髋臼周围截骨治疗成人髋关节发育不良

目的 探讨髋臼周围截骨治疗成人髋关节发育不良的手术适应证及疗效.方法 25例成人髋关节发育不良患者接受经改良Smith-Peterson人路的髋臼周围截骨术,女19例,男6例;年龄18～45岁,平均25.5岁.均为单侧发病,左侧14例,右侧11例.3例有既往手术史,2例Chari截骨术、1例Salter截骨术.髋关节骨关节炎T(o)nnis 0期13例、Ⅰ期9例、Ⅱ期3例.Shenton线不连续18例.髋臼外侧CE角4.57°±7.39°,前侧CE角0.95°±6.02°,髋臼顶倾斜角32.50°±5.96°,股骨头超出指数38.11%±5.70%,Harris髋关节评分(75.32±7.51)分.结果 全部患者随访2.0～7.5年,平均4.5年.3例髋关节骨关节炎T(o)nnis Ⅰ期者改善为0期,2例T(o)nnisⅡ期者改善为Ⅰ期,1例T(o)nnis Ⅰ期者进展为Ⅱ期.Shenton线不连续减少为10例.外侧CE角29.07°±5.81°,前侧CE角29.52°±4.51°,髋臼顶倾斜角19.17°±4.95°,股骨头超出指数24.20%±4.83%,Harris髋关节评分(84.88±4.88)分,与术前比较差异均有统计学意义.16例出现股外侧皮神经支配区感觉麻木,其中9例自行恢复,7例残留永久性麻木.1例出现髋关节周围Brooker Ⅰ型异位骨化.结论 经改良Smith-Peterson人路行髋臼周围截骨治疗成人髋关节发育不良可有效增加髋臼包容,改善关节功能,阻止髋臼周围硬化和囊性变,保持关节间隙,延缓骨关节炎进展.     

Periacetabular osteotomy for the treatment of acetabular dysplasia associated with major aspherical femoral head deformities

BACKGROUND: Acetabular dysplasia associated with deformity of the proximal part of the femur can result in hip dysfunction and degenerative arthritis in young adults. The optimal method of surgical correction for these challenging combined deformities remains controversial. METHODS: We retrospectively analyzed twenty-four hips in twenty patients who underwent a Bernese periacetabular osteotomy, which was done with a proximal femoral valgus-producing osteotomy in thirteen hips, for the treatment of acetabular dysplasia associated with proximal femoral structural abnormalities. The average age of the patients at the time of surgery was 22.7 years, and the average duration of clinical follow-up was 4.5 years. The Harris hip score and overall patient satisfaction with surgery were used to assess hip function and clinical results. Plain radiographs were used to assess the correction of the deformity, healing of the osteotomy, and progression of degenerative arthritis. RESULTS: The mean Harris hip score increased from 68.8 points preoperatively to 91.3 points at the time of the most recent follow-up (p<0.0001). Sixteen patients (nineteen hips) had an excellent clinical result, and one patient (one hip) had a good result. Two patients (two hips) had a fair result, and one patient (two hips) had a poor result. Twenty-two of the twenty-four hips improved clinically. There was an average improvement of 27.6 degrees in the lateral center-edge angle of Wiberg (p<0.0001), an average improvement of 33.1 degrees in the anterior center-edge angle of Lequesne and de Seze (p<0.0001), and an average improvement of 16.5 degrees in the acetabular roof obliquity (p<0.0001). The hip center was translated medially an average of 6.3 mm (p=0.0003). The T?nnis osteoarthritis grade was unchanged in twenty hips, progressed one grade in three hips, and progressed two grades in one hip. There were three major technical complications. At the time of the most recent follow-up, none of the hips had required total hip arthroplasty. CONCLUSIONS: The combination of acetabular dysplasia and proximal femoral deformities presents a complex reconstructive problem. The range of motion and radiographic assessment of the hip are major factors in the selection of patients for surgery. In selected patients, the periacetabular osteotomy combined with concurrent femoral procedures, when indicated, can provide comprehensive deformity correction and improved hip function.     

Long-Term Results of Periacetabular Rotational Osteotomy Concomitantly With Arthroscopy in Adult Acetabular Dysplasia

BackgroundAlthough the long-term results of periacetabular osteotomy in acetabular dysplasia have been well documented, there is paucity in reports on the long-term outcomes of periacetabular osteotomy with simultaneous hip arthroscopy. This study aimed to assess the cumulative 10-year outcomes of periacetabular rotational osteotomy with concomitant hip arthroscopy.MethodsThrough an arthroscopic procedure, the status of the labrum was assessed, and torn labrum was debrided. Evaluations on survival from conversion to total hip arthroplasty and success in radiographic and clinical long-term results were completed in 39 hips (36 patients). Acetabular parameters (center-edge angle, Sharp angle, acetabular-head index, and head lateralization index), Tönnis grades on radiograph, Harris Hip Score, and range of motion of the hip were evaluated. Survivorship analyses were evaluated with the Kaplan-Meier method.ResultsThirty-eight hips (97.4%, 95% confidence interval 0.832-0.996) were preserved for 12.8 ± 1.7 years on average, and only 1 hip was converted to total hip arthroplasty at 7.8 years. All the acetabular parameters were improved (P < .001). Twenty-eight hips (71.8%) showed unchanged or improved Tönnis grades at the latest follow-up. The average Harris Hip Score was significantly better than the preoperative value (P < .001), and range of motion was not significantly different until the latest follow-up.ConclusionSufficient acetabular reorientation, such as periacetabular rotational osteotomy, with concomitant arthroscopic debridement showed successful long-term outcomes for acetabular dysplasia in adults.     

Early results of the Bernese periacetabular osteotomy: the learning curve at an academic medical center

BACKGROUND: Most reports on the results of the Bernese periacetabular osteotomy for the treatment of developmental dysplasia of the hip have been by the originators of the procedure. In 1997, we began to use this osteotomy without direct training from the originators of the procedure. METHODS: Seventy-three patients (eighty-three hips) underwent a Bernese periacetabular osteotomy between 1997 and 2003 and were followed prospectively with use of the Harris hip score to assess clinical results and with use of anteroposterior pelvic and false-profile lateral plain radiographs to assess radiographic results. The three-dimensional position of the acetabulum was recorded preoperatively and postoperatively. The mean duration of follow-up was forty-six months. RESULTS: The average Harris hip score improved from 54 to 87 points (p < 0.001). Three hips (three patients) had a conversion to total hip arthroplasty at two, three, and four years after the periacetabular osteotomy. Preoperatively, fifty-four of the eighty-three acetabula were anteverted, and twenty-nine were either retroverted or had neutral wall relationships. Postoperatively, sixty-five hips (78%) were anteverted. Radiographically, in preoperatively anteverted hips, the average center-edge angle improved from 3 degrees to 29 degrees (p < 0.0001), the average anterior center-edge angle improved from 5 degrees to 31 degrees (p < 0.0001), and the acetabular index improved from 25 degrees to 5 degrees (p < 0.0001). In preoperatively retroverted or neutral hips, the average center-edge angle improved from 13 degrees to 33 degrees (p < 0.0001), the average anterior center-edge angle improved from 15 degrees to 36 degrees (p < 0.0001), and the acetabular index improved from 19 degrees to 2 degrees (p < 0.0001). Complications included four hematomas, three transient femoral nerve palsies, two deep wound infections, and one transient sciatic nerve palsy. Nine of the ten major complications and all four of the failed osteotomies occurred in the first thirty hips in which the index procedure was performed. CONCLUSIONS: In our experience, the early results of the Bernese periacetabular osteotomy have been encouraging, with a 92% survival rate at thirty-six months. The occurrence of complications demonstrates a substantial learning curve. Recognition of the true preoperative acetabular version and reorientation of the acetabulum into an appropriately anteverted position have become important factors in surgical decision-making. LEVEL OF EVIDENCE: Therapeutic Level IV.     

经髂腹股沟入路髋臼周围截骨治疗中年髋关节发育不良

 目的 探讨经髂腹股沟入路髋臼周围截骨治疗中年髋关节发育不良的手术适应证及疗效。方法 回顾性分析2005年8月至2010年2月采用经髂腹股沟入路髋臼周围截骨术治疗10例髋关节发育不良患者资料,男3例,女7例;年龄40～47岁,平均42岁;3例为双侧(单侧手术)、7例为单侧髋关节发育不良;左侧4例,右侧6例。2例有既往手术史,其中1例行Chari截骨术,1例行髋臼造盖术。髋关节骨关节炎分期：T?nnis 0期3例,Ⅰ期5例,Ⅱ期2例。6例Shenton线不连续。髋臼外侧CE角3.50°±4.88°,前侧CE角1.80°±5.07°,髋臼顶倾斜角18.20°±3.01°,股骨头超出指数31.30%±4.37%,Harris髋关节评分(67.40±7.75)分。结果 10例患者均获得随访,随访时间10～76个月,平均37个月。1例术前T?nnis Ⅰ期者术后改善为0期,1例Ⅱ期者改善为Ⅰ期,其余分期无变化。术后2例Shenton线不连续。末次随访外侧CE角30.40°±3.31°,前侧CE角29.50°±3.03°,髋臼顶倾斜角4.50°±2.55°,股骨头超出指数9.90%±4.33%,Harris髋关节评分(84.10±4.07)分。3例出现股外侧皮神经支配区感觉麻木,4～6个月自行恢复。1例出现髂窝血肿,2周后吸收消失,无残留症状。结论 只要严格掌握手术适应证,术中精细操作,经髂腹股沟入路髋臼周围截骨可治疗中年髋关节发育不良。     

Eccentric rotational acetabular osteotomy for acetabular dysplasia: follow-up of one hundred and thirty-two hips for five to ten years

BACKGROUND: Eccentric rotational acetabular osteotomy for the operative treatment of acetabular dysplasia consists of a spherical but eccentric osteotomy and rotation of the acetabulum that moves the center of rotation of the head of the femur medially and distally. No bone graft is needed. The reorientation of the acetabular fragment not only improves acetabular coverage but also restores the center of rotation of the subluxated hip. The purpose of this paper was to describe eccentric rotational acetabular osteotomy for the treatment of acetabular dysplasia and to evaluate its clinical and radiographic outcomes. METHODS: We performed this procedure consecutively in 132 hips in 126 patients with dysplasia of the hip. Eighteen hips had no osteoarthritis, fifty-three had early osteoarthritis, and sixty-one had advanced osteoarthritis. Seven patients were male, and 119 were female. The average age was 36.5 years at the time of the index operation, and the average duration of follow-up was 7.5 years. Twenty-three hips in twenty-two patients were also treated with intertrochanteric valgus osteotomy to further improve joint congruency at the time of the acetabular osteotomy. RESULTS: The average preoperative Harris hip score of 71 points improved to an average score of 89 points at the time of the latest follow-up. The average center-edge angle improved from 0 to 36 . An apparent change in the stage of the arthritis was observed in seven hips (5%), one of which had had early-stage disease and six of which had had advanced disease preoperatively. CONCLUSIONS: Eccentric rotational acetabular osteotomy appears to be a good treatment option for young patients with either early or advanced hip osteoarthritis secondary to dysplasia.     

Factors influencing the outcome of Chiari pelvic osteotomy: a long-term follow-up

We have reviewed 103 of 126 Chiari osteotomies carried out in our department between 1956 and 1987. The cases were graded radiologically, using the Japanese Orthopaedic Association (JOA) system, into a pre/early osteoarthritis (OA) group and an advanced OA group. In the pre/early group there were 86 hips. The mean follow-up was for 17.1 years (4 to 37). Preoperatively, 51 hips had an average JOA clinical score of 78.6+/-8.4 points and the final mean JOA clinical score was 89.4+/-12.5 points. Advanced degenerative change developed in 33.7% and one hip required a total replacement arthroplasty (TRA). Chiari osteotomy alone, without accompanying intertrochanteric osteotomy, was performed on 62 hips. For these the median survival time was 26.0+/-2.5 years, using as the endpoint progression to advanced OA. Differences in survivorship curves related significantly to the severity of the preoperative OA, the shape of the femoral head and the level of osteotomy. In the advanced OA group, we followed up 17 hips for a mean of 16.2 years (1 to 27). Before operation, the mean JOA clinical score in 13 hips was 63.2+/-7.9 points and the final score 84.0+/-12.0 points. TRA was eventually carried out on four hips. Our findings suggest that the Chiari osteotomy remains radiologically effective for about 25 years. The procedure is best suited to subluxated hips with round or flat femoral heads and early or no degenerative change. Intra-articular osteotomy can lead to osteonecrosis, and should be avoided. In hips with advanced OA, the Chiari procedure creates an acetabulum which facilitates later TRA, and may delay the need for this procedure in younger patients.     

髋臼旋转截骨术治疗早中期髋关节发育不良

目的探讨髋臼旋转截骨术治疗早中期髋关节发育不良的手术技术要点及中期疗效。方法2000年5月至2006年5月对12例（14髋）早、中期髋关节发育不良患者进行了髋臼旋转截骨术,所有患者均为女性,手术时年龄13—46岁,平均28．9岁。随访时间3．1—9．1年,平均6．0年。术前、术后及随访时X线片上测量CE角,髋臼顶角及头外移指数。Harris评分判断髋关节功能。手术采用Oilier外侧“U”形入路,股骨大转子截骨显露。术后未行外固定。结果患者疼痛症状得到明显改善,Harris评分术前72分,术后91分（P〈0．001）。CE角术前0．9°,术后27°（P〈0．001）;髋臼顶角术前为29°,术后5°;头外移指数术前为0．68,术后0．65。所有病例截骨块及股骨大转子截骨处愈合良好。结论Oilier外侧“U”形入路行髋臼旋转截骨术髋臼缘显露充分;治疗早中期髋关节发育不良可以缓解疼痛,延缓骨关节炎的进展速度,中期随访疗效满意。     

The periacetabular osteotomy. Minimum 2 year followup in more than 100 hips.

The results of 123 periacetabular osteotomies in 115 patients were reviewed at an average clinical followup of 4.3 years. The average age of the patients at the time of the operation was 32.9 years. The preoperative diagnosis was congenital dysplasia in 101 hips, Legg-Calve-Perthes disease in 10 hips, Charcot Marie Tooth disease in four hips, epiphyseal dysplasia in three hips, congenital coxa vara in two hips, slipped capital femoral epiphysis in one hip, and posttraumatic and postinfectious dysplasia in one hip each. The ilioinguinal approach was used in 67 hips and the modified Smith-Petersen approach was used in 56 hips. A periacetabular osteotomy was combined with an intertrochanteric osteotomy and/or trochanteric transfer in 32 hips. Ten hips underwent open reduction and internal fixation of an acetabular rim fracture and 18 arthrotomies were performed at the time of periacetabular osteotomy. The average Harris hip score increased from 65 points preoperatively to 89 points at latest followup. The average Merle d'Aubigne score increased from 13.6 points preoperatively to 16.3 points at latest followup. Overall, 83% of the hips were rated clinically as good to excellent. Seven hips have undergone total hip arthroplasty and six subsequent intertrochanteric osteotomies were performed. The majority of the major complications occurred when the osteotomy was performed through the ilioinguinal approach. The latest followup radiographic severity of osteoarthrosis, according to the criteria of T?nnis, improved or was unchanged in 117 hips (95%), and progressed in only six hips (5%). The majority of the hips with preoperative changes in the periarticular bone showed some evidence of regeneration, which was shown by a decrease in the subchondral sclerosis, disappearance of cysts, or healing of an acetabular rim fracture. The short term results of the periacetabular osteotomy are encouraging from the standpoint of improvements in clinical scores and in the appearance of the joint.     

Influence of acetabular coverage on hip survival after free vascularized fibular grafting for femoral head osteonecrosis

BACKGROUND: Osteonecrosis of the femoral head frequently results in collapse of the head and subsequent arthrosis of the joint. Surgical treatment has been based entirely on the evaluation of the femoral side of the hip joint, with little consideration given to the possible influence on outcome of the orientation of the acetabulum. METHODS: We retrospectively reviewed a consecutive series of 200 hips in 160 patients with osteonecrosis of the femoral head who had undergone free vascularized fibular grafting between 1997 and 1998. The mean duration of clinical follow-up was 7.5 years. Ninety-one hips in seventy-one patients were evaluated radiographically for evidence of progression of femoral head collapse at a minimum of two years, and a mean of three years, postoperatively. We defined conversion to a total hip arthroplasty and progression of femoral head collapse as the failure end points, and we analyzed the association of the acetabular center-edge angle of Wiberg, the area and laterality of the lesion, the amount of preoperative collapse of the femoral head, and the etiology of the osteonecrosis with the likelihood of failure. RESULTS: Forty-eight (24%) of the 200 hips had undergone conversion to a total hip arthroplasty at the time of the final clinical follow-up. In addition, 15% (fourteen) of the ninety-one hips with sufficient radiographic follow-up demonstrated progression of femoral head collapse at the time of the final radiographic examination. Of the hips with a center-edge angle of 30 degrees , 10% had progressive collapse (p = 0.002) and 6% were converted to a total hip arthroplasty (p < 0.001). Neither the etiology nor the size of the lesion was significantly correlated with progression of collapse or conversion to a total hip arthroplasty. CONCLUSIONS: Patients with osteonecrosis of the femoral head and a suboptimal center-edge angle of the hip are at substantial risk for progression of femoral head collapse and conversion to a total hip arthroplasty following free vascularized fibular grafting. An estimation of the degree of hip dysplasia should be included in the preoperative assessment of patients with osteonecrosis of the femoral head for prognostic and possibly surgical planning purposes.     

The Chiari pelvic osteotomy for patients with dysplastic hips and poor joint congruency: long-term follow-up

We report the mid- to long-term (mean 20.3 years, 10 to 32.5) results of the Chiari pelvic osteotomy in patients with pre- to advanced stage osteoarthritis in dysplastic hips. We followed 163 Japanese patients (173 hips) with a mean age at surgery of 20 years (9 to 54). Overall, 124 hips (72%) had satisfactory results, with Harris hip scores ≥ 80. Satisfactory results were seen in 105 of 134 hips with pre- or early osteoarthritis (78%) and 19 of 39 hips with advanced osteoarthritis (49%). A total of 15 hips (9%) underwent a total hip replacement (THR) with a mean interval between osteotomy and THR of 16.4 years. With conversion to THR as the endpoint, the 30-year survival rate was 85.9% (95% confidence interval 82.3 to 89.5). It was 91.8% for patients with pre- or early osteoarthritis and 43.6% for those with advanced osteoarthritis (p < 0.001). We now perform the Chiari osteotomy for patients with dysplastic hips showing poor joint congruency and who prefer a joint-conserving procedure to THR.     

Triple pelvic osteotomy as treatment for osteoarthritis secondary to developmental dysplasia of the hip

Joint-preserving osteotomies are an established treatment for adult hip pain secondary to developmental dysplasia of the hip. However, their value for advanced osteoarthritis is unclear. Therefore this study addresses the question of long-term results of triple pelvic osteotomy in patients with second grade osteoarthritis. Thirty-two patients with second grade osteoarthritis secondary to developmental dysplasia of the hip before triple pelvic osteotomy were clinically and radiographically assessed 11.5 years postoperatively. Five patients required conversion to total hip replacement. Kaplan-Meier survivorship analysis predicted a survival rate of 85.3%. The mean Harris hip score increased significantly with more than 56% good or very good results. A preoperative BMI > 25 and Harris hip score < 70 resulted in worse outcome or early conversion into total hip arthroplasty. The results indicate that developmental dysplasia of the hip even in second grade osteoarthritis can be treated with triple pelvic osteotomy.     

Chiari pelvic osteotomy for osteoarthritis secondary to hip dysplasia. Indications and long-term results

Of 142 Chiari pelvic osteotomies for osteoarthritis in dysplastic hips, most performed by Chiari himself, we were able to review 82 and obtain information about 18 by questionnaire. All patients were over 30 years of age at operation; follow-up averaged 15.5 years. Twenty hips had undergone secondary total hip replacement. The outcome was good in 75%, fair in 9% and poor in 16%. High osteotomies all gave good results, and the result also depended on adequate medialisation. Statistics were worse for patients over 44 years of age at the time of operation. For osteoarthritis secondary to hip dysplasia, the Chiari pelvic osteotomy is an alternative procedure to early hip replacement. In contrast to intertrochanteric osteotomy, it has the advantage of facilitating the implantation of an acetabular prosthesis should arthroplasty become necessary at a later stage.     

The Bernese periacetabular osteotomy: clinical, radiographic and mechanical 7-15-year follow-up of 26 hips

BACKGROUND: The Bernese periacetabular osteotomy is used in dysplastic hips to increase the load-bearing area of the hip and to prevent osteoarthritis.The aim of our work was to determine the contact hip stress before and after the osteotomy and to compare the relief of stress with the long-term radiographic and clinical outcome. PATIENTS AND METHODS: We followed 26 dysplastic hips (26 patients) for 7-15 years after the index operation. Clinical evaluation was based on the WOMAC score, osteoarthrosis was evaluated with the T?nnis classification, the angles of lateral (CE) and anterior (VCA) femoral coverage were measured, and biomechanical parameters were studied. RESULTS: Periacetabular osteotomy increased the mean CE from 15 degrees to 37 degrees , and the mean VCA from 22 degrees to 38 degrees . The mean normalized peak contact stress was reduced from 5.2 to 3.0 kPa/N. Four hips required total hip arthroplasty after an average of 4.5 years, 8 hips showed considerable arthrosis progression, and 14 hips had no or mild arthrosis at follow-up. Preoperative WOMAC score, preoperative T?nnis grade and postoperative normalized peak contact stress were the most important predictors of outcome. INTERPRETATION: The Bernese periacetabular osteotomy improves the mechanical status of the hip. Long-term success depends on the grade of arthrosis preoperatively and on the magnitude of operative correction of the contact hip stress.     

Long-term results of Chiari pelvic osteotomy in patients with developmental dysplasia of the hip: indications for Chiari pelvic osteotomy according to disease stage and femoral head shape

Background We evaluated the long-term results of Chiari pelvic osteotomy for developmental dysplasia of the hip (DDH) after follow-up of 10 years or more. The indications for Chiari osteotomy were assessed based on the results. Methods We evaluated 74 hips in 69 patients treated for DDH with Chiari osteotomy. The average postoperative follow-up period was 13 years. The mean age at the time of surgery was 32 years (range 6–64 years). The disease was classified into two stages based on joint space measurements on radiographs: an early stage (36 hips) in which the mean age at surgery was 21 years (range 6–48 years) and an advanced stage (38 hips) in which the mean age at surgery was 41 years (range 18–64 years). Femoral head shape was classified into two types based on measurements of the sphericity of the femoral head: spherical (33 hips) or flat (41 hips). Clinical manifestations were evaluated according to Japanese Orthopaedic Association (JOA) hip scores. The joint space was measured on radiographs as an index of the progression of osteoarthritis. We attempted to identify factors that affected the long-term results of Chiari osteotomy, especially in regard to disease stage and femoral head shape. Results The mean total JOA score was 72 preoperatively and 87 at final follow-up. It had improved in 66 hips and was worse in 7 hips. All of the worse cases were at the advanced stage at the time of surgery, and in 6 of the worse cases the femoral head was spherical. Hips with advanced DDH and a spherical femoral head had poor outcomes and exhibited joint space narrowing postoperatively. Conclusions Early DDH is considered a good indication for Chiari pelvic osteotomy because of the good results at 10 years or more. Even with advanced DDH, a flat femoral head predicts a good surgical outcome, but patients with a spherical femoral head may experience early progression to osteoarthritis.     

Rotational acetabular osteotomy for advanced osteoarthritis secondary to dysplasia of the hip

BACKGROUND: Satisfactory intermediate and long-term results of rotational acetabular osteotomy for the treatment of early osteoarthritis secondary to developmental dysplasia of the hip have been reported. The purpose of this study was to examine the results of rotational acetabular osteotomy in patients with advanced osteoarthritis secondary to developmental dysplasia of the hip. METHODS: We performed a retrospective review of the results of rotational acetabular osteotomy in forty-three patients (forty-three hips). All of the patients had radiographic evidence of advanced-stage osteoarthritis, defined as narrowing of the joint space with cystic radiolucencies and small osteophytes according to the staging system of the Japanese Orthopaedic Association. Forty-one patients were female, and two were male. The mean age was 43.8 years at the time of surgery, and the mean duration of follow-up was 8.5 years. Clinical follow-up was performed with use of the system of Merle d'Aubigné and Postel. The center-edge angle, acetabular roof angle, head lateralization index, and minimum width of the joint space were measured on radiographs made preoperatively, postoperatively, and at the time of final follow-up. Postoperative joint congruency was classified into four grades. RESULTS: The mean preoperative Merle d'Aubigné clinical score was 13.3 points, which improved to a mean of 15.4 points at the time of the latest follow-up (p < 0.0001). The mean center-edge angle improved from 0.7 degrees preoperatively to 29 degrees at three months postoperatively (p < 0.0001), the mean acetabular roof angle improved from 30 degrees to 11 degrees (p < 0.0001), the mean head lateralization index improved from 0.69 to 0.65 (p < 0.01), and the mean minimum width of the joint space improved from 2.2 to 2.5 mm (p < 0.0003). Ten hips had radiographic evidence of progression of osteoarthritis. Kaplan-Meier survivorship analysis, with radiographic signs of progression of osteoarthritis as the end point, predicted a ten-year survival rate of 72.2%. CONCLUSIONS: Rotational acetabular osteotomy for advanced osteoarthritis secondary to dysplasia of the hip in properly selected patients can improve clinical scores and is associated with a lack of radiographic signs of progression of osteoarthritis in most patients. LEVEL OF EVIDENCE: Therapeutic Level IV.     

应用S-ROM全髋关节置换术治疗Crowe Ⅳ型髋臼发育不良

目的总结采用粗隆下截骨和生物固定型带股骨柄模块的人工关节假体治疗CroweⅣ型髋臼发育不良伴骨关节炎的效果及经验。方法回顾从2004年2月到2009年4月对12例21髋CroweⅣ型髋臼发育不良伴骨关节炎患者治疗的详细过程及疗效,记录所有的并发症。全部采用粗隆下截骨和S-ROM生物固定型人工关节假体置换术进行治疗。髋臼杯假体均植入真臼位置,7例13髋采用自体股骨头于髋臼外上方作结构性植骨,均作了粗隆下缩短截骨术,平均截骨长度为39.4 mm(35~50 mm)。结果平均随访30.8个月(6~62个月)。髋关节Harris评分明显改善(t=24.862,P0.01),从术前的平均(38.2±6.4)分(28~48分)到术后平均(82.1±8.6)分(62~94分)。术后肢体均得到不同程度的延长(t=12.099,P0.01),平均(33.5±12.7)mm(11~65 mm)。术前所有患者均有明显跛行,术后4例有轻度跛行,2例仍需扶双拐行走。19髋股骨截骨处愈合良好,2髋截骨处延迟愈合。在最后一次回访时显示髋臼假体和股骨柄假体位置均良好,无松动、下沉、断钉、骨溶解及异位骨化出现。髋关节中心平均下移了73.0 mm(46~105 mm)。结论利用S-ROM带股骨柄模块的生物固定型人工关节假体的高度适配性,加上在真臼位置加深髋臼,适当植骨,以及精确的粗隆下截骨,是治疗CroweⅣ型髋臼发育不良伴骨关节炎的良好选择。     

Periacetabular osteotomy for the treatment of severe acetabular dysplasia

BACKGROUND: The optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients. METHODS: Sixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively. RESULTS: Comparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6 degrees (from -20.5 degrees to 24.1 degrees ) in the lateral center-edge angle of Wiberg, an average improvement of 51.0 degrees (from -25.4 degrees to 25.6 degrees ) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9 degrees (from 37.3 degrees to 11.4 degrees ) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures. CONCLUSIONS: The periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.