Bolland Benjamin J, Wahed Abdul, Al-Hallao Sariyah, Culliford David J, Clarke Nicholas M P
University Orthopaedics, Southampton General Hospital, Southampton, UK.
J Pediatr Orthop. 2010 Oct-Nov;30(7):676-82. doi: 10.1097/BPO.0b013e3181efb8c7.
Despite early recognition and appropriate treatment of congenital dislocation of the hip, there are a number of cases that subsequently require further surgery to prevent progressive dysplasia, instability, and eventual early osteoarthritis. This study aimed (1) to determine the incidence of pelvic osteotomy (PO) after late open (OR) or closed (CR) reduction for failed initial conservative treatment or late presentation; (2) study potential radiologic predictors of those that will require a secondary procedure; (3) and to evaluate the effect of potential confounding variables including age of reduction, Pavlik harness treatment, and surgical experience on PO rate.
All cases of congenital dislocation of the hip that presented late or had failed conservative treatment with subsequent late OR versus CR, that were carried out during 1988 to 2003, by the lead surgeon were included. Dislocations secondary to neuromuscular causes or teratologic causes were excluded. Intraoperative arthrograms confirmed the concentric or eccentric reduction and determined subsequent intervention. The AP pelvis plain radiograph was used to measure the height of dislocation, as described by Tonnis, and monitor Acetabular index, and ossific nucleus width and height postreduction.
After 134 OR's, 24 hips (19%, 95% CI: 16-23%) later required a pelvic osteotomy compared with 59 out of 104 hips (58%, 95% CI: 49-68%) in the CR cohort. There was no statistical difference in avascular necrosis rates between late OR (10.9%, 95% CI: 4.8-17%) and CR (11.4%, 95% CI: 5.8-17%). Acetabular index was a reliable predictor for the need of subsequent PO becoming significantly different in those that did (PO group) and did not (non-PO group) require further surgery approximately 1.5 years postreduction. There was no difference in the ON development after reduction in both PO and non-PO groups. The PO requirement was not affected by earlier failed Pavlik harness treatment but did change with ongoing surgical experience. Late OR produced the lowest secondary procedure rate without an increase in the incidence of avascular necrosis. There is a learning curve to this procedure that will affect these outcomes.
Level III (Case-control study).
尽管对先天性髋关节脱位能做到早期诊断并给予恰当治疗，但仍有许多病例随后需要进一步手术，以防止发育异常、关节不稳定以及最终早期骨关节炎的发生。本研究旨在：（1）确定初次保守治疗失败或就诊较晚后行晚期切开复位（OR）或闭合复位（CR）后骨盆截骨术（PO）的发生率；（2）研究那些需要二次手术的潜在影像学预测指标；（3）评估包括复位年龄、使用 Pavlik 吊带治疗以及手术经验等潜在混杂变量对 PO 发生率的影响。
纳入 1988 年至 2003 年间由主刀医生进行的所有先天性髋关节脱位就诊较晚或保守治疗失败后行晚期 OR 或 CR 的病例。排除神经肌肉性病因或畸形病因导致的脱位。术中关节造影确认复位是否同心或偏心，并确定后续干预措施。采用前后位骨盆 X 线平片测量如 Tonnis 所述的脱位高度，并监测复位后的髋臼指数、骨化核宽度和高度。
134 例行 OR 治疗后，24 髋（19%，95%可信区间：16 - 23%）随后需要骨盆截骨术，而 CR 组 104 髋中有 59 髋（58%，95%可信区间：49 - 68%）需要。晚期 OR 组（10.9%，95%可信区间：4.8 - 17%）和 CR 组（11.4%，95%可信区间：5.8 - 17%）的无血管性坏死率无统计学差异。髋臼指数是预测后续是否需要 PO 的可靠指标，在复位后约 1.5 年时，需要进一步手术（PO 组）和不需要进一步手术（非 PO 组）的患者之间差异显著。PO 组和非 PO 组复位后无血管性坏死的发生情况无差异。是否需要 PO 不受早期 Pavlik 吊带治疗失败的影响，但会随手术经验的增加而改变。晚期 OR 的二次手术率最低，且无血管性坏死发生率未增加。该手术存在学习曲线，会影响这些结果。
III 级（病例对照研究）。
