发育性髋脱位术后再脱位原因探讨

目的 探讨发育性髋脱位(DDH)手术治疗后再脱位原因和预防措施,提高DDH手术治疗效果.方法 对我院2007年3月至2016年1月收治的41例经过手术治疗后发生再脱位DDH患儿的术式、X线片资料和翻修手术中的发现进行回顾性总结,X线片资料用统计学进行分析.结果 发生再脱位的术式:Salter骨盆截骨术12例,Pemberton骨盆截骨术26例,骨盆联合截骨术3例,股骨粗隆下旋转截骨31例.术后应用下肢关节康复器(CPM)行功能训练开始时间:术后两周6例(2～2.5岁)、术后3～4周11例(大于3岁).翻修手术前髋臼指数25°～27°15例、28°～32°26例,股骨颈前倾角55°～75°41例,颈干角大于150°16例,髋臼缺损11例.翻修手术中发现髋臼前缘缺损6例,后缘缺损6例,髋臼浅短21例,髋臼后外缘缺损8例.股骨头嵌于外侧5例,髂胫束紧张35例,髂腰肌腱紧张25例,髋关节囊在假臼后上部19例,关节囊后缘向内腔突出15例,髋臼横韧带紧张15例,髋臼内有瘢痕组织充填41例.翻修手术行髂胫束松解35例,髂腰肌腱松解25例,髋臼横韧带切断15例,髋臼内瘢痕组织刮除41例,髋关节囊假臼部剥离19例.骨盆联合截骨术35例,Pem-berton骨盆截骨术6例.髋臼后缘植骨6例,髋臼后外缘植骨8例,股骨粗隆下旋转截骨纠正前倾角41例.翻修手术后髋臼指数小于20°～25°37例、26°～28°4例,股骨颈前倾角15°～25°38例、30°～35°3例.经6个月至7年的随访,发生再脱位后缘缺损1例,股骨颈前倾角35°1例),髋关节功能活动小于90°4例,股骨头缺血性坏死表现9例,双下肢不等长4例(后期行患肢胫骨延长2例,股骨延长2例).结论 DDH手术治疗后再脱位可能原因:①髋臼缘缺损和股骨颈前倾角和颈干角过大使髋关节不稳定,病理性组织阻碍复位;②术后髋关节固定不当及过早活动髋关节.再脱位预防措施:①根据患儿年龄、术前影像学资料和术中复测情况选择合适的术式和注重手术细节,修补髋臼缘缺陷和纠正股骨颈前倾角和颈干角,充分处理关节囊及周围组织的继发病变;②骨盆联合截骨髋臼旋转和植骨修补髋臼缘缺损增加对股骨头的复盖,以及术后正确和适当固定时间.

Causes of re-dislocation after open reduction for developmental dislocation of the hip

Objective To explore the causes and risk factors for re-dislocation after open reduction for developmental dislocation of the hip (DDH).Methods A retrospective study was conducted for 41 patients with re-dislocation after successful open reduction for DDH between March 2007 and February 2016.The associated factors,such as original method of open reduction,radiography (femoral neck anteversion angle,acetabular index &-acetabular defects) and perioperative findings,were analyzed to examine the predictors of reoperation.The mean follow-up period was 4.5 (2-9.5) years.Results All patients underwent reopen reduction.The original methods of open reduction for DDH were Slater's innominate osteotomy (n =12),Pemberton innominate osteotomy (n =26),triple pelvic osteotomy (n =3) and subtrochanteric rotary osteotomy (n =31).Continuous passive motion (CPM) as functional trainings of knees and hips was applied postoperatively for 2 weeks (n =6) and 3-4 weeks (n =11).Preoperative data:acetabular index was 25-27 degrees (n =15) and 28-32 degrees (n =26),femoral neck anteversion 55-75 degrees and femoral neck-shaft angle ＞ 150 degrees (n =16).The locations of acetabular defects were at anterior (n =6),posterior (n =6) and lateral (n =8) edges of posterior acetabulum.The methods of reopen reduction were triple pelvic osteotomy (n =35) and pemberton irnominate osteotomy (n =6).Bone grafting was performed for significant acetabular deficiency in posterior acetabular wall (n =6) and lateral posterior edge (n =8).Subtrochanteric rotary osteotomy was performed in corrective femoral neck anteversion angle (n =41) and femoral neck-shaft angle (n =21).There were re-dislocation (n =2),posterior acetabular deficiency (n =1),femoral neck anteversion angle of 35 degrees (n =1),range of motion (ROM) of hip joint function ＜90 degree (n =4),avascular necrosis (AVN) of the femoral head (n =9) and leg length discrepancy (n =4).Conclusions After open operative surgery of DDH,the causes or risk factors of re-dislocation may be correlated with incorrect selection of innominate osteotomy,non-repair of acetabular defects,improper femoral neck anteversion angle,hip joint capsule and soft tissue blocking femoral head reduction,postoperative motion earlier than sutured capsule healing completely and postoperative incorrect external fixation.Better outcomes are achieved by minimizing the above factors.