Gose Shinichi, Sakai Takashi, Shibata Toru, Murase Tsuyoshi, Yoshikawa Hideki, Sugamoto Kazuomi
Department of Orthopaedic Surgery, Morinomiya Hospital, Osaka, Japan.
J Pediatr Orthop. 2010 Sep;30(6):568-74. doi: 10.1097/BPO.0b013e3181e4f38d.
The cause of hip disorder in cerebral palsy (CP) has been thought to involve muscle imbalance, flexion, and adduction contracture of the hip joint, acetabular dysplasia, and femoral growth abnormalities. The aim of this study was to quantitatively evaluate the 3-dimensional femoral geometry and subluxation/dislocation of the hip in spastic CP using 3D-CT reconstructed images of the pelvis and the femur, focusing on the femoral growth abnormalities in CP.
Between June 2006 and September 2009, 186 hips in 93 bilateral spastic CP patients, including spastic diplegia (SD) in 73 patients and spastic quadriplegia (SQ) in 20 patients, who had not received any surgical treatment, were investigated using 3D-CT at our hospital. There were 59 boys and 34 girls with an average age of 5.3 years (range: 2.6 to 6.8 y). As an index for the femoral geometry, the neck-shaft angle, the femoral anteversion, and the femoral offset were 3-dimensionally measured. The center of the acetabulum and the femoral head were determined to calculate the CT migration percentage as the distance between these centers divided by the femoral head diameter. To elucidate the factors related to hip subluxation/dislocation, the relationships between the neck-shaft angle, the femoral anteversion, the femoral offset, and the CT migration percentage were investigated.
The mean neck-shaft angle was 150.4+/-9.4 degrees (range: 129.4 to 173.2 degrees). The mean femoral anteversion was 44.4+/-13.6 degrees (range: 5.8 to 84.0 degrees). The mean CT migration percentage was 22.4+/-22.7% (range: 3 to 129%). There was positive correlation between the CT migration percentage and the neck-shaft angle (r=0.49). Hips with large CT migration percentage tended to show coxa valga. There was an inverse correlation between the neck-shaft angle and the femoral offset (r=-0.90), but no correlation between the CT migration percentage and the femoral anteversion (r=0.26), between the femoral offset and the femoral anteversion (r=-0.25), or between the neck-shaft angle and the femoral anteversion (r=0.23). The neck-shaft angle, the femoral anteversion, and the CT migration percentage were significantly larger, and the femoral offset was significantly smaller, in patients with the Gross Motor Functional Classification System (GMFCS) level IV/V (nonwalking children) and SQ type, than in patients with GMFCS level II/III (mostly walking children) and SD type.
The 3-dimensional femoral geometry in CP patients can be analyzed quantitatively using 3D-CT regardless of the abnormal spastic posture. Our data indicate that 3-dimensional evaluation is accurate and useful for analysis of the femur and acetabulum in CP, and that the extent of coxa valga and femoral anteversion is more severe in the patients with GMFCS level IV/V and SQ type.
Level IV.
一直以来，人们认为脑瘫（CP）患者髋关节疾病的病因包括肌肉失衡、髋关节的屈曲和内收挛缩、髋臼发育不良以及股骨生长异常。本研究的目的是使用骨盆和股骨的三维CT重建图像，定量评估痉挛型脑瘫患者的三维股骨几何形状及髋关节半脱位/脱位情况，重点关注脑瘫患者的股骨生长异常。
2006年6月至2009年9月期间，我院对93例双侧痉挛型脑瘫患者（其中73例为痉挛性双瘫，20例为痉挛性四肢瘫）的186个髋关节进行了研究，这些患者均未接受过任何手术治疗。患者中，男孩59例，女孩34例，平均年龄5.3岁（范围：2.6至6.8岁）。作为股骨几何形状的指标，对颈干角、股骨前倾和股骨偏移进行三维测量。确定髋臼中心和股骨头中心，计算CT移位百分比，即两中心之间的距离除以股骨头直径。为阐明与髋关节半脱位/脱位相关的因素，研究了颈干角、股骨前倾、股骨偏移与CT移位百分比之间的关系。
平均颈干角为150.4±9.4度（范围：129.4至173.2度）。平均股骨前倾为44.4±13.6度（范围：5.8至84.0度）。平均CT移位百分比为22.4±22.7%（范围：3至129%）。CT移位百分比与颈干角呈正相关（r = 0.49）。CT移位百分比大的髋关节往往表现为髋外翻。颈干角与股骨偏移呈负相关（r = -0.90），但CT移位百分比与股骨前倾（r = 0.26）、股骨偏移与股骨前倾（r = -0.25）、颈干角与股骨前倾（r = 0.23）之间均无相关性。与粗大运动功能分级系统（GMFCS）II/III级（大多能行走的儿童）和痉挛性双瘫型患者相比，GMFCS IV/V级（不能行走的儿童）和痉挛性四肢瘫型患者的颈干角、股骨前倾和CT移位百分比显著更大，而股骨偏移显著更小。
无论痉挛姿势是否异常，均可使用三维CT对脑瘫患者的三维股骨几何形状进行定量分析。我们的数据表明，三维评估对于分析脑瘫患者的股骨和髋臼准确且有用，并且GMFCS IV/V级和痉挛性四肢瘫型患者的髋外翻和股骨前倾程度更严重。
IV级。
