大龄儿童发育性髋关节脱位的手术治疗

目的 探讨大龄儿童发育性髋关节脱位的手术治疗方法.方法 手术治疗6岁及以上大龄儿童发育性髋关节脱位39例(48髋),平均手术年龄8.5岁,有8例(11髋)为手术后再脱位的患儿.手术方式有Salter骨盆截骨术4例(6髋),Pemberton髋周截骨术19例(22髋),Dega截骨术12例(16髋);Westin截骨术4例(4髋).其中髋臼软骨有明显缺损,软骨下松质骨部分裸露23例(28髋),取自体股骨近端游离骨膜移植修复.全部病例均行股骨粗隆下去旋转短缩截骨,短缩2～4.5 cm(平均2.8 cm);去旋转25°～45°(平均32°),保留股骨颈前倾角10°～15°,股骨截骨处以鹅头钉或四孔钢板固定.结果 术后获得随访36例(45髋).随访时间5～10年(平均7.2年).随访结果按Mckay临床疗效标准,优17髋(37.8%)、良18髋(40.0%)、可6髋(13.3%)、差4髋(8.9%),优良率达77.8%;按Severin X线评定标准,优19髋(42.2%)、良17髋(37.8%)、可7髋(15.6%)、差2髋(4.4%),优良率达80.0%.术后髋臼指数平均降至18°;CE角平均30°;髋臼覆盖率达平均95%.术后半脱位2例(4.4%),股骨头缺血坏死4例(8.9%),髋关节功能障碍(屈曲＜60°)6例(13.3%).结论 大龄儿童DDH病理改变复杂,术前应根据X线片、CT等检查予以全面评估,制定个性化手术方案;术中松解内收肌和髂腰肌,联合股骨短缩去旋转截骨术,力争达到头臼中心性复位,并在此基础上重建髋臼;对关节软骨面缺损明显者,可移植自体游离骨膜予以修复;术后早期不负重功能锻炼、持续被动活动等,可以显著降低术后再脱位、关节僵硬、股骨头坏死等并发症,获得较满意的疗效.

Surgical treatment for developmental dysplasia of hip in older children

Objective To investigate the surgical treatment for developmental dysplasia of hip (DDH)in older children.Methods Thirty-nine patients(48 hips)with the mean age of 8.5 years ranging from 6 to 12 years underwent different surgical methods.of whom 8 patients(11 hips)got postoperative redislocation.Of all the cases,4 patients(6 hips)underwent Salter osteotomy,19(22 hips)underwent Pemberton aeetabuloplasty,12(16 hips)were underwent Dega osteotomy and 4(4 hips)underwent Westin osteotomy.Twenty-three patients(28 hips)whose cartilago acetabularis got obvious defect and subcartilage spongy bone was partly exposed accepted the repair by free periosteum transplantation from autogenous femur proximate end.All the patients underwent subtrochanter transverse femoral shortening and derotation osteotomy.Fixation of the femur with plates and screws was performed after the abovementioned two procedures.The average length shortening was 2.8 em(ranging from 2cm to 4.5cm).The average derotation degree was 32°(ranging from 25°to 45°)and anteversion of femoral neck was kept in the angle of 10°～15°.Results Thirty-six patients(45 hips)were followed up for 7.2 years(ranging from 5 to 10 years)after surgery.According to the McKay criteria,17 patients got excellent ranking(37.8%),18 good(40%),6 fair(13.3%)and 4 poor(8.9%),with the fineness ratio at 77.8%.And according to the Severin X-ray criteria,19 patients got excellent ranking (42.2%),17 good(37.8%),7 fair(15.6%)and 2 poor(4.4%),with the fineness ratio at 80.0%.After the surgery,the average acetabular index was 18°and average CE angle was 30.;the mean fraction of coverage of acetabulum was 95%.But 2 cases got postoperative semiluxation(4.4%).Four cases got femoral head ischemia necrosis(8.9%)and 6 cases had hip joint dysfunction(13.3%).Conclusions DDH of older children has more complicated pathological changes.Overall clinical evaluations according to the results of X-ray and CT scanning before operations are necessary.In those cases with obviOUS cartilago acetabularis defect can be repaired by free autogeneic periosteum transplantation.Functional exercise without weight loading and continuous passive movement(CPM)at the earlier period after operation can significantly decrease the incidence rate of complications,such as redislocation,anchylosis and femoral head ischemia necrosis.