Bhaskar Atul, Desai Hardik, Jain Gaurav
Children Orthopaedic Clinic, MHADA, Oshiwara, Andheri West, Mumbai, Maharashtra, India; Department of Orthopaedics, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India; Department of Orthopaedics - Dr. R N Cooper Hospital, Mumbai, Maharashtra, India.
Children Orthopaedic Clinic, MHADA, Oshiwara, Andheri West, Mumbai, Maharashtra, India; Department of Orthopaedics, MW Desai Municipal Hospital, Mumbai, Maharashtra, India.
Indian J Orthop. 2016 Sep;50(5):479-485. doi: 10.4103/0019-5413.189610.
Re-dislocation after primary treatment of developmental dysplasia of the hip is a serious complication. We analyzed the various risk factors that contribute to re-dislocation, and whether the bony ossific nucleus (ON) confers increased stability against re-dislocation.
Fifty-five children (60 hips) were classified into three treatment groups: Closed reduction (CR) in 15 children (17 hips), open reduction (OR) in 26 children (28 hips), and OR with bony surgery (ORB) in 14 children (15 hips). The mean age at initial treatment was 16 months (range 6-36 months). Fifty-one hips and 9 hips were Tonnis Grade 4 and 3, respectively. The mean preoperative acetabular index (AI) was 44.82° (range 32°-56°) for the study group. At initial treatment, bony ON was absent in 8 hips and present in 52 hips.
No hip developed stiffness and pain after primary treatment. Although the AI index, Tonnis grade, and absence of ossific nucleus were higher in the re-dislocated groups, this was not statistically significant. Excluding the re-dislocations, four children had a fair outcome, 11 had good outcome, and 36 had excellent outcome as per McKay's criteria. In the CR group (17 hips), two children (2 hips) with absent ON had re-dislocation. In the OR group (28 hips), three re-dislocations were seen (three children) at 3, 5, and 7 months, respectively. Two of these had an absent bony ON. In the ORB group (15 hips), one late sub-luxation occurred in a child with absent ON. The mean preoperative AI for the re-dislocated and located group was 44.66° (range 42°-48°) and 44.53° (range 39°-56°), respectively. The postoperative AI was 34.53.
The experience of the treating surgeon and technical factors play an overwhelming role in preventing early dislocation. The absence of ON should perhaps alert the surgeon for enhanced spica care, postoperative splinting, and meticulous intra-operative management.
发育性髋关节发育不良初次治疗后再脱位是一种严重的并发症。我们分析了导致再脱位的各种危险因素，以及骨化核（ON）是否能增强抵抗再脱位的稳定性。
55名儿童（60髋）被分为三个治疗组：15名儿童（17髋）行闭合复位（CR），26名儿童（28髋）行切开复位（OR），14名儿童（15髋）行切开复位联合骨性手术（ORB）。初次治疗时的平均年龄为16个月（范围6 - 36个月）。51髋和9髋分别为Tonnis 4级和3级。研究组术前平均髋臼指数（AI）为44.82°（范围32° - 56°）。初次治疗时，8髋无骨化核，52髋有骨化核。
初次治疗后无髋关节出现僵硬和疼痛。虽然再脱位组的AI指数、Tonnis分级和无骨化核情况较高，但差异无统计学意义。根据麦凯标准，排除再脱位病例后，4名儿童预后一般，11名儿童预后良好，36名儿童预后优秀。在CR组（17髋）中，2名无骨化核的儿童（2髋）发生了再脱位。在OR组（28髋）中，分别在3个月、5个月和7个月时出现了3例再脱位（3名儿童）。其中2例无骨化核。在ORB组（15髋）中，1例无骨化核的儿童出现了晚期半脱位。再脱位组和复位组术前平均AI分别为44.66°（范围42° - 48°）和44.53°（范围39° - 56°）。术后AI为34.53。
治疗医生的经验和技术因素在预防早期脱位中起主导作用。无骨化核可能应提醒外科医生加强髋人字石膏护理、术后夹板固定以及术中的精细管理。
