成人期股骨头骨骺滑脱症的全髋关节置换

[目的]探讨全髋关节置换术治疗成人期股骨头滑脱继发股骨头颈短缩畸形的临床疗效。[方法]2009年9月~2014年1月应用全髋关节置换术治疗成人期股骨头滑脱患者28例(30髋),男21例,女7例;年龄27岁~66岁,平均(48.6±9.3)岁。通过真臼重建、梯度软组织松解和撬拨复位良好地实现了髋关节置换。术后对患者满意度、髋关节功能恢复和双下肢长度恢复等情况进行评估。[结果]所有患者均获得随访,随访时间15~72个月,平均(38.5±3.7)个月。Harris髋关节评分由术前(48.1±4.5)分(41~62分)提高至末次随访时的(93.1±3.8)分(88~96分),术前及术后髋关节功能的差异有统计学意义(t=27.31,P<0.001)。其中优18例(20髋)、良10例(10髋),优良率100%。28例髋术后均立即实现了髋臼及股骨柄的生物性压配与初始稳定,术后3个月X线片上均获骨性固定。2例术后有腓总神经牵拉损伤症状,未行特殊处理,应用神经营养药物及保持下肢膝关节屈膝位,2~3周后下肢麻木消失,术后4周左右下肢肌力均完全恢复正常。随访期间无髋关节脱位、假体感染及松动发生。[结论]全髋关节置换术治疗成人期股骨头滑脱合并股骨头颈短缩可获得令人满意的手术效果,采用梯次松解法可对髋周软组织挛缩进行有效松解。     

一期人工全髋关节置换治疗股骨头粉碎性骨折

目的探讨一期人工全髋关节置换治疗股骨头粉碎性骨折的疗效。方法对11例股骨头粉碎性骨折患者行人工全髋关节置换术。结果11例均获随访,时间3～41（28±4.5）个月。6例基本达到骨折前的状况,5例生活基本自理。根据Harris评分标准：优（93±2.6分）6例,良（86±2.2分）5例。结论一期人工全髋关节置换治疗股骨头粉碎性骨折患者疗效满意,可减少并发症,改善生活质量。     

人工股骨头置换与全髋关节置换治疗老年股骨颈骨折

目的 评价人工股骨头置换与全髋关节置换治疗老年股骨颈骨折的临床疗效。方法 对134例老年股骨颈骨折行髋关节置换术，其中人工股骨头置换55例，全髋关节置换79例。结果 3例人工股骨头置换术后2年因髋臼磨损、髋关节疼痛明显行髋臼翻修，1例全髋关节置换术后半年因髋臼松动行髋臼翻修，其余病例均无明显髋部不适，髋关节活动良好。结论 老年股骨颈骨折治疗方法的选择取决于患者全身健康状况、术前的生活状态和活动量、骨的质量和年龄等因素。通过严格的术前评估，人工股骨头置换与全髋关节置换同样能取得良好的临床疗效。     

少年股骨头骨骺滑脱一例

患者，男，13岁，1999年4月12日入院。入院前2个月踢足球剧烈活动后出现左髋节疼痛，休息后症状有所缓解。但每遇行走或左髋关节活动后，疼痛再次加重，伴跛行。入院前1d，摔倒后左髋部着地，觉左髋关节疼痛难忍，不能活动，急送我院摄骨盆正位及左髋关节侧位X线片示：左股骨头骨骺向后下方移位。入院查体：左关节呈半屈外展     

双动人工股骨头与全髋关节置换治疗高龄股骨颈骨折的疗效比较

目的 比较双动人工股骨头置换与全髋关节置换治疗高龄股骨颈骨折的疗效，明确双动人工股骨头置换治疗高龄股骨颈骨折的优越性。方法 对1996年1月-2000年1月采用人工髋关节置换治疗的高龄股骨颈骨折87例进行回顾性分析，其中双动人工股骨头置换(FHR)56例，平均随访4年1个月，全髋关节置换(THR)31例，平均随访4年3个月。结果 FHR组术中出血量明显少于THR组，手术时间明显短于THR组，术后早期并发症的发生率明显少于THR组，且两组Harris功能评分无明显差异。结论 高龄股骨颈骨折采用双动人工股骨头置换的手术安全性高，术后并发症少，关节功能好，疗效满意，应优先选用。     

成人期股骨头骨骺滑脱症及其治疗的再认识

目的探讨成人期股骨头骨骺滑脱症(SEFH)的影像学和临床特点,并观察采用全髋关节置换术(THR)治疗该病的方法和疗效。方法描述本组26例患者(31髋)的影像学和临床特点,所有SEFH患者均接受THR,对符合CrownⅠ型者采用髋臼加深,对CrownⅡ～Ⅲ型者,采取自体植骨于髋臼内上后方10～3点钟位,以加深和下移髋臼,重建臼顶部和后柱后壁,新臼须适当下移以延长患肢,并正确安置各种类型假体。结果对26例31髋的SEFH患者进行平均5年10个月的随访,植入骨愈合,关节功能采用Harris评分,优(90)17例19髋,良(80～90)9例12髋,无尚可(70～79)和差(70)的患者。术后4例患者出现并发症,均已治愈或改善。结论根据脱位程度,加深髋臼或自体骨植骨重建髋臼顶部和后柱,再行THR,是治疗成人期SEFH成功的关键。     

全髋关节置换与人工股骨头置换术治疗高龄股骨颈骨折效果观察

目的观察全髋关节置换术(THR)与人工股骨头置换术(ATBA)治疗高龄股骨颈骨折的效果。方法随机将102例高龄股骨颈骨折患者分为2组,各51例。观察组实施THR,对照组行ATBA。比较2组疗效。结果观察组术中出血量、手术时间及住院时间均多于或长于对照组,差异均有统计学意义(P0.05)。随访6个月,观察组发生2例(3.92%)并发症,对照组为8例(15.69%),差异有统计学意义(P0.05)。末次随访,观察组患者的髋关节功能Harris评分优于对照组,差异有统计学意义(P0.05)。结论 ATBA治疗高龄股骨颈骨折,创伤小、操作简单;但THR术后并发症少,远期效果更好。     

疲劳性股骨头骨骺滑脱2例

例1，男，17岁，徒步野营途中右髋弹响后持续性疼痛2天、体检：发育营养状态良好，右下肢跛行，右够内收外旋位，X线观够正位片示右股骨头骨骺较健侧略扁，股骨颈上缘延长线切过股骨头骨骺上方，蛙式位片示右股骨头骨骺向后下方移位。诊断疲劳性股骨头骨骺滑脱。治疗行持续皮肤牵引，轻柔手法旋转摆正右下肢呈外展中立位，床边X光检查骨骺复位正常，持续牵引4周，不负重休息3个月。结果随访2年步态功能正常，X线示双侧股骨头发育正常，骨髓正常融合。例2，，女，14岁，长跑途中右髓部弹响后持续性疼痛1天。体检：发育营养状态良好，右下肢…     

股骨头坏死显微外科手术治疗失败病例的人工全髋关节置换

目的 比较股骨头缺血坏死显微外科保头治疗失败后全髋关节置换（THA）与初次全髋关节置换的疗效差别。方法对应用带血管蒂骨瓣转移治疗失败后改行THA治疗的57例（61侧）股骨头缺血性坏死与同期初次即选用THA治疗的58例（65侧）股骨头缺血性坏死进行随访观察，骨瓣组平均年龄47．2岁（36-65岁），非骨瓣组平均年龄60．5岁（48-82岁），THA手术前根据Ficat分期标准，骨瓣组Ⅲ期7侧，Ⅳ期54侧；非骨瓣组Ⅲ期29侧，Ⅳ期36侧。手术方式：骨瓣组：小切口26侧；常规切口手术35侧；非骨瓣组：小切口22侧；常规切口手术33侧。两组病例平均随访6．2年（2-9年）。比较两组病例切口长短、术中出血量、手术时间、围手术期并发症、术后半年及随访期末HHS评分及髋关节翻修情况的差异。结果骨瓣组手术切口长度9-17cm，平均12．8cm。对照组为9-16cm，平均12．2cm（P=0．213）；骨瓣组术中出血平均480ml（400-750ml）。非骨瓣组术中平均出血420ml（350-600ml；P=0．09）；骨瓣组平均手术时间为105min（90-130min），非骨瓣组为100min（90=120min；P=0．168）；骨瓣组围手术期并发症发生率为4．9％，对照组并发症发生率为8．6％（P〈0．05）；两组病人均未出现术中并发症。骨瓣组术后半年的HHS平均为85．8分（80-92分），非骨瓣组为80．5（76-90分），骨瓣组随访期末的HHS平均为96．9分（92-100分），非骨瓣组为92．6分（86-100分）（P〈0．05）。两组在随访期间均无翻修病例。结论应用显微外科技术保头手术治疗失败的股骨头坏死改行人工全髋关节置换不增加手术难度及围手术期并发症的发生率，术后关节功能恢复满意。     

全髋关节和人工股骨头置换治疗老年股骨颈骨折的比较

目的比较全髋关节置换及人工股骨头置换治疗老年股骨颈骨折的临床疗效。方法将56例老年股骨颈骨折患者随机分为A、B两组,分别行全髋关节置换和人工股骨头置换术。分别记录手术时间、术中出血量、并发症。结果 A组的手术时间、术中出血量高于B组,A、B组术后Harris评分均较术前有明显改善,随访3年时A组Harris评分优于B组。结论髋关节置换治疗老年股骨颈骨折可达到较满意的效果,全髋关节置换远期效果优于人工股骨头置换。     

全髋关节置换术治疗髋臼骨折

目的: 探讨全髋关节置换术治疗髋臼骨折的疗效与方法。方法: 回顾全髋关节置换术治疗髋臼骨折患者 17例, 总结分析其手术入路的选择, 异位骨化组织、内固定物以及髋臼骨缺损的处理方法。结果: 17例病人中有14例得到随访, 平均随访时间为 3年 7个月 (1年 2个月~9年 8个月)。出现感染 1例, 脱位 1例, 无菌松动 2例。术后再次异位骨化者 2例, 其中 1例引起坐骨神经症状, 再次行神经松解术。所有随访病例, 髋关节功能均有改善,Harris评分由术前平均 51分, 提高到术后 89分。结论: 选择正确的手术入路, 适当处理异位骨化组织和内固定物,重建髋臼骨缺损, 是全髋关节置换治疗髋臼骨折成功的关键。     

The oblique plane deformity in slipped capital femoral epiphysis

Background

Slipped capital femoral epiphysis (SCFE) is commonly treated with in situ pinning. However, a severe slip may not be suitable for in situ pinning because the required screw trajectory is such that it risks perforating the posterior cortex and damaging the remaining blood supply to the capital epiphysis. In such cases, an anteriorly placed screw may also cause impingement. It is also possible to underestimate the severity of the slip using conventional radiographs. The aim of this study was to describe and evaluate a novel method for calculating the true deformity in SCFE and to assess the interobserver and intraobserver reliability of this technique.

Methods

We selected 20 patients with varying severity of SCFE who presented to our institution. Cross-sectional imaging [either axial computed tomography (CT) scans or magnetic resonance imaging (MRI) scans] and anteroposterior (AP) pelvis radiographs were assessed by four reviewers with varying levels of experience on two occasions. The degree of slip on the axial image and on the AP pelvis radiographs were measured and, from this, the oblique plane deformity was calculated using the method as popularised by Paley. The intraclass correlation coefficient (ICC) was calculated to determine the interobserver and intraobserver reliabilities between and amongst the raters.

Results

The interobserver reliability for the calculated oblique plane deformity in SCFE ICC was 0.947 [95 % confidence interval (CI) 0.90–0.98] and the intraobserver reliability for the calculated oblique plane deformity of individual raters ranged from 0.81 to 0.94. The deformity in the oblique plane was always greater than the deformity measured in the axial or the coronal plane alone.

Conclusion

This method for calculating the true deformity in SCFE has excellent interobserver and intraobserver reliability and can be used to guide treatment options. This technique is a reliable and reproducible method for assessing the degree of deformity in SCFE. It may help orthopaedic surgeons with varying degrees of experience to identify which hips are suitable for in situ pinning and those which require surgical dislocation and anatomical reduction, given that plain radiographs in a single plane will underestimate the true deformity in the oblique plane.

Level of evidence

Level II diagnostic study.     

关节置换加自体股骨头移植治疗髋关节发育不良

目的：探讨关节置换加自体股骨头移植治疗髋关节发育不良。方法：自1995-2000年用关节置换加自体股骨头移植治疗髋关节发育不良40例(36例病人)，术前放射学评价髋关节发育不良的严重程度，术后随访分析移植物对假体的覆盖率、松动及移植物的固定情况。本组病人平均年龄44岁。术后移植的股骨头覆盖平均占髋臼28％。结果：随访2～7年，所有骨移植均融合，22例移植骨有部分吸收，但均在覆盖假体外上边缘，假体无移位。全部病例无疼痛或仅有轻度不适。结论：关节置换加自体股骨头移植是治疗髋臼不良的有效方法之一。     

Bone remodeling of a femoral head after transtrochanteric rotational osteotomy for osteonecrosis associated with slipped capital femoral epiphysis: a case report

A rare case of a 12-year-old boy on whom a joint-preserving operation for osteonecrosis after slipped capital femoral epiphysis (SCFE) was performed, is described. Firstly, in situ pinning was performed for acute-on-chronic SCFE. However, osteonecrosis and collapse of the femoral head occurred at 7 months after surgery. Secondly, transtrochanteric rotational osteotomy (TRO) was performed against progression of the collapse of the femoral head. Eight years of X-ray observation revealed bone remodeling at the osteonecrotic region. No documentation has been reported about the potential of bone remodeling of a femoral head with osteonecrosis after SCFE. This case indicates that a joint-preserving operation such as TRO is capable of promoting bone remodeling in such circumstances.     

Inter-observer and intra-observer agreement in the radiographic diagnosis of avascular necrosis of the femoral head following slipped capital femoral epiphysis

Introduction  

Slipped capital femoral epiphysis (SCFE) is a common pediatric hip disorder. Avascular necrosis (AVN) of the femoral head is a devastating complication of SCFE. The frequency of this complication reported in the literature has been variable. It was the objective of this study to estimate the inter- and intra-observer agreement between two experienced pediatric orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE.     

Early results of total hip arthroplasty in patients with slipped upper femoral epiphysis compared with patients with osteoarthritis

We have investigated the results of primary total hip arthroplasty (THA) performed in patients with slipped upper femoral epiphysis (SUFE). Through the New Zealand Joint Registry, we identified all patients with SUFE undergoing primary THA (n = 117) and all patients with primary osteoarthritis (OA) undergoing primary THA (n = 40 589) between January 1, 1999, and December 31, 2008. Baseline information, operative characteristics, and postoperative outcomes were analyzed and compared between the SUFE and the OA groups. There was no significant difference in postoperative Oxford Hip Score or revision rate between the 2 groups. Our results support THA as a successful surgical option in the management of degenerative arthritis in SUFE, with comparable functional outcomes and revision rates to THA performed for primary OA.     

Hip impingement in slipped capital femoral epiphysis: a changing perspective

Background

Femoroacetabular impingement (FAI) as a result of slipped capital femoral epiphysis (SCFE) has recently gained significant attention. Seen as an intermediate step toward the development of early osteoarthritis, symptomatic FAI develops in SCFE patients who have residual hip deformity characterized by relative posterior and medial displacement of the capital femoral epiphysis, leading to an anterolateral prominence of the metaphysis which abuts on the acetabular rim. This results in a decreased range of hip motion as well as progressive labral damage and articular cartilage injury, which cause symptoms of FAI. All degrees of slips from mild to severe can develop impingement.

Methods

The existing literature on the subject was thoroughly reviewed and all levels of studies that have made any meaningful changes to clinical practice were considered.

Results

Based on the literature review, current practice trends, and our own institutional practice pattern, all treatment options for SCFE in the impingement era have been presented with an open discussion regarding potential benefits and limitations.

Conclusions

Several surgical options exist for the SCFE patient who develops FAI. These are largely determined by the degree of deformity present and severity of the initial slip. Extraarticular (intertrochanteric, base of the neck) as well as subcapital osteotomies can be utilized with a goal of restoring proximal femoral anatomy in order to minimize the effect of the anterolateral prominence in more severe deformities. Patients with milder deformities can undergo osteochondroplasty of the femoral head and neck to remove impinging structures via either an open or arthroscopic approach. Also, proximal femoral osteotomy and open head–neck recontouring can be combined. Finally, patients who develop pain very early after in situ pinning must also be examined for potential iatrogenic screw-head impingement as a source of their pain and decreased hip motion, in addition to abnormalities in the proximal femoral anatomy. There are many centers that are approaching acute unstable SCFE patients as well as the more displaced stable cases with open reduction techniques that seem to be demonstrating good mid-term results. The goal of treatment is to improve patient function, alleviate hip pain, and to delay or prevent the development of early degenerative changes in adolescents and young adults. Prospective multi-center studies will be necessary so as to determine what methods work best in treatment and delay the onset and progression of osteoarthritis.

Level of evidence

V.     

Large diameter femoral head uncemented total hip replacement to treat fractured neck of femur

The aim of this study was to investigate the use of large diameter head THR to treat fractured neck of femur, and to demonstrate if this conferred greater stability.Forty-six independent, mentally alert patients with displaced intracapsular fractures underwent THR. Mean age was 72.1 years. Outcome measures were dislocation, reoperation/revision rate, Oxford hip score (OHS), EuroQol (EQ-5D) and residential status.At mean follow-up (13.5 months) there were no dislocations. Reoperation, revision and infection rate were all 0%. Two patients died (4.3%). Mean pre-injury and postoperative OHS were 12.1 and 17.6, respectively. Mean pre-injury and postoperative EQ-5D index scores were 0.97 and 0.83, respectively. Mean postoperative walking distance was 2.5 miles. There were no changes in residential status.This is the first published series using 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur. We have demonstrated that it affords patients excellent stability with no recorded dislocations.     

The association of HLA-DR4 antigen with juvenile chronic arthritis and slipped capital femoral epiphysis

Seventeen children who met the criteria for juvenile chronic arthritis (JCA) were reviewed. Throughout the study, the clinical examination, HLA phenotyping, and radiological assessment of the hips were performed by separate authors who were blinded to other data. At the end of the study, the results were also compared with 25 healthy, age- and sex-matched children. Six of the children with JCA also had radiological signs of slipped capital femoral epiphysis (SCFE; five with minimal slip pattern, one with moderate slip), and five of them had DR4 in their genotypes, in contrast to the remaining 11 patients who did not (p < 0.001). On the other hand, only 2 of 25 children in the control group had DR4 (p < 0.01). The difference was not significant when the patients without SCFE were compared with the control group (p = 1.0). The relative risk of cases with DR4 antigen for SCFE was 57.5, while it was below 1 for the other antigens. These results suggest that although DR4 is not specific for JCA, it is the common HLA antigen for those who have SCFE, and patients with JCA and HLA-DR4 antigen should be examined for evidence of SCFE, which was not reported before to exist with JCA. Received: 31 October 2000