Martinez Maximilian, Kim Seung-Ju, Sabharwal Sanjeev
Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ.
J Pediatr Orthop. 2017 Mar;37(2):111-120. doi: 10.1097/BPO.0000000000000600.
Treatment of a painful, chronically dislocated hip in nonambulatory children with cerebral palsy (CP) is challenging and controversial. Although many surgical options have been described, there is limited information, including patient-centered outcomes, following treatment. The purpose of our study was to evaluate the effect of a percutaneous subtrochanteric valgus osteotomy (SVO) using external fixation (EF) on hip abduction, radiographic parameters, and quality of life (QOL) measures in such patients.
Fifteen nonambulatory patients (8 male, 7 female) with CP with 19 chronically dislocated hips underwent SVO using EF and adductor tenotomy at an average age of 14.3 years (range, 10.7 to 26.8 y). Changes in hip abduction and radiographic angular correction following surgery were assessed. Caregivers completed 2 surveys detailing differences in the patient's QOL measures, including severity and duration of pain and ease of nursing care, and the modified Child Health Index of Life with Disabilities (CPCHILD).
Caregivers of 11 patients completed both surveys at an average follow-up of 50 months (range, 17 to 119 mo) after fixator removal. There was improvement in pain, sitting tolerance, ease of transfers, and perineal care in the majority (9/11) of patients. The modified CPCHILD (possible score, 10 to 50) improved from 27.2 to 16.23 (P=0.05). Hip abduction improved from -7 degrees (range, -32 to 5 degrees) to 24 degrees (range, 0 to 40 degrees) (P<0.0001). The average valgus osteotomy correction was 48.2 degrees (range, 2.2 to 93.2 degrees). The pelvic femoral shaft angle improved from -15.2 degrees (range, -47.7 to 7.4 degrees) to 15.4 degrees (-44.3 to 44.6 degrees). There was some correlation of both, change in hip abduction (R=0.55) and osteotomy angle (R=0.60), with improvement in QOL measures. There were 3 major complications (20%) in 15 patients.
On the basis of preliminary results, percutaneous SVO stabilized with EF improves QOL in the majority of nonambulatory CP patients despite untoward events and is a viable alternative to open osteotomy with internal fixation. More robust comparative studies are needed to further assess the optimal salvage technique in this patient population.
Level IV.
治疗非行走型脑瘫（CP）儿童疼痛性慢性髋关节脱位具有挑战性且存在争议。尽管已描述了许多手术选择，但治疗后的信息有限，包括以患者为中心的结局。我们研究的目的是评估使用外固定（EF）的经皮转子下外翻截骨术（SVO）对此类患者髋关节外展、影像学参数和生活质量（QOL）指标的影响。
15例非行走型CP患者（8例男性，7例女性）共19个慢性脱位髋关节，平均年龄14.3岁（范围10.7至26.8岁），接受了使用EF的SVO和内收肌切断术。评估了术后髋关节外展和影像学角度矫正的变化。护理人员完成了2项调查，详细说明了患者QOL指标的差异，包括疼痛的严重程度和持续时间、护理的难易程度，以及改良的儿童残疾生活健康指数（CPCHILD）。
11例患者的护理人员在去除固定器后平均随访50个月（范围17至119个月）时完成了两项调查。大多数（9/11）患者在疼痛、坐位耐受、转移难易程度和会阴护理方面有改善。改良的CPCHILD（可能得分10至50）从27.2提高到16.23（P = 0.05）。髋关节外展从-7度（范围-32至5度）改善到24度（范围0至40度）（P < 0.0001）。平均外翻截骨矫正角度为48.2度（范围2.2至93.2度）。骨盆股骨干角从-15.2度（范围-47.7至7.4度）改善到15.4度（-44.3至44.6度）。髋关节外展变化（R = 0.55）和截骨角度（R = 0.60）与QOL指标改善均存在一定相关性。15例患者中有3例发生严重并发症（20%）。
根据初步结果，尽管有不良事件发生，但使用EF稳定的经皮SVO可改善大多数非行走型CP患者的QOL，是开放性内固定截骨术的可行替代方法。需要更有力的比较研究来进一步评估该患者群体的最佳挽救技术。
IV级。
