The hip in arthrogryposis multiplex congenita

The hip is involved in up to 80% of individuals with a diagnosis of arthrogryposis multiplex congenita. The hip deformity consists of contracture with or without dislocation. Isolated contracture can usually be treated conservatively by manipulation and splinting, only occasionally requiring operative intervention. Dislocation is as frequently bilateral as unilateral. Bilateral hip dislocations are best left unreduced; only accompanying contractures should be treated. The unilateral dislocation should be treated aggressively, because persistent dislocation will give rise to pelvic obliquity and scoliosis. Open reduction is always necessary.     

臀肌起点下移治疗臀肌挛缩症

目的 介绍一种新的治疗臀肌挛缩症的手术方法。方法 应用臀肌起点下移方法松解臀肌挛缩,改善髋关节节屈曲障碍及展畸形。结果 治疗２８例患儿,经６个月～１０年随访,畸形全部得到矫正,髋关节功能完全恢复正常或接近正常。结论 本术式与传统的治疗方法比较有以下优点：松解彻底,手术操作便,因手术部位在髂嵴臀肌肌起部,避免了损伤我血管、神经的可能。术后处理简单,本手术方法术后无需任何外固定,４８～７２小时后即可进     

盆下型骨盆倾斜的分型与治疗

目的：对盆下型骨盆倾斜进行临床分型和分型治疗。方法：盆下型骨盆倾斜以畸形演变机制为基础，结合临床表现分为2个类型，即髋关节周围挛缩型，下肢不等长型。结果：作者从1987年起对1085例骨盆倾斜进行了分型治疗，其中在髋关节周围挛缩型中，患侧肢体髋关节周围挛缩型58例，健侧肢体髋关节周围挛缩型232例；在下肢不等长型中，代偿性骨盆倾斜762例，固定型骨盆倾斜33例，采用分型治疗方法，骨盆倾斜纠正满意。     

Neurophysiologic aspects of the etiology and pathogenesis of congenital hip dislocation

Till today the meaning of neuromuscular factors in etiology and treatment of congenital dislocation of the hip is not quite clear. Our observation in 62 children with 78 dislocated hips show that neurophysiological mechanisms play of very important role in the development and upkeep of CDH. The neurological examination in 17 children pointed to the typical asymmetries of the children which correlated with the side of the dislocated hip. The knowledge of neurophysiological disturbances on the dislocated hip is of great value for the diagnosis of CDH and even more for the exercise treatment in hips with severe adduction contracture.     

Treatment of coxa magna in Perthes disease by pelvic osteotomy (author's transl)

In M. Perthes a progressive deformation and flattening of the epiphysis is caused by the stress in the hip. In the beginning stages a varisation osteotomie gives a sufficient reduction of the joint pressure and a modelling of the enlarged head by the acetabulum is possible. In later stages a detoriation of the head deformity with fixed adduction contracture can be caused by varisation osteotomie. Enlarging the acetabulum laterally and ventrally and medializing the hip-joint by means of a Chiari pelvic-osteotomy reduces the joint pressure so far, that a restitution of the hip joint with round and congruent joint surfaces can be expected. A lateralisation of the deformed femoral head with a secondary insufficiency of the acetabulum should also be treated by an additional pelvic osteotomy, if in the arthrography the lateral part of the head does not enter the acetabulum in abduction position. In secondary osteochondritis in hip luxation the treatment should be equal. Even an advanced secondary osteoarthritis after M. Perthes could be stopped by pelvic osteotomy over years.     

关节镜监视下射频汽化治疗注射性臀肌挛缩症的初步报告

目的探讨关节镜监视下射频汽化技术治疗注射性臀肌挛缩症的临床效果。方法自2001年6月～2002年7月,采用关节镜监视下射频汽化治疗双侧注射性臀肌挛缩症患者18例,男7例,女11例;年龄8～40岁,平均14岁。侧卧位,术前标记坐骨神经走行、股骨大转子、臀肌挛缩带和手术入口。于大转子顶点切开5 mm,骨膜剥离器插入皮下筋膜组织与臀肌挛缩带之间,钝性分离出5 cm×5cm的工作腔隙。生理盐水充盈后在关节镜监视下,用射频汽化电极斜行切断并松解臀肌挛缩纤维束带,直到无活动性出血、髋关节无弹响、被动活动自如为止。结果术后随访6～13个月,平均7个月,根据步态、并膝下蹲、交腿试验、对运动和体力劳动的影响进行综合评价,优17例,良1例。伤口一期愈合15例,2例血肿形成,无神经、血管损伤。结论关节镜监视下射频汽化臀肌挛缩切断松解术操作安全,疗效可靠,创伤小,痛苦少,有利于早期功能锻炼。     

Intertrochanteric corrective osteotomy in slipped capital femoral epiphysis. A long-term follow-up study of 26 patients

The results of intertrochanteric corrective osteotomy in a series of 26 hips with moderate to severe chronic slipped capital femoral epiphysis are reported from follow-up studies in 1976 and 1986. In hips with a slippage of less than 40 degrees (ten hips), arthrosis was present in one hip. In the remaining 16 cases in which slippage exceeded 40 degrees, osteoarthrosis was present in 15, even though correction was adequate. From these observations it can be concluded that intertrochanteric corrective osteotomy does not prevent degeneration in cases with the most severe slip. On the basis of the present observations on treated and untreated cases, the authors advocate treatment by fixation without realignment, accepting the deformity in moderate and severe chronic slips. Rotational osteotomy may be considered in the event of hip joint contracture.     

Postburn shoulder medial-adduction contracture: Anatomy and treatment with trapeze-flap plasty

Background

Shoulder-adduction contractures after burn, most frequent among big joints, cause functional deficiency of the upper limb and, therefore, benefits from surgical correction. Many reconstructive techniques and flaps have been suggested for contracture treatment, but the problem in choosing an adequate reconstructive technique based on the anatomy of the contracture remains. Shoulder-adduction contracture has been given less emphasis in research than any other type and its surgical reconstructive technique remains of concern.

Methods

Anatomic features of scar shoulder-adduction contractures were studied in 346 patients, personally operated upon. This allowed us to classify all contractures into three types: edge, medial and total. New surgical techniques specifically for medial contractures were developed.

Results

Eighty percent of patients had edge contractures in which the axillary fossa was spared. In 20% of patients, axilla, including the hairy dome, was involved. These cases were anatomically classified into two types: medial, making up 30% of the cases, when contracted scars involved only axilla, and total caused by scars, tightly surrounding the shoulder joint. The scars, causing medial contracture, form a crescent-shaped fold along the medial axillary line. The fold's sheets are scars in which there is skin surface surplus in width, which allows the contracture release with local tissues. Surface deficiency in length has a trapezoid form. Medial contracture can be successfully treated with opposite transposition of trapezoid adipose-scar flaps prepared from both sheets of the fold.

Conclusion

Medial shoulder-adduction contracture is a newly described type with specific anatomic features. Contracture can be successfully treated with local tissues using trapeze-flap plasty.     

Smith－Petersen和Watson－Jones联合切口在髋关节置换术中的应用

对严重髋关节屈曲挛缩畸形或伴有下肢短缩畸形的患者，行髋关节假体置换术重建髋关节功能十分困难。为了使髋关节松解术与假体置换术一次完成，对手术切口进行了改进，将Ｓｍｉｔｈ－Ｐｅｔｅｒｓｏｎ和Ｗａｔｓｏｎ－Ｊｏｎｅｓ切口联合应用，在髋关节松解的同时进行髋关节假体置换手术１１例，全部顺利完成手术。经１～３年随访，未见假体松动及下沉。总满意率为９０．９％。     

Total hip and total knee arthroplasty in juvenile rheumatoid arthritis

Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is indicated for patients with juvenile rheumatoid arthritis (JRA) when marked joint destruction is present and pain or deformity compromises function despite optimal medical therapy. Relief of pain, reduction of the deformity, and dramatic improvement in functional status and quality of life can be achieved in most patients. Functional impairment and deformity rather than pain are usually the primary indications for THA or TKA. When there is both hip and knee involvement, hip arthroplasty should probably be done first. Regional anesthetic appears to be the anesthetic of choice. Careful preoperative planning and the availability of custom and minisized components are essential. Small bone size, osteoporosis, and severe soft tissue disease make the surgery technically demanding. Skeletal immaturity may not contraindicate surgery if the patient is otherwise bedridden with progressive deformity. In the hip trochanteric osteotomy is often necessary for adequate exposure, with the possible exception being a patient with juvenile ankylosing spondylitis who is subject to heterotopic bone formation. Although complete capsulectomy and psoas tenotomy may be necessary to relieve a hip flexion contracture, a soft tissue release that produces leg lengthening may lead to nerve palsy. In the hip component loosening has been less common in patients with JRA than in other young patients who have undergone THA, but it is still the most frequent cause of failure. In the knee preoperative and postoperative serial casts can aid in the correction of severe flexion contracture. Secondary patellar pain has been the most common cause of late failure. Patellar resurfacing should probably be performed at the time of the original knee arthroplasty in all patients with JRA.     

Surgical treatment of developmental dysplasia of the hip in the periadolescent period

The surgical management of patients with neglected developmental dysplasia of the hip (DDH) after the age of 6 years has been the subject of controversy. We present 11 cases (16 hips) of neglected DDH that were treated operatively by means of open reduction and derotational subtrochanteric osteotomy. Patient age ranged between 10 and 17 years (mean, 12 years). Follow-up ranged from 5 to 13 years (mean, 8.7 years). The results have been satisfactory both clinically (evaluated using the modified Harris hip score) and radiographically (evaluated using Severins classification). Our data suggest that neglected DDH cases, not only during early childhood, but also in the periadolescent period, should be considered for surgical treatment.     

儿童臀肌挛缩症并骨盆倾斜的手术治疗

目的探讨儿童臀肌挛缩症并骨盆倾斜的手术治疗方法及疗效。方法臀部挛缩组织切断松解或延长术(29例)、臀肌起点下移术(11例)治疗儿童臀肌挛缩症并骨盆倾斜。结果40例术后平均随访5年,采用臀部挛缩组织松解或延长术29例中,臀肌挛缩体征及骨盆倾斜完全消失24例,部分改善3例,2例无明显改善。臀肌起点下移术11例中,臀肌挛缩及骨盆倾斜症状完全消失9例,部分改善2例。结论经臀肌大转子顶端的小切口进行臀部挛缩组织切断松解或者延长手术,对治疗轻症臀肌挛缩症并骨盆倾斜简便、有效;而臀肌起点下移术是治疗儿童重症臀肌挛缩并骨盆倾斜的有效方法。     

改进动力髋螺钉治疗不稳定型股骨转子部骨折

目的探讨自行改进动力髋螺钉（DHS）治疗不稳定型股骨转子部骨折的临床效果。方法采用自行改进的DHS治疗不稳定型股骨转子部骨折20例。结果20例随访时间9．33个月。髋关节功能参照Harris评分：优13例,良5例,可2例。结论改进DHS治疗不稳定型股骨转子部骨折固定牢靠,有效防止了DHS的退钉、肢体短缩发生。     

Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity

During the 1990s three new techniques to reduce spasticity and dystonia in children with cerebral palsy (CP) were introduced in southern Sweden: selective dorsal rhizotomy, continuous intrathecal baclofen infusion and botulinum toxin treatment. In 1994 a CP register and a health care programme, aimed to prevent hip dislocation and severe contractures, were initiated in the area. The total population of children with CP born 1990-1991, 1992-1993 and 1994-1995 was evaluated and compared at 8 years of age. In non-ambulant children the passive range of motion in hip, knee and ankle improved significantly from the first to the later age groups. Ambulant children had similar range of motion in the three age groups, with almost no severe contractures. The proportion of children treated with orthopaedic surgery for contracture or skeletal torsion deformity decreased from 40 to 15% (P = 0.0019). One-fifth of the children with spastic diplegia had been treated with selective dorsal rhizotomy. One-third of the children born 1994-1995 had been treated with botulinum toxin before 8 years of age. With early treatment of spasticity, early non-operative treatment of contracture and prevention of hip dislocation, the need for orthopaedic surgery for contracture or torsion deformity is reduced, and the need for multilevel procedures seems to be eliminated.     

Idiopathic hypertonicity as a cause of stiffness after surgery for developmental dysplasia of the hip

INTRODUCTION

There are various complications reported with surgical treatment of DDH. Most studied complication is avascular necrosis of the femoral head and hip stiffness. The purpose of this report was to describe a case with severe stiffness of the hip due to hypertonicity in periarticular muscles after it was treated for developmental dysplasia of the hip (DDH).

PRESENTATION OF CASE

Three-year-old patient referred to our institution with bilateral DDH. Two hips were operated separately in one year with anterior open reduction, femoral shortening osteotomy. Third month after last surgery, limited right hip range of motion and limb length discrepency identified. Clinical examination revealed that patient had limited range of motion (ROM) in the right hip and compensated this with pelvis obliquity. Gluteus medius, sartorius and iliofemoral band release performed after examination under general anesthesia. Symptoms were persisted at 3rd week control and examination of the patient in general anesthesia revealed full ROM without increased tension. For the identified hypertonicity, ultrasound guided 100 IU botulinum toxin A injection performed to abductor group and iliopsoas muscles. Fifth month later, no flexor or abductor tension observed, and there was no pelvic obliquity.

DISCUSSION

Stiffness as a complication is rare and is usually resolved without treatment or simple physical therapy. Usually it is related with immobilization or surgery associated joint contracture, and spontaneous recovery reported. Presented case is diagnosed as hip stiffness due to underlying local hypertonicity. That is resolved with anesthesia and it was treated after using botulinum toxin A injection.

CONCLUSION

Hypertonicity with hip stiffness after surgical treatment of DDH differ from spontaneous recovering hip range of motion limitation and treatment can only be achieved by reduction of the muscle hypertonicity by neuromuscular junction blockage.     

Treatment of deformities of the locomotor system in hemiplegia]

In spastic hemiplegia mainly one side of the body is affected. In both the upper and the lower extremity the distal parts (hand and foot) are more severely involved than the proximal region. In cases of minor involvement the goal of treatment in the upper extremity is to achieve functional improvement by means of splinting and surgery. In cases of severe alterations cosmetic improvement without much functional gain is all that can be expected. Gait analysis has demonstrated that there are four basic patterns that can be related to the severity of involvement. In type I muscle imbalance exists without a contracture. In type II there is contracture of the muscles of the posterior compartment of the calf. In type III, in addition to the changes around the ankle joint, contractures around the knee are present, and in type IV also hip problems. Functional improvement can be achieved by means of splinting and surgery in all types. Basic principles of treatment have developed as a result of the application of gait analysis and dynamic electromyography. Specific examples of such treatment principles have recently been presented by Gage.     

Normal ranges of hip motion in infants six weeks, three months and six months of age.

Flexion contracture, internal rotation and external rotation of the hip were reported in 40 infants at 6 weeks and 3 months and in an independent sample of 40 infants at 6 months of age. Population means and normal ranges of motion were determined for use in the evaluation of hip problems and their treatment. A mean hip flexion contracture of 19 degrees was present at 6 weeks of age, decreasing to 7 degrees by three months, but still persisting at 6 months suggesting that forceful extension of the hip in infants may be contraindicated. Hip flexion contracture decreased in every child from 6 weeks to three months. In all cases, external rotation was greater than internal rotation. Internal rotation greater than external rotation before the age of 6 months appears contrary to normal development. There was a significant correlation between the changes in hip flexion contracture and internal rotation from 6 weeks to 3 months. An interesting extension of this study would be a longitudinal follow-up of infants beyond 6 months of age to further define these developmental trends.     

Heterotopic ossification after hip surgery in cerebral palsy

Heterotopic ossification is a post-surgery complication occasionally observed in patients with infantile cerebral palsy. In the majority of the cases such lesions are found at the hip after surgery on the skeleton and the soft tissues. At our Institute in the last five years, this complication has been observed four times, in 39 patients, who underwent mainly soft tissue releases because of flexion and adduction contracture of the hip. In these cases, as in a further patient with myelomeningocele, the periarticular heterotopic ossification appeared in the hip after tenotomy of the ilio-psoas at the lesser tronchater associated to other surgical procedures. Conversely, no cases of ossification have been found after tenotomy of the adductors or the gracilis or selective tenotomy of the psoas at the pelvic brim. The exact causes of this complication are still unclear, but after an analysis of the literature and patient history it can be hypothesised that it may be related to the surgical procedures carried out.     

手术治疗股骨距碎裂的股骨颈骨折

目的探讨股骨距碎裂的股骨颈骨折的手术方法及疗效。方法手术治疗14例股骨距碎裂的股骨颈骨折患者,5例骨折无明显移位者行闭合复位折断式加压螺钉内固定;5例移位明显者术中将其切开复位后行股方肌骨瓣移植加空心加压螺纹钉内固定;4例行骨水泥型人工关节置换,其中2例去除股骨距骨块。结果14例获9个月~3年随访。前两种术式中9例股骨距骨折块达骨性愈合,闭合复位组中1例变成死骨;股骨颈骨折均愈合;发生股骨头坏死1例。行骨水泥型人工关节置换的4例中2例保留的股骨距骨块愈合,1例出现假体松动。结论合并股骨距碎裂的股骨颈骨折年龄较轻者应选择骨折复位内固定,老年患者则可选择人工关节置换,尽量保留股骨距的骨块。     

人工全髋关节置换术后假体脱位的治疗

目的探讨人工全髋关节置换术后假体脱位的治疗方法。方法1997年7月～2004年10月，共收治人工全髋关节置换术后假体脱位23例，男9例，女14例；年龄53～79岁。行CT及X线片检查，了解假体松动情况及假体位置，并分析脱位原因。无假体松动者，麻醉下手法复位、行稳定性试验。手法复位成功且稳定者，胫骨结节牵引4～6周。手法复位失败或不稳定者，原入路切开，根据术前及术中情况，调整offset值及部分假体组件。稳定者，关节囊修补，胫骨结节牵引4～6周。仍不稳定或松动者采用翻修手术。结果23例患者，1例松动者采用全髋关节翻修；10例手法复位治疗成功；12例手法复位后不稳定或失败患者中，5例行切开复位关节囊修补，2例采用加长股骨头增加offset值，2例改用防脱位髋臼内衬，1例采用加长股骨头并调整异常髋臼内衬位置，2例仍不稳定者采用全髋关节翻修。患者均获随访1～5年，平均1．9年。均未出现再脱位。术后1年Harris评分72～94分，平均87分。结论人工全髋关节置换术后假体脱位，应根据脱位原因和术中稳定情况选择不同的治疗方法。