婴幼儿化脓性髋关节炎后遗症的处理

本文报告１０例婴幼儿化脓性髋关节炎后遗症的治疗，年龄２～１１岁，大多数为新生儿时期发病，严重者股骨头战坏死吸收致头颈缺如，患肢短缩畸形。对１０例不同术式治疗病例经２～８年平均３．７年随访，作者认为股骨牵引下移同时行髋臼成形术，以大转子代替股骨头负重，股骨不短缩，髋关节功能好，而且大转子骨骺随着生长进一步生长发育，临床效果较其它术式满意。     

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。     

髋关节牵伸器在重度髋关节发育不良关节成形术中的应用

目的 探讨髋关节牵伸器在重度髋关节发育不良关节成形术中的应用价值.方法 2006年4月至2008年10月对6例(9髋)CroweⅣ型髋关节发育不良及1例(2髋)髋内翻继发髋关节发育不良患者行关节成形术,男2例,女5例;年龄12～5岁,平均30岁.术前用自行研制的髋关节牵伸器牵伸髋关节,首次牵开1.0～2.0 cm,次日开始以1 mm/d速度缓慢牵伸,直至股骨头降至真臼旋转中心水平.更换为皮牵引,重量3kg,牵引针眼愈合后行关节置换术6例(10髋)、臼盖成形术1例(1髋).结果 6例(9髋)的股骨头或大转子顶端牵伸至真臼旋转中心水平.牵伸距离4.0～5.5 cm,平均4.45 cm;牵伸时间30～60 d,平均43 d.无坐骨神经损伤及针眼严重感染发生.关节成形术中未行软组织松解及股骨短缩截骨.1例(2髋)在一侧髋关节牵伸至6.0 cm时加快牵伸速度为1.25 mm/d,12 h后出现腓深神经不全损伤.行分期全髋关节置换,术中股骨短缩截骨3 cm,腓深神经不全损伤半年后恢复.全部患者随访1.5～3.0年,平均2.5年.均获得双下肢等长,臀中肌肌力增加1～2级.Harris髋关节评分由术前平均56.2分提高至术后1年92.2分.结论 髋关节牵伸器可将股骨头牵伸至真臼旋转中心水平,行关节成形术时无须软组织松解及股骨短缩截骨,可减少创伤,缩短手术时间,改善外展肌功能.应严格按照1mm/d速度牵伸,以免引起神经损伤.     

Dega骨盆截骨术治疗儿童发育性髋关节脱位

目的观察采用Dega骨盆截骨术治疗儿童发育性髋关节脱位的临床疗效。方法在2003年11月至2008年9月,共治疗38例发育性髋关节全脱位患儿,均为单侧,其中女34例,男4例,年龄平均3.84岁,术前股骨头脱位高度平均2.4 cm。结果术后随诊时间平均约3年,按McKay的临床评定标准,29例为优,6例为良,2例为可,1例差,出现I型股骨头缺血性坏死3例。采用Severin的评定标准,25例为优,8例为良,4例为可,还有1例因术中股骨短缩不足出现术后再脱位。结论采用Dega骨盆截骨加股骨旋转、短缩截骨术治疗儿童发育性髋关节脱位适应证较宽,手术创伤较小,配合术前牵引及术后皮肤牵引下功能锻炼,疗效满意,具有临床推广价值。     

转子下截骨短缩全髋关节置换治疗髋关节发育不良

目的探讨股骨转子下截骨短缩人工髋关节置换治疗成人CroweIV型髋关节发育不良的临床疗效。方法CroweIV型髋关节发育不良患者18例24髋，均为女性，平均年龄46．8岁（38-55岁）。采用S-ROM或AML假体结合股骨转子下横断截骨短缩行人工关节置换术，按术前计划、股骨重叠情况及软组织和坐骨神经张力截除相应长度股骨。术前、术后行Harris评分及功能评价。结果全部病例随访9-72个月，平均29个月。Harris评分由术前41分增加到术后89分，优良率83．3％。髋旋转中心平均下降56mm，平均截骨短缩长度为31mm。截骨平均愈合时间为8个月。1髋术中、2髋术后并发股骨骨折，发生率12．5％，用加压钢板及钢丝固定，平均10个月后骨折愈合。术前Trendelenburg征均为阳性，术后15例阴性、3例阳性，转阴时间平均为13个月。单侧患者肢体不等长发生率为25％。无一例出现关节感染、假体松动、脱位、神经功能损伤等并发症。结论股骨转子下截骨短缩人工髋关节置换治疗髋关节发育不良高位脱位可避免坐骨神经损伤，单侧患者易形成肢体不等长，软组织平衡及肌力恢复需要一定时间，Trendelenburg征转阴时间长，易并发术中及术后股骨骨折，需用钢丝环扎预防。     

Pemberton手术加短缩截骨治疗大龄发育性髋脱位临床分析

[目的]应用Pemberton截骨术加股骨近端粗隆下短缩旋转截骨为主多种辅助手段一期手术治疗大龄发育性髋脱位,评估术后髋脱位股骨头坏死和关节僵硬的发生率.[方法]自2002年6月～2006年12月用Pemberton截骨术加股骨粗隆下短缩旋转截骨为主多种辅助手段治疗大龄(7～14岁)发育性髋脱位149例,随访到101例(136髋),随访1年2个月～5年6个月,平均2年7个月.辅助手段包括:(1)术中髂腰机及内收肌切断;(2)单髋人字石膏制动;(3)术后4～6周拆石膏住院CPM活动髋关节加主动功能锻炼;(4)髋关节早活动晚负重.[结果]术后髋关节脱位16髋,占11.76%.按照Salter提出的股骨头坏死的诊断标准,136髋中股骨头坏死38髋占27.94%.髋关节屈曲少于90°者31髋占22.79%.[结论]Pemberton髋臼周围截骨结合股骨粗隆下短缩截骨一期手术治疗大龄发育性髋脱位,疗效可靠,降低了术后再脱位、股骨头坏死率及髋关节僵硬等并发症的发生率.     

改良Chiari截骨髋臼加盖延伸成形术治疗小儿发育性髋关节脱位58例远期疗效观察

[目的]探讨应用改良Chiari截骨髋臼加盖延伸成形术治疗发育性髋关节脱位的方法与疗效,减少再脱位、股骨头坏死等并发症的发生.[方法]1998年5月～2007年10月采用改良Chiari截骨+髋臼加盖延伸成形/联合股骨近端短缩旋转截骨术治疗小儿发育性髋关节脱位58例(63髋)为治疗组,随机选取同时期Chiari截骨术治疗小儿发育性髋关节脱位60例(60髋)为对照组.[结果]两组术后均随访5 ～ 12年,两组手术时间、住院时间、术中出血量比较无统计学意义,再脱位并发症、远期功能疗效满意度方面均有显著统计学差异.[结论]应用改良Chiari截骨+髋臼加盖延伸成形/联合股骨近端短缩旋转截骨术治疗小儿发育性髋关节脱位疗效好,容易掌握,治疗风险较低;便于在相关医疗机构推广应用.     

髋臼重建及股骨转子下短缩截骨全髋关节置换治疗Crowe Ⅳ型髋关节发育不良

 目的 探讨髋臼重建及股骨转子下短缩截骨全髋关节置换治疗Crowe Ⅳ型髋关节发育不良的临床疗效。方法 2003年9月至2012年9月收治Crowe Ⅳ型髋关节发育不良患者21例(24髋),男3例,女18例;年龄28~71岁,平均(54±10)岁。采用髋臼重建,股骨转子下横行短缩截骨,股骨近端非骨水泥假体全髋关节置换术。髋臼成形后联合自体结构性骨移植修复骨缺损,生物型假体或钛网骨水泥重建髋臼。陶瓷-聚乙烯股骨头臼界面17例(20髋),金属-聚乙烯4例(4髋)。股骨截骨端自体骨移植18例(21髋),异体骨移植原位钢丝捆扎3例(3髋)。术后采用Harris髋关节评分系统评估髋关节功能。结果 3例失访。随访18例(21髋),随访时间0.5~9年,平均3.5年。Harris髋关节评分从术前(47.9±9.1)分提高至术后6个月(88.4±3.5)分。术后髋关节疼痛明显改善,肢体活动度增加,步态接近正常。1例术后并发坐骨神经麻痹,无伤口感染病例。术后6个月X线片均显示髋臼假体骨性覆盖、假体及植骨床压配较好,无髋臼假体松动及植骨块明显吸收,截骨端骨愈合良好。结论 髋臼重建及股骨转子下短缩截骨全髋关节置换适用于Crowe Ⅳ型髋关节发育不良,尤其是高龄髋关节高脱位患者。操作相对简单,能够改善肢体不等长,可避免一次性过度肢体延长导致的坐骨神经损伤。     

先天性婴儿型髋内翻误诊为髋脱位的原因分析

[目的]先天性婴儿型髋内翻象髋脱位一样可有臀纹不对称、下肢缩短、Allis征阳性等体征。X线片显示髋关节内侧间隙增宽,股骨近端上移,股骨颈干角不易测量,容易误诊为小儿先天性髋关节脱位。本文旨在分析探讨先天性婴儿型髋内翻误诊为先天性髋关节脱位的原因。[方法]作者在为54例73髋先天性髋脱位患儿实施诊疗中,由于体格、影像检查时的疏忽,导致6例6髋先天性婴儿型髋内翻误诊为髋脱位,并按照髋脱位进行保守治疗。因治疗效果欠佳,经再次认真体格检查、仔细阅读影像资料、注重保守治疗效果等综合分析之后,发现该6例6髋患儿确系先天性婴儿型髋内翻,而非髋关节脱位。[结果]总结出先天性婴儿型髋内翻有如下特点:股骨大转子肥大上移;股骨颈短宽低平;髋关节内侧间隙增宽;股骨颈与股骨小转子重叠;髋臼指数基本正常;Shenton线连续性尚好;股骨头骺角增大;股骨头骨化中心出现晚,发育差。多合并短股骨、股骨弯曲、锁颅骨发育不全、马蹄足等畸形。[结论]股骨头二次骨化中心在出生后6~9个月时才出现,此前判断其是髋脱位或是髋内翻,确实困难。只有正确了解婴儿型髋内翻的临床与X线表现特征,才能正确早期诊断先天性婴儿型髋内翻,避免误诊误治。     

环关节囊骨盆截骨术治疗大龄DDH(附7例报告)

[目的]探讨大龄(8～13岁)DDH有效术式。[方法]行Smith-Peterson切口,显露髂骨外板至坐骨大切迹,内板显露前1/4和耻骨上枝近缘;在真臼上缘环绕髋臼向内、后用弧形骨凿截骨;距离坐骨大切迹1 cm弧向坐骨,向内弧向Y形软骨;逐渐下压远端使截骨间隙张开,取三角骨块楔入植骨。关节囊切除近端多余部分,使T形变V形端端缝合。股骨近端短缩旋转截骨视股骨头上缘与髋臼上缘距离短缩。术后3周去石膏裤固定,CMP练习髋关节活动。[结果]2001年11月～2008年9月治疗7例8岁以上发育性髋脱位随访平均18个月,髋关节平均伸屈活动范围在90°以上;肢体短缩平均1.2 cm。[结论]Pemberton骨盆截骨术改进用于大龄(8～13岁)DDH,在恢复髋关节的生理位置和关节活动功能、保留肢体长度、减少创伤和并发症、缩短治疗时间和费用等方面有其他术式不能替代的优势,是一种有效的术式。     

可吸收钉内固定治疗股骨头骨折并髋关节后脱位的临床体会

目的 总结可吸收钉内固定治疗股骨头骨折并髋关节后脱位的临床体会. 方法 采用可吸收钉内固定治疗股骨头骨折并髋关节后脱位患者7例.股骨头骨折按照Pipkin's骨折分型:Ⅰ型2例,Ⅱ型3例,Ⅲ型1例,Ⅳ型1例.股骨头骨折块最小2.0 cm×2.0 cm×2.5 cm,最大4.5 cm×3.5 cm×4.0 cm.受伤至就诊时间为1 h～12d.Ⅰ型2例和Ⅱ型3例经Smith-Peterson入路,Ⅲ型1例和Ⅳ型1例采用Kocher-Langenbeck入路,以直径4.5 mm,长度35～55mm的可吸收螺钉内固定股骨头骨折块.结果 本组7例均获随访,平均时间31.7(14 ～57)个月.按Thompson-Epstein临床和影像学评定标准评定疗效,优3例,良2例,可1例,差1例,优良率71.4％.1例Ⅳ型股骨头骨折患者,术后出现股骨颈骨折不愈合,1年后出现股骨头坏死,伤后2.5年行人工全髋置换术,其余均完全愈合. 结论 可吸收钉治疗股骨头骨折并髋关节后脱位具有无需二次手术、取材方便等优点,值得临床推广应用.     

Cementless total hip arthroplasty and limb-length equalization in patients with unilateral Crowe type-IV hip dislocation

BACKGROUND: Total hip arthroplasty in patients with unilateral congenital high dislocation of the hip (Crowe type IV) presents many challenges, including the problem of a marked limb-length discrepancy. The purpose of this retrospective study was to analyze the results of total hip replacement with limb-length equalization in these patients. METHODS: From 1988 to 1996, fifty-six patients (forty-seven women and nine men) with unilateral Crowe type-IV dislocation of the hip were treated with a cementless total hip arthroplasty at a mean age of 35.4 years. The preoperative limb-length discrepancy averaged 4.9 cm. Prior to the total hip arthroplasty, forty-eight patients with a limb-length discrepancy of >4.0 cm underwent iliofemoral distraction with use of an external fixator for eight to seventeen days. The acetabular cup was placed in the anatomical position in every patient. Shortening femoral osteotomies were not required. RESULTS: The iliac fixator pins loosened in six patients. No patient had a pin-site infection, hip joint infection, or nerve palsy. At the time of follow-up, at an average of 147.2 months, the Harris hip score averaged 90.2 points. Overall, the mean lengthening after the total hip arthroplasty was 4.6 cm. There were no revisions of the femoral stem. Nine cups were revised, four because of polyethylene wear and five because of loosening. CONCLUSIONS: We were able to safely place the acetabular cup at the anatomical position without femoral shortening by bringing the femoral head to the normal level preoperatively; thus, we could restore nearly normal limb length. We believe that our twelve-year results are similar to those of total hip arthroplasty in patients without dysplasia.     

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.     

股骨转子下叠加缩短截骨在CroweⅣ型成人髋脱位全髋置换术的应用

目的总结CroweⅣ型成人髋脱位采用股骨转子下叠加缩短截骨行全髋置换术的方法与疗效。方法2000年1月至2003年12月，收治8例（11髋）CroweⅣ型成人髋脱位患者，男3例，女5例；年龄40-57岁，平均48岁；单髋5例，双髋3例；先天性发育不良7例，陈旧性髋关节结核1例。假体臼杯为金属杯＋聚乙烯内衬设计，其中Duraloc（Depuy，Warsaw，USA）8髋，Pressfit SⅡ（LINK，Ger-many）3髋。股骨柄假体采用AML（Depuy，Warsaw，USA）4髋，Summit（Depuy，Warsaw，USA）4髋，Ribbed（LINK，Germany）3髋。假体均采用生物学固定。手术均采用股骨转子下叠加缩短截骨，并附加断端“V”形截骨，其中6髋因最小号股骨柄假体置 入困难，而附加股骨劈开成形术。结果无一例发生感染、脱位等并发症，无一例行臀大肌或臀中、小肌等短肌松解。转子下平均缩短截骨长度为4．5cm（4～6cm），无一例因截骨过短，导致股骨头假体复位困难或坐骨神经牵伸伤；也无一例因截骨过长，导致股骨头假体松弛性脱位。术后X线片示臼杯均位于真臼区，股骨柄假体的初始固定均优良，截骨断端在3～6个月后均骨性愈合。测量显示患肢平均延长3cm（2．5～3．5cm）。随访3～7年，髋关节Harris评分从术前的25～32分改善至1年后的90～98分。无一髋假体显示有X线松动和邻近骨溶解。结论股骨转子下叠加缩短截骨术可用于CroweⅣ型成人髋脱位的全髋置换术治疗。     

Do Larger Femoral Heads Improve the Functional Outcome in Total Hip Arthroplasty?

Use of larger diameter femoral heads has been popularised in total hip arthroplasty (THA). Recent studies have implicated larger femoral heads in early failure. We evaluated what effect the size of the femoral head had on the early functional outcome in order to determine the optimal head size for the maximal functional outcome. There were 726 patients who underwent elective THA and were divided into 3 groups according to head size then compared with respect to functional outcome scores and dislocation rates. This study failed to show that increasing the size of the femoral head significantly improved the functional outcome at 1 year after total hip arthroplasty but that the use of a 36 mm or greater femoral head did reduce the dislocation rate.     

A Reduction Technique of Arthroplasty Without Subtrochanteric Femoral Shortening Osteotomy for the Treatment of Developmental High Dislocation of Hip: A Case Series of 28 Hips

In total hip arthroplasty for the treatment of developmental dysplasia of the hip (DDH) with high hip dislocation, it can be technically challenging to locate the true acetabulum and restore limb length without subtrochantric femoral shortening osteotomy. We explored and described total hip arthroplasty without subtrochanteric femoral shortening osteotomy in 28 hips with Crowe type III and IV dislocation by intravenous injection of rocuronium at 0.9 mg/kg 1 minute before reduction and hip reduction combined with continuous strong traction of the affected limb with patients in a position with hip and knee flexion. All patients did not show dislocation, prosthesis loosening, and other severe complications. It is thus a safe and feasible reduction technique for arthroplasty of Crowe type III or IV dislocation of DDH.     

全髋关节置换术中大转子骨折的原因与治疗

目的探讨全髋关节置换术及翻修术中股骨大转子骨折的原因与治疗方法。方法对1996年5月至2005年1月,471髋行全髋关节置换及96例全髋关节翻修术发生大转子骨折及大转子截骨不愈合的14例患者进行回顾性分析。其中大转子骨折11例,截骨不愈合3例。2例保守治疗,12例采用螺钉或克氏针加张力带钢丝固定的方法治疗。结果术后随访5~64个月,平均25个月。14例患者全部愈合。Harris评分从术前平均48分恢复到术后随访时平均90分。结论骨质疏松、髋内翻、髋脱位及股骨颈截骨不当等因素是全髋关节置换术及翻修术中股骨大转子骨折的主要原因。采用螺钉或克氏针加张力带钢丝固定的方法治疗效果良好。     

Resurfacing of only the femoral head for osteonecrosis: Long-term follow-up study

Fourteen patients (21 hips) with osteonecrosis of the femoral head with collapse had the femoral head resurfaced with a cemented titanium shell. All of the femoral heads were Ficat stage III or IV. Of the 21 surgeries, 7 were failures. Treatment for all 4 patients with sickle cell disease or trait failed (100%). When the cases of 17 patients who did not have sickle cell disease or trait were reviewed separately, the success rate was 14 of 17 (82%). The follow-up periods (all > 5 years) of the 14 successful patients in this group averaged 6.2 years, and their average Harris hip score was 87 (10 excellent, 4 good). Of the 14 successes, 10 patients had a follow-up period longer than 5 years (average, 7.7 years) and an average Harris hip score of 94 (7 excellent, and 3 good). There was no evidence of loosening and there was no osteolysis. It is concluded that this operation provides an alternative to hemiarthroplasty, total joint arthroplasty surgery, or bipolar arthroplasty. This is a time-buying first-stage operation and, for younger patients, will not last a lifetime. The concept appears prudent because the surgical procedure is directed at the site of primary disease, the femoral head.     

Prevention of dislocation after hip arthroplasty: lessons from long-term followup.

Regarding dislocation after total hip arthroplasty, prevention is worth an ounce of cure. The current authors evaluated dislocation after total hip arthroplasty during the 26-year practice of one surgeon to identify potential variables that can contribute to the prevention of dislocation. Between 1970 and 1996, dislocation after total hip replacement occurred after 7.2% of primary hip arthroplasty procedures (298 of 4164 primary hip replacements) and 11.2% of revision hip arthroplasty procedures (90 of 803 revision hip replacements). Significant findings included an increase in dislocation when 22-mm modular femoral heads were used and a decrease in dislocation after revision for dislocation when constrained liners were used. An additional finding was that 26% of first time dislocations occurred more than 2 years after surgery. Concerning prevention of dislocation, small head modular femoral components should be used cautiously, and constrained liners should be considered in complex revision cases. Patients should be counseled concerning the potential for dislocation many years after their arthroplasty.