Huh Kenneth, Rethlefsen Susan A, Wren Tishya A L, Kay Robert M
Starship Children's Hospital, Grafton, Auckland, New Zealand.
J Pediatr Orthop. 2011 Dec;31(8):858-63. doi: 10.1097/BPO.0b013e31822e0261.
Controversy exists regarding surgical treatment of hip subluxation/dislocation in children with cerebral palsy (CP). The purpose of this study was to compare isolated varus derotational osteotomy (VDRO) and VDRO combined with open hip reduction and/or pelvic osteotomy in children with CP and hip subluxation/dislocation.
Retrospective review was performed of 75 patients with CP (116 hips) and hip subluxation/dislocation treated surgically, with a minimum of 2 years follow-up. Ninety-two hips had undergone VDRO alone, and 24 had undergone VDRO and open reduction and/or pelvic osteotomy (with the decision to proceed with open hip reduction and/or pelvic osteotomy made intraoperatively based on fluoroscopy and arthrogram). Clinical variables, functional level, radiographic variables, and complications/revisions were compared between groups.
Patients requiring combined surgery (VDRO+) had higher baseline migration percentages (MP) (84% ± 18 VDRO+, 51% ± 21 VDRO), higher acetabular indices (34 ± 10 VDRO+, 28 ± 7 VDRO), more negative center-edge angles (-36 ± 28 VDRO+, -0.3 ± 18 VDRO), and higher neck-shaft angles (162 ± 12 VDRO+, 157 ± 10 VDRO) (all P < 0.02). Postoperative radiographic variables were similar between groups. The percentage of patients with MP >30% at final follow-up was similar between groups (38% VDRO+, 33% VDRO). There were no differences in complications or revision rates between groups. Of the hips with MP >50% preoperatively and treated with VDRO alone, 41% developed postoperative MP of ≥ 30% and 21% developed a MP of ≥ 40%.
The study results confirm that combined procedures should be considered in patients with high MP. However, this study supports a sequential approach to surgical management of subluxated/dislocated hips in patients with CP as many hips with MP >50% were successfully managed with VDRO alone. We recommend performing VDRO and soft tissue release first, assessing reduction using fluoroscopy and arthrogram and proceeding with open reduction and/or pelvic osteotomy if reduction and/or femoral head coverage are inadequate.
Level III, retrospective comparative study.
脑性瘫痪（CP）患儿髋关节半脱位/脱位的手术治疗存在争议。本研究的目的是比较单纯内翻旋转截骨术（VDRO）与VDRO联合切开复位髋关节及/或骨盆截骨术治疗CP合并髋关节半脱位/脱位患儿的疗效。
对75例CP患儿（116髋）行手术治疗的髋关节半脱位/脱位病例进行回顾性分析，随访至少2年。92髋仅接受了VDRO，24髋接受了VDRO及切开复位和/或骨盆截骨术（术中根据透视和关节造影结果决定是否行切开复位髋关节及/或骨盆截骨术）。比较两组间的临床变量、功能水平、影像学变量及并发症/翻修情况。
需要联合手术（VDRO+）的患者基线时的移位百分比（MP）更高（VDRO+组为84%±18，VDRO组为51%±21），髋臼指数更高（VDRO+组为34±10，VDRO组为28±7），中心边缘角更负（VDRO+组为-36±28，VDRO组为-0.3±18），颈干角更高（VDRO+组为162±12，VDRO组为157±10）（所有P<0.02）。两组术后影像学变量相似。末次随访时MP>30%的患者百分比在两组间相似（VDRO+组为38%，VDRO组为33%）。两组间并发症或翻修率无差异。术前MP>50%且仅接受VDRO治疗的髋关节中，41%术后MP≥30%，21%术后MP≥40%。
研究结果证实，MP高的患者应考虑联合手术。然而，本研究支持对CP患儿半脱位/脱位髋关节采取序贯手术治疗方法，因为许多MP>50%的髋关节仅通过VDRO就成功治疗。我们建议先进行VDRO和软组织松解，通过透视和关节造影评估复位情况，若复位和/或股骨头覆盖不足，则继续行切开复位和/或骨盆截骨术。
III级，回顾性比较研究。
