Braatz Frank, Eidemüller Annette, Klotz Matthias C, Beckmann Nicholas A, Wolf Sebastian I, Dreher Thomas
Clinic for Orthopedics and Trauma Surgery, Heidelberg University Clinics, Heidelberg, Germany,
Int Orthop. 2014 Nov;38(11):2237-43. doi: 10.1007/s00264-014-2379-x. Epub 2014 Jun 27.
Neurogenic hip dislocation is frequently observed in patients with cerebral palsy (CP). If the hip is not centred but not dislocated, the hip joint can be recentered with minor operative effort. Reconstructive procedures are indicated if the femoral head is subluxated or dislocated. There are no data as to when destruction of the femoral head requires a salvage procedure or whether hip reconstruction surgery is successful in restoring joint congruity in patients with CP. Our aim was to investigate femoral head plasticity after hip reconstruction surgery in a long-term outcome study.
We studied a large cohort of patients with CP and high hip dislocation (Tönnis grade IV) before surgery. Sixty-eight patients were assessed, of whom 23 presented with bilateral high hip dislocation, and 91 complex hip reconstructions were conducted. Standardised radiographic examination was performed before and directly after surgery and at the long-term follow-up examination.
Pain was the most frequent reason for complex hip-joint reconstruction (49 patients, 72%). An impressive improvement in pain was demonstrated postoperatively. Forty-five hip joints presented aspheric incongruity postoperatively, which improved on average 7.7 years after surgery and 59 hip joints showed congruency. Only 15% of patients experienced pain at the time of final follow-up, and that was of low intensity.
Early conservative treatment for hip dislocation is helpful, and operative reconstruction should also be scheduled early. Continued surveillance is necessary, and Reimers index is useful for monitoring the development of hip centering. In case of hip pain and femoral head deformity, our long-term study indicates that hip reconstruction surgery as a part of multilevel surgery improves pain and function in patients with CP and Tönnis IV hip dislocation, even if the hip joint is incongruent after operation. This incongruity improves over the long-term. If possible, a reconstruction procedure should be performed before the femoral head becomes deformed. High plasticity of the hip joint suggest that even if the femoral head is deformed, hip reconstruction can be recommended.
神经源性髋关节脱位在脑瘫（CP）患者中较为常见。若髋关节未居中但未脱位，通过较小的手术操作即可使其重新居中。若股骨头半脱位或脱位，则需进行重建手术。目前尚无关于股骨头破坏何时需要进行挽救手术的数据，也不清楚髋关节重建手术能否成功恢复CP患者的关节一致性。我们的目的是在一项长期预后研究中调查髋关节重建手术后股骨头的可塑性。
我们对一大群术前患有CP和高位髋关节脱位（Tönnis Ⅳ级）的患者进行了研究。共评估了68例患者，其中23例为双侧高位髋关节脱位，共进行了91次复杂的髋关节重建手术。在手术前、手术后即刻以及长期随访检查时均进行了标准化的影像学检查。
疼痛是进行复杂髋关节重建最常见的原因（49例患者，占72%）。术后疼痛有显著改善。45个髋关节术后出现非球形不匹配，平均在术后7.7年得到改善，59个髋关节显示匹配。在最后随访时，只有15%的患者有疼痛，且疼痛程度较轻。
髋关节脱位的早期保守治疗是有帮助的，手术重建也应尽早安排。持续监测是必要的，Reimers指数有助于监测髋关节居中情况的发展。对于髋关节疼痛和股骨头畸形，我们的长期研究表明，作为多级手术一部分的髋关节重建手术可改善CP和Tönnis Ⅳ级髋关节脱位患者的疼痛和功能，即使术后髋关节不匹配。这种不匹配在长期内会得到改善。如果可能，应在股骨头变形之前进行重建手术。髋关节的高可塑性表明，即使股骨头变形，也可推荐进行髋关节重建。
