted selective ultrasound screening in patients with symptomatic acetabular dysplasia after skeletal maturity.

Methods

A prospective hip specialty center registry was used to identify 68 consecutive skeletally mature patients undergoing corrective osteotomy for symptomatic acetabular dysplasia. Risk factors for DDH evaluated in all patients included sex, family history of hip osteoarthritis or DDH, breech, method of delivery, previous hip treatments, and birth order. Radiographs [lateral center edge angle (CEA), anterior CEA, Tönnis grade, and Tönnis angle] were measured preoperatively.

Results

Sixty-seven females and one male were identified. No patients were previously diagnosed with DDH or received treatment for their hips. The majority of patients (85.3 %) did not meet selective ultrasound screening guidelines following a stable neonatal hip exam and, therefore, would not have been screened in a selective screening program. Of the findings outside of screening guidelines, 98.5 % were females, 52.9 % were first born, and 36.8 % had a family history of hip osteoarthritis.

Conclusions

The majority (85.3 %) of patients with symptomatic acetabular dysplasia at skeletal maturity would not have met current recommendations for selective ultrasound screening in the USA had they been born today.     

Dysplasia of the hip in adolescent patients successfully treated for developmental dysplasia of the hip

Background  

The purpose of this study was to analyze whether hips treated for developmental dysplasia of the hip (DDH) during infancy, which were clinically and radiologically fully normalized by walking age, may become dysplastic again during later growth.     

Three-dimensional hip joint congruity evaluation of the borderline dysplasia: Zonal-acetabular radius of curvature

In theory, a hemispherical acetabulum provides the ideal hip congruity in any hip position. However, it remains unknown how the three-dimensional acetabular morphology of borderline dysplastic and frank dysplastic hips compare to normal hips. This study inquires if borderline dysplastic zonal-acetabular curvatures in the anterior, superior, and posterior zones are different from normal or dysplastic hips three-dimensionally. One-hundred and fifteen hips, grouped as control (25°≤ LCEA <40°), 36 hips; borderline (20°≤ LCEA <25°), 32 hips; dysplasia (LCEA ≤20°), 47 hips were analyzed. The radii of acetabular curvature for the anterior, superior, and posterior zones were calculated as the zonal-acetabular radius of curvature (ZARC). The mean acetabular roof obliquity of the borderline (10.6 ± 4.3 [SD]°) was significantly larger than the control (3.0° ± 5.4°; P < .001) and smaller than the dysplasia (19.3° ± 5.7°; P < .001). Although the mean acetabular anteversion angle of the borderline (21.3° ± 3.7°) was significantly larger than control (17.9 ± 3.5°; P = .001), that of the borderline was not different from the dysplasia (23.3° ± 4.0°; P = .053). The mean anterior ZARC in the borderline (29.8 ± 2.6 mm) was significantly larger than the control (28.0 ± 2.2 mm; P = .011) and smaller than the dysplasia (31.5 ± 2.7 mm; P = .009). The mean superior ZARC in the borderline (25.7 ± 3.0 mm) was not different from the control (25.9 ± 2.2 mm; P = .934) or the dysplasia (25.8 ± 2.5 mm; P = .991). Although the mean posterior ZARC in the borderline (27.2 ± 2.5 mm) was not different from the control (26.4 ± 1.9 mm; P = .455), that of the borderline group was significantly smaller than the dysplasia (30.4 ± 3.3 mm; P < .001); that is, the severity of lateral under-coverage affects the anterior and/or posterior zonal-acetabular curvature.