闭合空心螺钉治疗儿童股骨头骨骺滑脱

股骨头骨骺滑脱(slipped capital femoral epiphysis,SCFE)是一种股骨头骨骺经生长板移位为特征的儿童和青少年髋关节疾病,好发于10～16岁之间,常伴有肥胖、内分泌、代谢异常(如甲状腺功能减退、垂体功能减退)等[1].临床上股骨头骺滑脱的漏诊误诊率不低,延误诊治将影响患儿髋功能.本文回顾我院8例采用空心螺钉闭合固定治疗股骨头骺滑脱患儿的诊治情况,探讨股骨头骺滑脱的诊治特点.     

骨牵引在青少年股骨头骨骺滑脱治疗中的应用价值

目的 探讨骨牵引在青少年股骨头骨骺滑脱治疗中的作用与意义.方法 2002年9月至2007年8月作者治疗青少年股骨头骨骺滑脱12例,其中男8例,女4例.发病年龄11～14岁,平均年龄13.1岁;稳定型滑脱7例,不稳定型5例.轻度稳定型滑脱采用经皮1枚空心螺钉原位固定(3例).中、重度稳定型滑脱(4例)及不稳定型滑脱(4例)先行股骨远端外展内旋位骨牵引2周,后在全麻下行经皮1～2枚空心螺钉固定.采用X线摄片测量股骨近端正侧位头干角,自身比较股骨头骨骺复位情况.采用Iowa髋关节评分评价最后随访时髋关节功能.结果 12例均获随访,随访时间1.5～5年,平均2.6年.稳定滑脱组牵引前-牵引后-术后的正位头干角与侧位头干角均无显著差异;不稳定型滑脱组正位头干角牵引前与牵引后和术后均有显著差异(P<0.05).除1例治疗经过复杂的不稳定型滑脱发生股骨头缺血性坏死外,其余未见严重并发症.该例Iowa髋关节评分86分,其余均在90分以上.结论 空心钉固定前骨牵引对于不稳定型滑脱复位效果良好,值得推广;对于中、重度稳定型滑脱,骨牵引无效.     

移位儿童股骨颈骨折的手术治疗——3年随访报告

目的 回顾性评估切开复位、髋关节减压及内固定治疗移位股骨颈骨折患儿的中期临床效果.方法 2002年3月至2005年2月,应用减压、切开复位及内固定治疗了16例移位的股骨颈骨折患儿,其中男10例, 女6例,平均年龄9.5岁(4～15岁).按照Delbet分型原则, Ⅰ型(股骨头骺滑脱)2例、Ⅱ型(经颈型骨折)5例, Ⅲ型(颈基底型骨折)9例;受伤机制包括:3例摩托车祸伤、8例高处坠落伤、2例滑雪伤,自行车摔伤、卡车车祸伤及滑冰伤各1例.方法 为切开复位、髋关节囊小切口减压,直视下解剖复位,应用加压螺钉或克氏针内固定治疗.结果 16患儿均获得随访,平均随访时间3.6年.术后髋关节X线片评估复位效果:优8例、良5例、一般3例;14例应用加压螺钉固定,2例行克氏针固定.随访终了时的髋关节X线片提示1例患儿术后股骨头骺早闭,3例患儿合并股骨头坏死;13例患儿髋关节功能良好,日常生活无明显影响.结论 移位的股骨颈骨折患儿,早期的小切口髋关节内减压、解剖复位及坚强内固定可减少股骨头坏死等相关并发症的发生,中期随访效果肯定.     

儿童移位型股骨颈骨折16例临床分析

目的 评估16例采用切开复位、髋关节减压及内固定治疗的移位股骨颈骨折患儿的中期临床效果.方法 本院近期采用减压、切开复位及内固定治疗移位股骨颈骨折患儿16例,其中男10例,女6例,平均年龄9.5（4～15）岁.按照Delbet分型原则,Ⅰ型（股骨头骺滑脱）2例,Ⅱ型（经颈型骨折）5例,Ⅲ型（颈基底型骨折）9例;受伤原因：3例摩托车车祸伤,8例高处坠落伤,2例滑雪伤,1例自行车摔伤,1例卡车车祸伤,1例滑冰伤.方法 为切开复位、髋关节囊小切口减压,直视下解剖复位,应用加压螺钉或克氏针内固定治疗.结果 16例患儿均获随访,平均随访时间3.6年,髋关节X线片评估复位效果：8例为优,5例为良,3例为一般;14例应用加压螺钉固定,2例行克氏针固定.最后1次髋关节X线片随访提示1例术后股骨头骺早闭,3例合并股骨头坏死;13例髋关节功能良好,日常生活无明显影响.结论 移位股骨颈骨折患儿采取小切口髋关节内减压、解剖复位及坚强内固定,可减少股骨头坏死等并发症的发生,中期随访疗效满意.但Delbet分型Ⅰ型骨折的患儿术后股骨头坏死的发生率较高,预后差.     

改良Chiari术治疗Perthes病术后随访研究

目的：评估改良Chiari骨盆截骨＋滑膜部分切除术治疗Perths病的远期疗疗效,方法：对接受该术式治疗5年以上的47个患儿进行定期随访,通过询问病史,查体和摄片,了解其症状及髋关节变化。结果：47例患儿中6例出现骺板早闭,11例发生大转子上移,3例患髋疼痛,高由术前64．36％增至74．85％。髋殷明显加深,加宽,倾斜度减小,髋对股骨头包容满意,患侧股骨头的负重力矩较健侧增大,最后随访时髋关节Stulberg分级,I,II级占73．9％,III,IV级占24．0％,V级占2．1％,Herring分类与骺高恢复,并病发年龄与Stulberg分级分别显著丰关,结论：本术式治疗Perthes病远期效果满意,Herring分类及患儿发病年龄对本病具有确切的预后价值。     

原位空心钉固定治疗股骨头骨骺滑脱的临床观察

目的探讨原位空心钉固定治疗股骨头骨骺滑脱的临床疗效。方法自2002年起采用C型臂引导下原位空心钉固定技术治疗股骨头骨骺滑脱3例，并定期随访。结果原位空心钉固定后1周即可以床上活动，4-6周可以下床活动，术后近期尚未发现股骨头坏死和软骨溶解等并发症。结论原位空心钉固定治疗股骨头骨骺滑脱，操作方法简便，有利于患儿早期活动，值得推广。     

机器人手术系统辅助经皮原位固定术治疗儿童股骨头骨骺滑脱的比较研究

目的观察儿童股骨头骨骺滑脱在机器人导航下经皮原位固定的临床应用效果。方法以2010年1月至2021年1月佛山市中医院收治的20例儿童股骨头骨骺滑脱病例为研究对象。根据治疗方法不同分为试验组(n=8)和对照组(n=12)。试验组患者采用机器人导航下经皮原位固定治疗,共8例(8髋),其中男5例(62.5%),女3例(37.5%),平均年龄为(10.7±2.9)岁;对照组患者采用传统经皮闭合原位固定治疗,共12例(12髋),其中男8例(67%),女4例(33%),平均年龄(11.9±1.6)岁。术前及末次随访时,采用Harris髋关节评分评估髋关节功能,测量术后X线片上的Southwick角。结果 20例(20髋)均获得随访,随访时间最短2个月,最长37个月,平均随访时间(15.3±6.0)个月。试验组Harris髋关节功能评分从术前的(35.1±15.7)分提高到末次随访时的(86.6±8.60)分,髋关节功能改善,差异有统计学意义(t=-8.23,P0.05);术后Southwick角较术前平均减小29.7°(95%CI:16.9°～42.4°,P0.05)。对照组Harris髋关节功能评分从术前(50.8±22.2)分提高到末次随访时(82.2±7.9)分,髋关节功能改善,差异有统计学意义(t=5.50,P0.05);术后Southwick角较术前平均减小16.5°(95%CI:2.2°～30.8°,P0.05)。截至末次随访时无一例伤口感染、断钉、骨不连、股骨头缺血坏死等不良事件及并发症发生。结论机器人导航下经皮原位固定治疗儿童股骨头骨骺滑脱安全有效,具有精准、微创、操作方便的优势,可最大程度减少儿童髋部医源性损伤,预后优良。     

CT三维重建与仿真手术在股骨头骺滑脱治疗中的应用

目的 探讨CT三维重建与仿真手术在股骨头骺滑脱治疗中的作用.方法 回顾性分析2004～2008年期间,因诊断为股骨头骺滑脱入院,并采用空心螺钉固定,获得随访的29例患儿(31例髋),平均年龄10.4岁.术前均行双髋正侧位X线片和髋关节CT扫描,三维重建和仿真手术.在正位X线片上测量Southwick角.在侧位X线片上测量外侧骺干角(LESA角).利用CT扫描的数据进行髋关节三维重建,并重建一根6.5mm的螺钉进行仿真手术,确认该螺钉固定股骨头骺是否可行.根据X线片评估结果和CT重建仿真手术的结果将患儿分为两组.第一组,仅通过X线片和CT片就能确定可以完成空心螺钉固定,第二组,X线片和CT片不能确定能否完成空心螺钉固定,CT重建仿真手术可以确定.结论 所有患儿均在术前X线片、髋关节CT三维重建和仿真手术结果的基础上完成治疗.第一组患儿为24例髋关节,第二组为7例髋关节,两组的Southwick角平均分别为(128.8±9.3)°和(116.3±10.4)°,两组比较差异有统计学意义(P=0.014).两组的LESA角平均分别为(37.4±6.9)°和(56.1±7.7)°,两组比较差异有统计学意义(P＜0.001).在第二组中的7例中,有2例的仿真手术结果不能完成空心螺钉固定,其中1例采取保守治疗,另1例进行股骨头骺下截骨并空心螺钉固定.结论 CT三维重建与仿真手术能有效指导SCFE的治疗,尤其是在滑脱程度严重的病例中.

Abstract：

Objective To evaluate the role of three dimensional reconstruction and virtual operation after CT scanning in the treatment of slipped capital femoral epiphysis(SCFE).Methods Twenty-nine cases of SCFE (31hips) were treated by screw fixation between 2004 and 2008.The Southwick angle and the lateral epiphyseal-shaft angle(LESA) were measured by hip anteroposterior and frog-lateral radiographs.All of them underwent to CT and three dimensional reconstruction.And then virtual operation with a screw was performed.The patients were divided into two groups by the results of X ray,CT and the virtual operation.Internal fixation might be successfully performed as group 1 based on the virtual operation.Otherwise,patients were allocated to the group 2.Results The cases of group 1 were 24 hips,and the cases of group 2 were 7 hips.The Southwick angle in group 1 was significant higher than that of group 2(128.8±9.3 vs 116.3±10.4).The LESA in group 1 was 37.4±6.9,which was significant less than that in group 2(56.1±7.7).In the 7 cases of group 2,the virtual operation results of 2 cases showed the screw fixation could not be performed.One case was treated conservatively,and another case was treated by physeal osteotomy and screw fixation.Conclusions The treatment of SCFE could be effectively directed by three dimensional reconstruction and virtual operation,especially in serious cases.     

牵引复位有限制动治疗发育性髋关节脱位的远期疗效

目的 采用牵引复位、功能性装具有限制动治疗发育性髋关节脱位(DDH)患儿,评价其远期治疗结果.方法 选择1983年7月至2001年7月的86例(119髋)DDH患儿,初诊时平均年龄为19.5个月,经平均18 d牵引后配戴功能性装具.除6例(9髋)在全麻下复位外,其余80例(110髋)均在床旁成功复位,仅有1例(2髋)做了内收肌切断术.配戴功能性装具平均为10.4个月.结果 平均随访时间为10年2个月,21例随访至骨骼成熟Y型软骨骺闭合.随访时临床优良率为85.7%(102/119),放射学评估优良率为77.3%(92/119).8例(8髋)发生股骨头缺血性坏死(6.7%);8髋在复位后有部分或全部骨骺核出现不规则骨化.19例(26髋)由于残余畸形于保守治疗结束后3～8年施行了补充性手术.结论 牵引复位功能性装具有限制动是治疗DDH的一种确切、有效、并发症相对较低的方法;对DDH的保守治疗,要做长期随访.     

改良Salter骨盆截骨联合股骨旋转、短缩截骨术在小儿发育性髋关节脱位治疗中的应用

目的探讨应用改良Salter骨盆截骨联合股骨旋转、短缩截骨术治疗小儿发育性髋关节脱位(DDH)的疗效。方法回顾性分析本院2001年2月-2011年8月收治的28例(31髋)DDH患儿,采用Salter截骨选择性联合应用股骨旋转、短缩截骨术治疗的临床资料。结果术后患儿均获随访,随访时间22～43个月,平均27个月。术后功能评定根据Mckay临床评定标准,其中优10例,良13例,可4例,差1例,优良率82%;Severin X线评定标准:优11例,良15例,可1例,差1例,优良率92.8%。结论改良Salter骨盆截骨联合股骨旋转、短缩截骨术治疗小儿DDH可获得较满意的疗效,是治疗DDH可靠的方法之一。     

Épiphysiolyse fémorale supérieure

Slipped capital femoral epiphysis (SFCE) is a disorder of the hip, characterized by a displacement of the capital femoral epiphysis from the metaphysic through the femoral growth plate. The epiphysis slips posteriorly and inferiorly. SCFE occurs during puberty and metabolic and epidemiologic risk factors, such as obesity are frequently found. Most chronic slips are diagnosed late. Sagittal hip X-rays show epiphysis slip. In case of untreated SCFE, a slip progression arises with an acute slip risk. Treatment is indicated to prevent slip worsening. The clinical and radiological classification is useful to guide treatment and it is predictive of the prognosis. In situ fixation of stable and moderately displaced SCFE with cannulated screws gives excellent results. Major complications are chondrolysis and osteonecrosis and the major sequelae are femoroacetabular impingement and early arthritis.     

Silent slipped capital femoral epiphysis in overweight and obese children and adolescents

Abnormal loading of the hip in obese children may lead to anatomic alterations and an increased prevalence of slipped capital femoral epiphysis (SCFE). The aims of this study were to examine the hip motion in obese children and adolescents and to estimate the prevalence of SCFE in a subgroup of patients characterized by pathological clinical examination and/or pain in the knee or hip joint. A total of 411 individuals (196 males), mean age 14.5?±?2.5?years (7.8-20.4), mean BMI of 32.9?±?5.6?kg/m(2) (20.3-51.5, z score +2.65) who were consecutively admitted for an inpatient weight loss program were included in the study. Twenty-six percent of the patients had load-dependent and 11.7?% had load-independent pain in the knee joint. A total of 9.3?% had load-dependent and 4.7?% had load-independent pain in the hip joint. Two patients (0.5?%) underwent surgical treatment of SCFE prior to entry. A total of 18.2?% of the patients showed a reduced range of motion for hip flexion (<90°) and 18.5?% a pathological decreased internal rotation (<10°). Radiological evaluation of the hips in the clinically conspicuous subgroup (n?=?54) revealed an abnormal head-neck ratio as a sign of prior silent slipped capital femoral epiphysis in 11 patients (20.4?% of the 54 patients, 2.7?% of total cohort). In conclusion, these data show a high prevalence of SCFE-like tilt deformities in a selected group of severely obese children. Mild deformation of the epiphysis at young age might be a major predisposing factor for the development of hip osteoarthritis in obese adults.     

Clinical practice

Hip problems in children are relatively rare but usually serious, potentially causing lifelong disability. Early diagnosis and treatment is, therefore, mandatory. The aim of this review is to discuss the most frequent diseases of the hip from birth to adolescence. The different affections are relatively closely related to age periods. After birth and in infancy, developmental dislocation of the hip (DDH) and septic arthritis are more prominent. DDH is not always present at birth and should regularly be checked for in the first 6 months of life. Septic arthritis is an emergency and should be adequately treated within 4 days of the beginning of the infection with open drainage of the hip. Transient synovitis and Legg–Calvé–Perthes disease (LCPD) are mostly found between 4 and 10 years of age. Transient synovitis is the most frequent hip disorder in that age group. It is a self-limiting noninfectious effusion in the joint without serious consequences. Differential diagnosis with septic arthritis should, however, be made. LCPD is an idiopathic avascular necrosis of the hip causing flattening and deformity of the femoral head, depending on the extent of the necrosis. Treatment by containment is aimed at favoring the remodeling of the deformed femoral head. Finally, between the age of 10 and 15 years, slipped capital femoral epiphysis (SCFE) should be the preferential diagnosis, especially in the limping obese boy. SCFE is an inferior and posterior displacement of the proximal epiphysis of the femur in the growth plate. It should be treated as an emergency with a screw fixation.     

Slipped capital femoral epiphysis in growth hormone-deficient patients

Slipped capital femoral epiphysis (SCFE), a potentially disabling hip disorder, occurs primarily during the pubertal growth spurt. It has been reported in association with pituitary gigantism, growth hormone deficiency, hypothyroidism, hypogonadism, and panhypopituitarism. We estimated the frequency of SCFE among children with growth hormone deficiency (treated or untreated) and compared it with the reported frequency of SCFE among Connecticut residents under 25 years of age. Based on this comparison, the risk of developing SCFE is significantly greater in growth hormone-deficient children than in the general population.     

Reliable X-ray diagnosis of slipped capital femoral epiphysis by combining the conventional and a new simplified geometrical method

BACKGROUND: The diagnosis of subtle slipped capital femoral epiphysis (SCFE), for example in the contralateral asymptomatic hip, may require use of an exactly defined and reproducible lateral view where the slipping angle can be measured. OBJECTIVE: To test a simplified geometrical method and compare it to the conventional method (AP and frogleg views). MATERIALS AND METHODS: The two methods were compared in 95 normal children 9-14 years old and 100 children 9-20 years old with SCFE. RESULTS: The slipping angle (SA) measurements had very high reproducibility, and the new method was diagnostically superior to the conventional method ( P<0.05). CONCLUSION: An exactly defined and reproducible lateral view is recommended for the X-ray diagnosis of SCFE. Nontraumatic SCFE appears to be bilateral in all cases.     

Can GnRH-agonist treatment cause slipped capital femoral epiphysis?

Slipped capital femoral epiphysis (SCFE) mainly occurs in pubertal children and is associated with delayed skeletal maturation, obesity, high growth velocity and tall stature. Furthermore, SCFE often coincides with endocrine disorders. This is the first report of a possible relationship between SCFE and GnRH agonist treatment: four patients developed SCFE during or shortly after treatment with GnRH agonists was stopped. We compared the clinical aspects of these patients with patients described in the literature who developed SCFE. Puberty started at the age of 3.3, 9.6, 0.0 and 5.6 years respectively. One patient developed sequential SCFE of both hips. SCFE occurred at the age of 11.9 (patient 1), 12.7 (patient 2), 14.3 (patient 2), 11.3 (patient 3) and 11.3 (patient 4) years. Of the five incidences of SCFE, one occurred during GnRH agonist treatment and four shortly after treatment was stopped. None of our patients met the typical criteria seen in SCFE and no 'regular' characteristics of patients with SCFE could be designated. Probably the hormonal changes during and shortly after treatment with GnRH agonists make the epiphysis more prone to slip. Considering our observations and by reviewing the literature, GnRH agonist treatment might present a risk factor for the occurrence of SCFE.     

Epiphyseolysis capitis femoris

Slipped capital femoral epiphysis (SCFE) is one of the most frequent hip disorders in adolescents. In cases of delayed diagnosis and therapy, severe and evitable complications might occur. This article outlines diagnostic tools and therapy strategies for SCFE. With an open proximal femoral physis the metaphysis displaces anterolaterally from the proximal femoral epiphysis. Concerning etiology, several biomechanical, biochemical and genetic factors are under investigation. The clinical presentation ranges from a sudden inability to stand and walk to a complete lack of symptoms. In many cases mild and unspecific knee pain is the only symptom. The classification of SCFE can be temporal (e.g. acute, acute on chronic and chronic), clinical (e.g. stable and unstable) and radio-morphological (e.g. mild, moderate, and severe). Short-term sequelae are avascular necrosis of the epiphysis or chondrolysis, medium and long-term sequelae are femoroacetabular impingement (FAI) and osteoarthritis of the hip joint. The contralateral side is affected in 60–80?% of cases and is usually treated prophylactically at least in Europe.     

Bilateral slipped capital femoral epiphysis in a male adolescent with familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC), chronic renal failure, and severe hyperparathyroidism

Slipped capital femoral epiphysis (SCFE) is the most common orthopedic hip disorder affecting otherwise healthy adolescents. The majority of SCFE cases are classified as idiopathic; rarely, it may be secondary to different endocrinopathies including hyperparathyroidism due to chronic renal failure (CRF). However, over the last decades, the association between SCFE and CRF has almost disappeared, probably due to better management of renal osteodystrophy. Familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC, OMIM no. 248250) is a rare autosomal recessive tubulopathy characterized by renal wasting of calcium and magnesium leading to hypomagnesemia, hypercalciuria, nephrocalcinosis, and CRF. Patients usually show hyperparathyroidism before the onset of advanced CRF caused by FHHNC-related metabolic disturbances. We report on a 15-year-old patient with FHHNC and CRF who developed extreme hyperparathyroidism and high-grade bilateral SCFE after self-discontinuation of supportive treatment of underlying conditions. Conclusion: We believe that SCFE was caused not only by untreated CRF but also by metabolic disturbances related to FHHNC. To prevent this complication, careful management of disturbances of calcium, phosphate, and magnesium homeostasis seems to be crucial.     

儿童髋部锁定加压接骨板和空心钉治疗儿童股骨颈骨折(Delbet Ⅱ、Ⅲ型)的比较研究

目的 探讨儿童髋部锁定加压接骨板和空心钉治疗儿童股骨颈骨折(Delbet Ⅱ、Ⅲ型)的治疗效果.方法 收集2011年6月至2015年6月间厦门大学附属福州第二医院、湖南省儿童医院、佛山市中医院、华中科技大学同济医学院附属同济医院、广州市妇女儿童医疗中心、华中科技大学同济医学院附属协和医院和大连医科大学附属大连儿童医院,因股骨颈骨折(Delbet Ⅱ、Ⅲ型)接受儿童髋部锁定加压接骨板和空心钉内固定治疗114例患儿的临床资料.其中,男68例,女46例.受伤年龄3.0～14.0岁,平均9.30岁.骨折分型:Delbet Ⅱ型83例,Ⅲ型31例.行儿童髋部锁定加压接骨板内固定术25例(儿童髋部锁定加压接骨板组),行空心钉内固定术89例(空心钉组).末次随访采用Ratliff分级功能评分,并发症评估包括股骨头坏死、骨骺早闭及髋内翻等.结果 术后随访12～48个月,平均23.3个月.儿童髋部锁定加压接骨板组术后Ratliff分级功能评分(优22例,良2例,差1例)优于空心钉组(优54例,良19例,差16例),差异有统计学意义(P=0.036).儿童髋部锁定加压接骨板组术后总并发症发生率20.00％(5/25)低于空心钉组42.70％(38/89),差异有统计学意义(P=0.039),且空心钉组5例术后因内固定失效行二次翻修手术.儿童髋部锁定加压接骨板组术后影像学上达到骨性愈合的时间为(9.64±1.60)周与空心钉组(10.11±1.87)周比较,差异无统计学意义(P=0.252).结论 相对于空心钉,儿童髋部锁定加压接骨板治疗儿童股骨颈骨折(Delbet Ⅱ、Ⅲ型)术后Ratliff功能评分更高,并发症发生率更低,在治疗上可能更有优势.