Schörle C M, Manolikakis G
Orthopädische Klinik Wichernhaus im Krankenhaus Rummelsberg, Abteilung für infantile Zerebralparese, Rummelsberg 71, 90592 Schwarzenbruck, Germany.
Orthopade. 2004 Oct;33(10):1129-37. doi: 10.1007/s00132-004-0686-4.
The surgical treatment of secondary dislocation of the hip is one of the most challenging issues in cerebral palsy. The selection and application of adequate surgical techniques require an outstanding knowledge of pathophysiology in order to achieve a good outcome with minimal operative expenditure. The hips of cerebral palsied children show no pathological findings at birth. The dislocation of the hip is a secondary process, due to the influence of permanently deteriorating muscle dysbalances that first cause a decentration and finally result in a complete dislocation. Physiotherapeutic treatment supports the development of gait, muscle balance and weight bearing in the early childhood, however, severe hip dislocation can not be prevented with physiotherapy alone. Surgical treatment aims to prevent hip dislocation in order to maintain the ability to walk and to sit, and to avoid secondary skin ulcers. Soft tissue release is performed to neutralize muscle dysbalances. Progressive dislocation requires extended surgical treatment. The combination of soft tissue release, varisation osteotomy and acetabular osteotomy enable an adequate repositioning of the hip and have proved to preserve hips from reluxation. Palliative operations including soft tissue release in combination with angulation osteotomy, and proximal femoral head resection are restricted to failed reconstruction operations or severe luxations, and are performed to attempt pain reduction or the facilitation of perineal care. Surgical planning distinguishes patients able to walk from those who are unable to walk or to sit without support. The manifestation of cerebral palsy and the aim of adequate pain reduction and the maintenance of statomotoric abilities also have a great impact on surgical planning. The treatment of secondary hip dislocation in cerebral palsy is facilitated by the use of a graduated treatment concept with early preventive soft tissue release, extended reconstruction and optional palliative care.
髋关节继发性脱位的外科治疗是脑瘫治疗中最具挑战性的问题之一。选择和应用合适的外科技术需要对病理生理学有深入的了解,以便以最小的手术代价获得良好的治疗效果。脑瘫患儿出生时髋关节无病理表现。髋关节脱位是一个继发过程,是由于持续恶化的肌肉失衡的影响,首先导致半脱位,最终导致完全脱位。物理治疗有助于幼儿期步态、肌肉平衡和负重能力的发展,然而,仅靠物理治疗无法预防严重的髋关节脱位。外科治疗旨在预防髋关节脱位,以维持行走和坐立能力,并避免继发性皮肤溃疡。进行软组织松解以中和肌肉失衡。进行性脱位需要更广泛的手术治疗。软组织松解、内翻截骨术和髋臼截骨术相结合能够使髋关节充分复位,并已证明可防止髋关节复发。姑息性手术,包括软组织松解联合成角截骨术和股骨近端切除,仅限于重建手术失败或严重脱位的情况,旨在减轻疼痛或便于会阴护理。手术规划将能够行走的患者与需要支撑才能行走或坐立的患者区分开来。脑瘫的表现以及充分减轻疼痛和维持运动能力的目标也对手术规划有很大影响。采用分级治疗理念,早期进行预防性软组织松解、广泛重建和选择性姑息治疗,有助于脑瘫继发性髋关节脱位的治疗。