髋关节发育不良合并股骨头缺血性坏死的治疗

目的 :为了探讨髋关节发育不良引起的股骨头缺血坏死的治疗方法。方法 :根据髋关节发育不良的程度 ,应用带旋股外侧血管横支大转子骨瓣和升支髂骨瓣转移进行股骨头的修复和再造。结果 :经 2～ 8年随访 ,所有患者髋关节功能均有不同程度的改善。结论 :带血管蒂大转子骨瓣和髂骨瓣转移方法适用于髋关节发育不良引起的股骨头缺血性坏死。     

全髋关节置换术治疗成人先天性髋关节发育不良伴股骨头坏死中期随访疗效观察

目的探讨全髋关节置换术(THA)治疗伴有股骨头坏死的成人先天性髋关节脱位的临床疗效。方法对15例(23髋)伴有股骨头坏死的成人先天性髋关节脱位进行THA治疗。结果随访18～61个月,采用Harris评分评定髋关节功能,由术前35.6分恢复到术后90.2分。疼痛均得到缓解,关节屈伸、行走、生活自理能力完全恢复,未见髋关节脱位,假体周围骨折,神经、血管、肌肉损伤。结论对于先天性髋关节发育不良伴股骨头坏死应严格掌握手术适应证,处理好髋臼及股骨近端的畸形,合理松解髋关节周围软组织,选择合适假体,THA则是一种较好的治疗方法。     

髋关节镜在股骨头缺血性坏死诊治中的应用

<正>股骨头缺血性坏死(avascular necrosis of the femoral head, AVNFH)是一种无菌性骨坏死,由股骨近端血液供应中断所引起,病情进展最终导致髋关节骨关节炎。AVNFH通常影响30～50岁年龄段病人,在美国每年有2～3万例病人被诊断为AVNFH,且呈患病率逐年递增趋势;它是造成约10%全髋关节置换手术的主要病因^[1],我国每年约有7.5～15万新发病例。     

股骨头缺血坏死保髋治疗研究进展

股骨头坏死(osteonecrosis of the femoral head,ONFH)好发于青壮年人群,致残率高,其病因、病理机制的研究尚无突破性进展。目前认为ONFH主要为各种因素引起股骨头微循环障碍,骨组织缺血坏死,后期纤维、血管增生使髓内压增高,而髓内高压进一步影响股骨头血供,形成恶性循环。对于早中期ONFH如何逆转缺血环境、保存股骨头是近几年研究的热门话题,本文在综合分析相关文献基础上将保髋治疗现状及进展总结如下。     

全髋关节置换治疗股骨头缺血坏死伴髋臼病损

我科自1996年10月～2000年10月4年间,共收治了32例股骨头缺血坏死伴髋臼病损的病人,行髋臼重建后,全髋关节置换,经随访效果满意,现报告如下.     

髋关节镜手术治疗股骨头缺血性坏死

目的 探讨应用髋关节镜手术治疗股骨头缺血坏死的疗效。方法 对３３例Ⅱ期或Ⅲ期的股头缺血坏死患者，进行了关节镜下髓心减压入路；游离骨膜及骨柴植入或经关节囊带血管蒂髂骨瓣转移的方法治疗，平均随访１年９个月。结果 所有病人疼痛消失，行走正常，髓关节活动范围正常或接近正常，Ｘ线片示股骨头轮廓清晰，囊性变消失，骨密度均匀，关节间隙正常。结论 关节镜下手术治疗股骨头缺血性坏死具有损伤小、准确、有效、简便的优点     

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。     

两种髋人类位髋人字石膏治疗婴幼儿髋关节发育不良比较

[目的]比较闭合复位膝上与标准人类位髋人字石膏固定治疗婴幼儿发育性髋关节发育不良的临床效果。[方法]回顾性分析2010年1月—2018年12月伊犁州新华医院小儿骨科治疗121例年龄6～18个月的DDH患儿的临床资料。依据与患者家长沟通结果,58例（76髋）采用膝上髋人类位髋人字石膏固定（膝上组）,63例（80髋）采用常规标准髋人类位髋人字石膏固定（标准组）。比较两组临床及影像资料。[结果]两组患者均一次复位成功,膝上组的早期再脱位率11.8%(9/76),标准组为2.5%(2/80),两组间差异有统计学意义（P<0.05）。再脱位的患儿均择期行切开复位术,并排除之后的研究。两组患儿透视次数、带石膏的时间、石膏压疮等差异均无统计学意义（P>0.05）。两组患儿平均随访时间（5.3±2.0）年。拆除石膏后开始站立时间、开始行走时间差异无统计学意义（P>0.05）。影像方面,与治疗前相比,末次随访时两组患儿T?nnis评级均显著改善（P<0.05）。与拆石膏后相比,末次随访时两组Severin评级和CE角均无明显改变（P>0.05）。随时间推移两组患者AI均显著...     

髋关节脱位合并股骨头骨折的治疗

自1995-2003年收治合并髋关节脱位的股骨头骨折22例，现就治疗的有关问题加以讨论。     

The course and treatment of avascular necrosis of the femoral head in developmental dysplasia of the hip

Proximal femoral growth disturbance, commonly referred to as avascular necrosis (AVN) of the femoral head in the literature, is a potentially devastating complication in the treatment of developmental dysplasia of the hip (DDH). The early onset of debilitating degenerative changes in the hip joint when treatment options are limited remains the biggest fear. Controversy exists regarding the pathophysiology of this disorder, as well as exactly defining and diagnosing this problem. The natural history of AVN in the setting of DDH is very variable. Current practice concentrates primarily on prevention of this disorder, as there are no reliable ways to intervene at an early stage when changes are potentially reversible. Newer techniques using magnetic resonance imaging may have a role in early diagnosis of this condition before irreversible damage has occurred, and allow for interventions that will favorably affect the natural history of AVN. Treatment options for established AVN in DDH concentrate on improving the biomechanics of the proximal femur but unfortunately do not obviate the need for arthrodesis or arthroplasty at a later date.     

Correlation between center-edge angle and acetabulum-head index in developmental dysplasia of the hip with avascular necrosis of the femoral head

In order to clarify the relationship between the center-edge angle and the acetabulum-head index, we reviewed 97 hips in 86 patients suffering from developmental dysplasia of the hip. We measured the center edge angle and the acetabulum-head index, and evaluated avascular necrosis of the femoral head according to Kalamchi classification. The center-edge angle correlated highly with the acetabulum-head index in non-avascular necrosis, and in Kalamchi groups I and II, but not in Kalamchi groups III and IV. Because of difficulties in measurement, it is possible that the center-edge angle does not precisely indicate acetabular coverage of developmental dysplasia of the hip with avascular necrosis.     

Core decompression and conservative treatment for avascular necrosis of the femoral head: a meta-analysis

Core decompression for avascular necrosis (AVN) of the femoral head continues to be a controversial procedure. Meta-analysis techniques were employed to identify 22 studies with a single surgical core decompression technique. A similar procedure identified eight studies that treated patients conservatively. The success rates for core decompression were 84%, 63%, and 29% for Steinberg stages I, II, and III, respectively. Conservatively treated patients with stage 0, I, III, and III AVN demonstrated success rates of 86%, 61%, 59%, and 25%, respectively. Chi-square analysis showed the success rate of core decompression to be statistically higher than conservative treatment for stage I hips only. Large multicenter prospective double-blinded studies with patients randomized to either core decompression or conservative treatment, then stratified by stage, cause, and bilaterality, are needed to determine the best treatment for early-stage AVN.     

Medial percutaneous hemi-epiphysiodesis improves the valgus tilt of the femoral head in developmental dysplasia of the hip (DDH) type-II avascular necrosis: Good outcome in 11 hips

Background and purpose

Avascular necrosis (AVN) is a major cause of disability after treatment of developmental dysplasia of the hip (DDH), leading to femoral head deformity, acetabular dysplasia, and osteoarthritis in adult life. Type-II AVN is characterized by retarded growth in the lateral aspect of the physis or by premature lateral fusion, which produces a valgus deformity of the head on the neck of the femur. We investigated the effect of medial percutaneous hemi-epiphysiodesis as a novel technique in the treatment of late-diagnosed type-II AVN.

Patients and methods

9 patients (11 hips) with a diagnosis of type-II AVN who underwent medial percutaneous hemi-epiphysiodesis after the surgical treatment for DDH were included in the study. 10 patients (12 hips) with the same diagnosis but who did not undergo hemi-epiphysodesis were chosen as a control group. Preoperative and postoperative articulotrochanteric distances, head-shaft angles, CE (center-edge) angles, and physeal inclination angles were measured. The treatment group underwent medial hemi-epiphysodesis at a mean age of 8 years. The mean ages of the treatment group and the control group at final follow-up were 14 and 12 years respectively. The mean duration of follow-up was 5.7 years in the treatment group and 8.3 years in the control group.

Results

Preoperative articulotrochanteric distance, head-shaft angle, and functional outcome at the final follow-up assessment were similar in the 2 groups. However, preoperative and postoperative CE angles and physeal inclination angles differed significantly in the treatment group (p < 0.05). The final epiphyseal valgus angles were better in the treatment group than in the control group (p = 0.05). The treatment group improved after the operation.

Interpretation

Medial percutaneous epiphysiodesis performed through a mini-incision under fluoroscopic control is a worthwhile modality in terms of changing the valgus tilt of the femoral head.Avascular necrosis (AVN) of the proximal femoral epiphysis is an iatrogenic complication of treatment for developmental dysplasia of the hip (DDH) (Danielsson 2000, Dhar 2003, Domalzki and Synder 2004, Roposch et al.2013). A late abnormality that may be the manifestation of the lateral portion of the capital femoral growth plate in type-II AVN alters the morphology of hip joint (Kalamchi and MacEwen 1980). When a progressive valgus deformity occurs in a patient with type-II AVN, problems associated with hip dysplasia may follow (Siffert 1981, Campbell and Tarlos 1990, Kim et al. 2000, Wu et al. 2010, Herring 2014). Due to inadequate coverage, reduced contact area between acetabulum and femoral head leads to early secondary osteoarthritis (Aronson 1986, Inoue et al. 2000, Herring 2014).The treatment decision for type-II AVN is challenging. Procedures such as varus femoral osteotomy and redirectional acetabular osteotomy have been used with a view to preventing future degenerative disease. However, these procedures are technically difficult and may result in serious complications (Siebenrock et al. 2013). On the other hand, as the main pathology is the growth disturbance at the lateral aspect of the femoral head, some form of arrest of the medial portion of the growth plate may be more logical in the treatment of type-II AVN (Herring 2014). We analyzed the radiographic and clinical outcomes of 11 hips in 9 patients with late-diagnosed type-II AVN who underwent percutaneous hemi-epiphysiodesis of the femoral head.     

The incidence of avascular necrosis following a cohort of treated developmental dysplasia of the hip in a single tertiary centre

PurposeAvascular necrosis (AVN) may occur following treatment for developmental dysplasia of the hip (DDH). The primary aim of this study was to identify the incidence of AVN in a cohort of patients treated for DDH. Secondary aims were to classify AVN using available classification systems, analyze the correlation between the systems and investigate their relationship with the age at diagnosis of DDH.MethodsAn 11-year retrospective study was carried out at a single tertiary centre, using data from the clinical portal (patient records database) and IMPAX (system used to store plain radiographic images). Clinical details (patient demographics and outcomes) and plain radiographic images were used to identify cases of DDH and categorize cases of AVN using available classification systems: Tonnis and Kuhlmann, Kalamchi and McEwen, Bucholz and Ogden and Salter. Severin was used to assess final clinical outcome.ResultsIn total, 405 (522 hips) cases of DDH were identified, of which 213 resolved without treatment, 93 were treated conservatively and 99 surgically. Only treated cases were included in the analysis (n = 192). AVN (45/99; 45.5%) was found to occur only postoperatively. A positive correlation was present between age at presentation and severity of AVN as classified according to Salter’s criteria (chi-squared p value < 0.01).ConclusionAVN incidence was 23.4% (45/192) and only occurred in surgically treated patients. Older age at diagnosis was associated with a higher incidence of AVN, as defined according to Salter’s criteria. The classification systems appeared to show no correlation amongst each other (p-value < 0.01).Level of evidence:III - Retrospective cohort study     

Management in avascular necrosis of the femoral head (author's transl)]

For differentiated indication for operative treatment of avascular necrosis of the femoral head following points have to be considered: age, sex and profession of the patient, precedent treatments, state of contralateral and neighbouring joints. -- Methods of operation: Osteotomy for redistribution, filling with spongious bone and muscle-pedicle-bone graft, transplantation of homeoplastic osteochondral cups of the femoral head, Smith-Petersen-Cup arthroplasty- alloarthroplastic replacement of the femoral head, total replacement of the hip joint, resection of the femoral head and angulation-osteotomy of the diaphysis, arthrodesis of the hip joint. These methods are discussed with regard to personal conditions, surgical techniques, postoperative treatment as well as their advantages and disadvantages. There is no causative treatment of avascular necrosis of the femoral head. Therefore it is especially important to use the different methods appropriate to the special situation.     

Intraobserver and interobserver reliability of Kalamchi and Macewen's classification system for evaluation of avascular necrosis of the femoral head in developmental hip dysplasia

This study evaluates the intraobserver and interobserver reliability of the Kalamchi and MacEwen's classification system of avascular necrosis of the femoral head. Radiographs of 48 developmentally dysplastic hips that had an average follow-up of 40.5 months (range: 36 to 52 months) and that had been treated by the same operative technique were interpreted twice by four experienced pediatric orthopaedic surgeons. When the absence or presence of avascular necrosis was taken into consideration the average intraobserver agreement percentage and kappa coefficient were 86% and 0.71, respectively. The average interobserver agreement percentage and kappa coefficient were 83% and 0.66, respectively. When the agreement on the type of avascular necrosis was analyzed, the average intraobserver agreement percentage and kappa coefficient were 85% and 0.74, respectively. The average interobserver agreement percentage and kappa coefficient were 81% and 0.66, respectively. No statistically significant difference was found between the rates of avascular necrosis of four observers. The Kalamchi and MacEwen's classification system was found to be reliable and reproducible.     

大直径陶瓷/陶瓷人工全髋关节置换治疗股骨头缺血坏死

目的评价应用大直径陶瓷/陶瓷股骨头人工全髋关节置换术治疗股骨头缺血坏死的临床疗效。方法回顾性分析本组3年内收治的23例股骨头缺血坏死患者实施单侧大直径陶瓷/陶瓷股骨头人工全髋关节置换术,患者手术时平均年龄53.5岁。平均随访26个月,手术前后评估患者髋关节Harris评分,术后进行X线检查评价假体位置情况及主观满意度调查。手术前后及随访时监测患者肾功能的变化。结果所有患者均获得随访,在随访期内影像学显示假体位置良好,无假体松动,脱位等并发症。Harris评分由术前50.7分改善为术后91.2分,优良率为95.7%,总体满意率为95.7%。手术前后及随访时患者肾功能无明显变化。结论大直径陶瓷/陶瓷股骨头全髋关节置换术治疗股骨头缺血坏死可获得较好的安全性和近、中期疗效。     

The role of arthrography-guided closed reduction in minimizing the incidence of avascular necrosis in developmental dysplasia of the hip

Avascular necrosis of the femoral head is the most serious complication after closed reduction in developmental dysplasia of the hip. Although arthrography has a well-established role in the treatment of developmental dysplasia of the hip, its use is not universal. A prospective study was conducted to compare the incidence of avascular necrosis after closed reduction in developmental dysplasia of the hip performed with and without arthrography in 85 patients, with a minimum of 5 years follow up. Arthrographic criteria were evaluated including lateralization of the femoral head and the type of limbus encountered. Hips treated by closed reduction based on arthrographic evaluation had significantly less incidence of avascular necrosis when compared with those treated by closed reduction without arthrographic guidance. Closed reduction with lateralization of more than 4 mm, and those hips with an inverted limbus were associated with an increased risk of avascular necrosis.     

Operative treatment for type II avascular necrosis in developmental dysplasia of the hip

Lateral growth disturbance of the proximal femur may occur after treatment of developmental dysplasia of the hip, although usually it is not recognized until the child is older. This resultant dysplasia is also known as Kalamchi and MacEwen Type II avascular necrosis. The valgus configuration of the proximal femur and associated acetabular dysplasia may need operative reconstruction. Our purpose in doing this study was to assess the results of reconstruction in these patients. We reviewed 24 patients (30 hips) with Type II avascular necrosis who had acetabular and/or proximal femoral osteotomy after treatment for developmental dysplasia of the hip. The results were assessed according to the timing and type of operation and were graded using the Severin classification (I and II satisfactory and III and IV unsatisfactory). All patients were followed up past skeletal maturity. At a mean followup of 22 years, 15 of 24 patients (17 of 30 hips) had a satisfactory result. The patients with hips that were reconstructed after the diagnosis of Type II avascular necrosis had more satisfactory results than those operated on before the diagnosis of (70% versus 50%) avascular necrosis. Patients with 10 of the 13 hips that had acetabular and femoral reconstruction had a satisfactory result.