先天性髋脱位4种手术疗效的比较

目的　探讨 4种术式治疗先天性髋关节脱位 (CDH)疗效。方法　随访采用翻转造盖术2 4例 (30髋 )、插入造盖术 2 3例 (30髋 )、Salter截骨术 2 5例 (30髋 )和Chiari骨盆内移截骨术 2 4例 (2 7髋 )治疗CDH患者 96例 117髋。结果　平均随访时间 5年 10个月 ,疗效从临床功能和X线形态两方面评估 ,术后髋臼指数 (AI)的改善分别是 (2 0 2± 7 2 7)°、(2 1 9± 6 33)°、(15 0± 4 5 6 )°、(11 4±5 1)°,术后臼头指数 (AHI)分别是 (0 92± 0 2 4 )°、(1 0 0± 0 18)°、(0 80± 0 19)°、(0 82± 0 14 )° ;四种术式临床优良率分别是 90 %、86 7%、73 4 %和 6 6 6 % ,共发生再脱位 3例 ,关节僵硬 10例 ,股骨头坏死 7例。结论　临床疗效及对髋臼形态改善翻转、插入造盖术优于Salter截骨术和Chiari骨盆内移截骨术 ;翻转造盖术、插入造盖术安全有效是先天性髋关节脱位的首选术式。     

The Chiari pelvic osteotomy. A long-term review of clinical and radiographic results

We have reviewed a series of 94 Chiari pelvic osteotomies carried out from 1966 to 1982. In 83 hips the indication for surgery had been pain, and of these patients 73 (88%) had appreciable relief within one year of operation. The other 11 hips were all in children and were painless; in them the osteotomy had successfully stabilised progressive subluxation of the hip. At review after a mean follow-up of 10 years (range, 2 to 18 years) 68 previously painful hips were reassessed. Although function of the hips had deteriorated slowly with time, four of the seven cases with 18 years' follow-up had good function and only minor symptoms. A detailed analysis of the radiographic changes produced by the Chiari osteotomy was made, using computerised analysis of variance. The beneficial effects of the osteotomy resulted from complex changes, among which the provision of a stable fulcrum for the hip seemed to be the most important.     

Does Chiari osteotomy compromise subsequent total hip arthroplasty?

We compared 28 total hip arthroplasties done in dysplastic hips after previous Chiari osteotomy (group I) with a well-matched control group of 50 primary procedures (group II) done during the same period at an average follow-up of 5 years (range, 25-199 months). Group I required significantly less acetabular augmentation, had significantly shorter operative times, had less intraoperative blood loss, and had fewer complications than group II. There was no significant difference between the 2 groups in terms of clinical or radiographic outcome. Total hip arthroplasty after a successful Chiari osteotomy leads to medium-term results similar to those of other dysplastic hips. In our experience, less bone grafting was required, better coverage of the cup by host-bone was obtained, and the center of motion of the hip was more anatomic. Chiari osteotomy may delay the need for total hip arthroplasty, may facilitate acetabular reconstruction, and does not seem to compromise the medium-term clinical or radiographic outcome.     

Chiari pelvic osteotomy for advanced osteoarthritis in patients with hip dysplasia

BACKGROUND: It is not clear whether a Chiari pelvic osteotomy performed for the treatment of advanced osteoarthritis can delay the need for total hip arthroplasty. We present the mid-term results of the Chiari pelvic osteotomy performed for the treatment of T?nnis grade-3 osteoarthritis (large cysts, severe narrowing of the joint space, or severe deformity or necrosis of the head with extensive osteophyte formation), with a particular focus on whether this procedure can delay the need for total hip arthroplasty. METHODS: We followed thirty-two hips in thirty-one patients with T?nnis grade-3 osteoarthritis who had refused total hip arthroplasty and had been treated with a Chiari pelvic osteotomy. The mean age at the time of surgery was 35.2 years. The mean duration of follow-up was 11.2 years, at which time clinical evaluation with the Harris hip score and radiographic evaluation were performed. RESULTS: The average Harris hip score improved from 52 points preoperatively to 77 points at the time of follow-up; the average pain score improved from 20 to 31 points. Three hips with a hip score of <70 points required total hip arthroplasty. With a hip score of <70 points as the end point, the cumulative rate of survival at ten years was 72%. The clinical outcome was significantly influenced by the preoperative center-edge angle (p = 0.004), the preoperative acetabular head index (p = 0.039), achievement of the appropriate osteotomy level (p = 0.011), and superior migration (p = 0.009) and lateral migration (p = 0.026) of the femoral head. CONCLUSIONS: Although the clinical results were inferior to those of total hip arthroplasty, Chiari pelvic osteotomy may be an option for young patients with advanced osteoarthritis who prefer a joint-conserving procedure to total hip arthroplasty and accept a clinical outcome that is predicted to be less optimal than that of total hip arthroplasty. Moderate dysplasia and moderate subluxation without complete obliteration of the joint space and a preoperative center-edge angle of at least -10 degrees are desirable selection criteria.     

综合保髋手术治疗髋关节发育不良晚期病变远期疗效评价

目的:探讨Chiari截骨、血管束植入为基础的综合手术治疗髋关节发育不良晚期病变的远期疗效。方法:42例（61髋）髋关节发育不良晚期病变患者接受以Chiari截骨、血管束植入为基础术式的综合手术治疗。本组年龄27⁴2岁,平均36.1岁。61髋中行单纯Chiari骨盆截骨、股骨头内血管束植入术39髋,配合髋臼加盖术16髋,配合股骨近端旋转截骨术2髋,配合髋臼加盖术及股骨近端旋转截骨术4髋。结果:本组平均随访时间8.4年,最后随访时,5例5髋已行人工髋关节置换,其他37例56髋Harris评分术前平均58分,术后平均83分,疗效优良43髋（76.8%）。CE角:术前平均8.7°,术后平均28.5°。股骨头覆盖指数:术前平均61.4%,术后平均83.2%。结论:该综合手术方法对髋关节发育不良晚期病变可以显著缓解临床症状,改善髋关节功能,提高患者生活质量,大大延缓人工全髋关节置换术的时间。     

综合保髋手术治疗髋关节发育不良晚期病变远期疗效评价

目的:探讨Chiari截骨、血管束植入为基础的综合手术治疗髋关节发育不良晚期病变的远期疗效。方法:42例(61髋)髋关节发育不良晚期病变患者接受以Chiari截骨、血管束植入为基础术式的综合手术治疗。本组年龄27~42岁,平均36.1岁。61髋中行单纯Chiari骨盆截骨、股骨头内血管束植入术39髋,配合髋臼加盖术16髋,配合股骨近端旋转截骨术2髋,配合髋臼加盖术及股骨近端旋转截骨术4髋。结果:本组平均随访时间8.4年,最后随访时,5例5髋已行人工髋关节置换,其他37例56髋Harris评分术前平均58分,术后平均83分,疗效优良43髋(76.8%)。CE角:术前平均8.7°,术后平均28.5°。股骨头覆盖指数:术前平均61.4%,术后平均83.2%。结论:该综合手术方法对髋关节发育不良晚期病变可以显著缓解临床症状,改善髋关节功能,提高患者生活质量,大大延缓人工全髋关节置换术的时间。     

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.     

Joint-preserving operation for osteoarthrosis of the hip in adult cerebral palsy

BACKGROUND: A joint-preserving operation was performed on 15 hips with osteoarthrosis, involving 12 patients who had adult cerebral palsy. METHODS: Eleven hips underwent Chiari pelvic osteotomy only; three hips underwent Chiari pelvic osteotomy with femoral osteotomy and the other one hip underwent femoral varus osteotomy only. The mean follow-up period after surgery was 6 years and 2 months (with follow-up range of 2 years and 3 months to 10 years and 6 months). RESULTS: Good results were achieved in 13 of the 15 hips (86.6%). Two patients with athetotic tetraplegia treated with Chiari pelvic osteotomy had pelvic obliquity. Progressive osteoarthrotic change continued in bilateral hips in one case treated with Chiari pelvic osteotomy. CONCLUSION: We confirm that usual treatment for osteoarthrosis of the hip was also applicable for osteoarthrosis of the hip in cases of adult cerebral palsy, provided sufficient attention is given to the complications accompanying spastic paralysis.     

JOINT‐PRESERVING OPERATION FOR OSTEOARTHROSIS OF THE HIP IN ADULT CEREBRAL PALSY

Background : A joint‐preserving operation was performed on 15 hips with osteoarthrosis, involving 12 patients who had adult cerebral palsy. Methods : Eleven hips underwent Chiari pelvic osteotomy only; three hips underwent Chiari pelvic osteotomy with femoral osteotomy and the other one hip underwent femoral varus osteotomy only. The mean follow‐up period after surgery was 6 years and 2 months (with follow‐up range of 2 years and 3 months to 10 years and 6 months). Results : Good results were achieved in 13 of the 15 hips (86.6%). Two patients with athetotic tetraplegia treated with Chiari pelvic osteotomy had pelvic obliquity. Progressive osteoarthrotic change continued in bilateral hips in one case treated with Chiari pelvic osteotomy. Conclusion : We confirm that usual treatment for osteoarthrosis of the hip was also applicable for osteoarthrosis of the hip in cases of adult cerebral palsy, provided sufficient attention is given to the complications accompanying spastic paralysis.     

Dome (modified Chiari) pelvic osteotomy: 10- to 18-year followup study

Ninety-six dome (modified Chiari) pelvic osteotomies in 87 patients with pain and disability because of osteoarthrosis secondary to hip dysplasia were reviewed. The mean age of the patients at the time of surgery was 29 years (range, 16-55 years). The mean followup was 13 years (range, 10-18 years). Forty-one hips were classified into a hip dysplasia stage, 32 hips into an early stage of osteoarthrosis, and 23 hips into an advanced stage of osteoarthrosis according to the radiographic grading of the Japanese Orthopaedic Association. The average preoperative Merle d'Aubigné and Postel hip score was 13.8, and the average score at final followup was 16.6. Excellent or good results with a score greater than 14 were achieved in 96% of the hips at final followup. Radiographically, signs of progression of osteoarthrosis were not seen in 87% of the hips. Osteoarthrosis progressed during the postoperative course in 13% of the hips. Four patients (four hips) eventually had a total hip arthroplasty at 13.8 years (range, 12.5-15.3 years) after surgery. The survival rate of dome pelvic osteotomy, using clinical failure as an end point, was 82% at 15 years. Using radiologic failure as an end point, 61 hips in 54 patients (survival rate, 78%) survived at 15 years. Using hip replacement as an end point, 92 hips in 83 patients (survival rate, 82%) survived at 15 years. Dome pelvic osteotomy is an excellent and effective operation for pain relief and functional maintenance of the hip.     

Combined intertrochanteric and Chiari pelvic osteotomies for hip dysplasia

Thirty-two dysplastic hips with secondary osteoarthritis, in 28 patients aged 18 to 42 years, were treated by combined intertrochanteric and Chiari osteotomy. They were followed up for 2.5 to 10 years. Pain was the main presenting symptom in all the patients. The indication for surgery was based on the severity of disease with respect to congruency, secondary degenerative change and degree of dysplasia. The average pre-operative Harris hip score was 47.7 and the majority had severe dysplasia with degenerative changes. On final review the average score was 88. The radiographic appearances of degenerative arthritis regressed in 72% of hips and dysplasia was improved in all cases. The results of this conservative form of surgery are better in hips with less severe dysplasia and mild secondary degenerative change.     

Chiari osteotomy and shelf augmentation in the treatment of hip dysplasia

The clinical and radiographic results of Chiari osteotomy and shelf augmentation for acetabular dysplasia in 30 hips were reported. The average age at operation was 17 years for Chiari osteotomy and 13.8 years for shelf augmentation. The mean follow-up was 7.1 years for Chiari osteotomy and 4.1 years for shelf augmentation. Of the 14 Chiari osteotomies, 12 had good results by Tonnis clinical grading and 2 had poor results. There were significant improvements in the radiographic parameters measured (p < 0.01). They included center-edge angle of Wiberg, the acetabular angle of Sharp, the percentage of femoral head coverage, and the "c/b" ratio. For the 16 shelf augmentations, there were 8 good, 2 fair, and 6 poor results. The radiographic parameters measured were also all significantly improved (p < 0.01). The final Severin grading of the hips were improved by both Chiari osteotomy and shelf augmentation.     

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.     

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.     

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.     

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.     

Behavior of the proximal femur during the treatment of congenital dysplasia of the hip: a clinical long-term study

The influence of the acetabular cover on the development of the proximal femur during the treatment of congenital dysplasia of the hip was studied in 47 children (58 hips) with a follow-up of 22 years. Varus osteotomy failed to correct hip dysplasia in 33 hips of 27 children. Chiari osteotomy was followed by a positive anti-Chiari effect (oval shaped acetabulum with proximal migration of the femoral head) in 15 children (20 hips). In five children (five hips) with coxa vara due to avascular necrosis, the anti-Chiari effect was negative. The combination of Chiari and varus osteotomy before the age of 8 years was followed by a positive anti-Chiari effect and recurrence of valgus deformity in seven of eight hips. The long-term failure of the varus and Chiari osteotomy, together with a review of clinical and experimental surveys, led us to prefer the acetabular redirectional osteotomy.     

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.     

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 Tönnis 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° to 37°, and the mean VCA from 22° to 38°. 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 Tönnis 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.

?     

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.