Alexiev V, Georgiev H, Mileva S
Sofia Medical University, Department of Paediatric Orthopaedics, Sofia, Bulgaria.
Acta Chir Orthop Traumatol Cech. 2017;84(5):386-390.
PURPOSE OF THE STUDY When developmental dysplasia of the hip (DDH) is irreducible by conservative means, then surgical open hip reduction is the choice. When done before walking age simple open hip reduction (SOHR) is most often enough to stabilize the hip. We tested the hypothesis that simple open hip reduction gives enough stability even in severe Tönnis 4 grades of dislocation. We tried to find what is the cut-off age to safely perform SOHR with lower complications. MATERIAL AND METHODS From 193 open hip reductions (OHR) of irreducible DDH in 123 children for the period 1995-2010 year with X-ray follow up of at least 8 years and full documentation we investigated 75 SOHR. Mean age at follow-up was 13 years and 5 months for the whole group and 8 years and 3 months for the SOHR patients. Age at operation - 7 months to 7.5 years for all patients with OHR, with average OR age for SOHR - 18 months. The traditional surgical technique of open hip reduction was performed through lateral Murphy's approach but with sparing the attachment of the piriformis muscle with the underlying blood supply to the epiphysis during circumferential capsulotomy. We used McKay clinical criteria, radiological classifications of Tönnis, Severin, Herring-Mose and Kalamchi & MacEwen. RESULTS When analyzing the results, there came up a strong statistical correlation between bilaterality and Tönnis grade 4. The final CE angle of Wiberg was on average 28º. According to Severin classification: 74% were excellent and 10% good or 84 % successful results. But according to Herring-Mose sphericity scoring - 60% were good and 30% fair. Mose's fair is a potential cam-type femoro-acetabular impingement (FAI). Clinically according to McKay criteria - 10% excellent and 54% good, or 64% of the operated hips were clinically acceptable, which correlates more with the radiological results according to Mose than with Severin. Avascular necrosis (AVN) of the femoral head (FH) according to Kalamchi was: Type I - 6%, Type II - 12 %, Type III - 0%, Type IV - 8 %. Types II and IV represent 20 % of the operated hips. The presence of ossific nucleus in the femoral epiphysis on initial X-ray didn't have a statistical impact on AVN frequency. When analyzing the impact of severity of dislocation and trying to find the cut-off age for fewer complications, there came up a strong statistical significance between AVN IV type appearance in Tonnis grade 4 hips when age at operation was above 9 months. CONCLUSIONS The thorough capsuloplasty after FH reduction in the acetabular socket is enough for stability even in Tonnis 4. When OR age is below 9 months severe AVN is lower and Herring-Mose FH sphericity scoring is higher. Key words: DDH, simple open hip reduction, avascular necrosis of femoral head.
研究目的 当髋关节发育不良（DDH）无法通过保守方法复位时，手术切开复位是选择。在行走年龄之前进行手术时，单纯切开复位（SOHR）通常足以稳定髋关节。我们检验了这样一个假设，即即使在严重的Tönnis 4级脱位中，单纯切开复位也能提供足够的稳定性。我们试图找出安全进行SOHR且并发症较少的临界年龄。材料与方法 对1995年至2010年间123例儿童不可复位性DDH进行的193例切开复位（OHR）进行研究，这些病例有至少8年的X线随访及完整记录，我们调查了75例SOHR。整个组随访时的平均年龄为13岁零5个月，SOHR患者为8岁零3个月。所有OHR患者的手术年龄为7个月至7.5岁，SOHR的平均手术年龄为18个月。切开复位的传统手术技术通过外侧墨菲氏入路进行，但在环形关节囊切开时保留梨状肌附着及其对骨骺的血供。我们使用了麦凯临床标准、Tönnis、塞韦林、赫林 - 莫斯和卡拉姆奇及麦克尤恩的放射学分类。结果 在分析结果时，双侧性与Tönnis 4级之间存在很强的统计学相关性。最终的维伯格CE角平均为28°。根据塞韦林分类：74%为优，10%为良，即84%的结果成功。但根据赫林 - 莫斯球形评分 - 60%为良，30%为尚可。莫斯的尚可表示潜在的凸轮型股骨髋臼撞击（FAI）。临床上根据麦凯标准 - 10%为优，54%为良，即64%的手术髋关节在临床上可接受，这与莫斯的放射学结果相关性更强，而非塞韦林的结果。根据卡拉姆奇的标准，股骨头缺血性坏死（AVN）情况为：I型 - 6%，II型 - 12%，III型 - 0%，IV型 - 8%。II型和IV型占手术髋关节的20%。初始X线片上股骨骨骺中骨化核的存在对AVN发生率没有统计学影响。在分析脱位严重程度的影响并试图找出并发症较少的临界年龄时，当手术年龄超过9个月时，Tönnis 4级髋关节中AVN IV型的出现有很强的统计学意义。结论 即使在Tönnis 4级情况下，髋臼内股骨头复位后彻底的关节囊成形术足以提供稳定性。当手术年龄低于9个月时，严重AVN发生率较低，且赫林 - 莫斯股骨头球形评分较高。关键词：DDH，单纯切开复位，股骨头缺血性坏死
