Poul J, Pesl M, Pokorná M
Klinika detské chirurgie, ortopedie a traumatologie, Detská nemocnice, FN Brno.
Acta Chir Orthop Traumatol Cech. 2004;71(6):360-5.
The aim of this retrospective study was to compare the efficacy of femoral osteotomy alone with that of osteotomy combined with an acetabular procedure in patients with unstable hips due to spastic cerebral palsy.
Sixty-one hip joints in 50 patients who had shown distinct subluxation or dislocation of the joint were operated on. Eleven patients underwent bilateral surgery. Before bone surgery, soft-tissue release involving both the flexors and adductors was performed on 19 hips. Femoral osteotomy alone was performed on 29 hip joints and combined femoral and pelvic osteotomy was carried out on 32 joints.Twelve resections of the proximal femur in seven patients were evaluated as a separate group. All treated hip joints were assessed by clinical and radiographic examination at a follow-up of more than 5 years.
The skiagraphs taken in a strictly neutral position of the lower limbs before surgery and at the final examination were evaluated on the basis of Reimers's migration index and Wiberg's centre-edge angle. The locomotor abilities of each child were categorized according to the Vojta scoring system for locomotor development. The range of motion in the treated hip joint was assessed using the standard S. F. T. R. method. The results obtained were statistically analyzed by the Kruskal- Wallis, one-way ANOVA test.
A comparison of the results of femoral osteotomy alone with those of combined femoral and pelvic osteotomy showed that the post-operative values of the migration index and centre-edge angle, as compared with the pre-operative ones, were statistically higher (p<0.05) in the latter. In a long-term perspective, the surgery had no adverse effects on a natural development of locomotor abilities of the child. The children had higher scores by the modified Vojta rating system. There was no change in the range of motion in the treated hip joints after the operation.
In 28, out of the 32 joints treated by combined femoral and pelvic osteotomy, Salter osteotomy was performed and it showed a high efficacy in providing hip joint stability. The main emphasis during surgery was placed on the maximum acetabular rotation laterally. Femoral osteotomy alone was less effective in providing hip joint stability; in addition, in order to achieve this, tilting of the proximal fragment to a varus position was generally higher than in combined operations. In three patients this treatment resulted in fixed adduction of the hip joint with negative consequences for movement.
In the treatment of unstable hip joints a combination of varus derotation femoral osteotomy and pelvic osteotomy provides better containment of the joint than femoral osteotomy alone.
本回顾性研究旨在比较单纯股骨截骨术与截骨术联合髋臼手术治疗痉挛性脑瘫所致髋关节不稳定患者的疗效。
对50例关节明显半脱位或脱位患者的61个髋关节进行了手术。11例患者接受了双侧手术。在骨手术前，对19个髋关节进行了涉及屈肌和内收肌的软组织松解。29个髋关节仅进行了股骨截骨术，32个关节进行了股骨和骨盆联合截骨术。7例患者的12例股骨近端切除术作为一个单独的组进行评估。所有接受治疗的髋关节在随访超过5年时均通过临床和影像学检查进行评估。
根据赖默斯移位指数和维伯格中心边缘角，对术前和最终检查时在下肢严格中立位拍摄的X线片进行评估。根据vojta运动发育评分系统对每个儿童的运动能力进行分类。使用标准的S.F.T.R.方法评估治疗后髋关节的活动范围。通过Kruskal-Wallis单因素方差分析对所得结果进行统计学分析。
单纯股骨截骨术与股骨和骨盆联合截骨术的结果比较表明，与术前相比，后者术后的移位指数和中心边缘角值在统计学上更高（p<0.05）。从长期来看，手术对儿童运动能力的自然发展没有不良影响。通过改良的vojta评分系统，儿童得分更高。术后治疗的髋关节活动范围没有变化。
在32例接受股骨和骨盆联合截骨术治疗的关节中，有28例进行了Salter截骨术，其在提供髋关节稳定性方面显示出很高的疗效。手术的主要重点是髋臼最大程度地向外旋转。单纯股骨截骨术在提供髋关节稳定性方面效果较差；此外，为了达到这一目的，近端骨折块向内翻位置的倾斜通常比联合手术更高。在3例患者中，这种治疗导致髋关节固定内收，对运动产生负面影响。
在治疗不稳定髋关节时，内翻旋转股骨截骨术和骨盆截骨术联合应用比单纯股骨截骨术能更好地包容关节。
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