R. K. Kanojia, S. Gupta, Department of Orthopaedics, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India A. Kumar, Department of Paediatrics and Neonatology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India B. K. Reddy, Department of Orthopaedics, Ashwini Hospital CDA Sector 1, Cuttack, Orissa, India.
Clin Orthop Relat Res. 2018 Jul;476(7):1479-1490. doi: 10.1097/01.blo.0000533616.93007.46.
When treatment of acute septic arthritis of the hip is delayed, severe sequelae can occur. This may take the form of coxa breva, vara, or valga. Pseudoarthrosis of the femoral neck is a rare complication with only a few studies to guide treatment.
QUESTION/PURPOSES: In a small series of patients with pseudarthrosis of the femoral neck after acute septic arthritis, we wanted to determine (1) whether femoral neck union can be achieved using a variety of surgical approaches; (2) whether these patients satisfied criteria outlined by Hunka and Choi, defined as a stable hip, a flexion arc ≥ 70° and no fixed adduction or abduction contractures, fixed flexion deformity not more than 20°, pain relief, and restoration of activities of daily living after surgery; and (3) any treatment-related complications if observed.
We reviewed the charts of patients who had presented to the orthopaedics outpatient department at Lady Hardinge Medical College and Associated Hospitals with the diagnosis sequelae of septic arthritis of the hip. Between 2003 and 2014, a total of 54 pediatric patients (61 hips) with sequelae of a septic hip had undergone various hip reconstructive procedures. Of these, 16 patients (30%) were diagnosed with pseudarthrosis of the femoral neck and were included in this study. All patients with this diagnosis were treated surgically. In this group, the median age at first contact with our treating team was 48 months (range, 18-96 months). The age of onset of the initial infection was 0.3 months to 84 months (median, 8 months). These 16 patients underwent a total of 24 surgical procedures to achieve union at the pseudoarthrosis site. We performed close reduction, fibula graft, and valgus osteotomy in most of the patients. Wagner's double intertrochantric osteotomy with a fibula graft was done in patients in whom there was a short femoral neck along with pseudoarthrosis. In all patients, the pseudarthrosis site was not exposed. Median followup was 6 years (range, 3-12 years). No patient was lost to followup before 3 years. Union was defined when there was complete radiologic healing at the pseudoarthrosis site. All the patients were clinically evaluated as per Choi's criteria. Parents were also asked about daily activities and pain. Other related complications were also recorded.
Fifteen of 16 patients achieved union at the pseudarthrosis site within 6 to 24 months (median, 9 months). Ten patients underwent a single procedure to achieve union, whereas four patients underwent two surgical procedures and two patients underwent three procedures. Fifteen patients achieved Choi's criteria and one patient could not achieve this. While attempting this reconstruction, complications occurred in the form of deep infection and avascular necrosis.
Surgical reconstruction of pseudarthrosis of the femoral neck after pyarthrosis of the hip is difficult, but a successful result may be possible in many patients. Every effort should be made to achieve pseudarthrosis repair while the femoral head remains viable on radiographs. Once union is achieved, clinical function and hip stability improve. At early followup, many patients have adequate ROM with minimal pain, an acceptable limp, and are able to do indoor and outdoor activities without support. Long-term results are unknown, and we caution that treating the sequelae of childhood hip disease is challenging.
Level IV, therapeutic study.
当髋关节急性化脓性关节炎的治疗被延误时，可能会出现严重的后遗症。这些后遗症可能表现为短颈、内翻或外翻畸形。股骨颈假关节是一种罕见的并发症，仅有少数研究可以指导治疗。
问题/目的：在一组患有急性化脓性关节炎后股骨颈假关节的小系列患者中，我们想要确定：(1) 能否通过多种手术入路实现股骨颈愈合；(2) 这些患者是否符合 Hunka 和 Choi 提出的标准，即髋关节稳定、屈曲弧≥70°且无固定内收或外展挛缩、固定屈曲畸形不超过 20°、疼痛缓解以及日常生活活动能力恢复；以及(3) 如果观察到任何与治疗相关的并发症。
我们回顾了在 Lady Hardinge 医学院和附属医院骨科门诊就诊的诊断为髋关节化脓性关节炎后遗症的患者的病历。在 2003 年至 2014 年间，共有 54 名（61 髋）患有化脓性髋关节后遗症的儿科患者接受了各种髋关节重建手术。其中，16 名（30%）患者被诊断为股骨颈假关节，并纳入本研究。所有这些诊断为假关节的患者均接受了手术治疗。在这组患者中，初次与我们治疗团队接触时的中位年龄为 48 个月（范围：18-96 个月）。初次感染的发病年龄为 0.3 个月至 84 个月（中位数：8 个月）。这 16 名患者总共进行了 24 次手术以实现假关节部位的愈合。我们对大多数患者进行了闭合复位、腓骨移植和外翻截骨术。对于伴有假关节的短颈股骨颈患者，我们采用 Wagner 的双转子间截骨术联合腓骨移植。所有患者的假关节部位均未暴露。中位随访时间为 6 年（范围：3-12 年）。在 3 年之前，没有患者失访。当假关节部位有完全的影像学愈合时，我们定义为愈合。所有患者均按照 Choi 的标准进行临床评估。我们还询问了家长关于日常活动和疼痛的情况。同时还记录了其他相关并发症。
16 名患者中有 15 名在 6 至 24 个月（中位数 9 个月）内实现了假关节部位的愈合。10 名患者通过单次手术实现了愈合，而 4 名患者进行了两次手术，2 名患者进行了三次手术。15 名患者达到了 Choi 的标准，而 1 名患者未达到。在进行这种重建时，并发症以深部感染和缺血性坏死的形式出现。
髋关节化脓性关节炎后股骨颈假关节的手术重建较为困难，但许多患者可能会获得成功的结果。应尽最大努力在影像学上显示股骨头仍存活时实现假关节修复。一旦愈合，临床功能和髋关节稳定性会得到改善。在早期随访中，许多患者的 ROM 足够，疼痛轻微，跛行可接受，能够在没有支撑的情况下进行室内和室外活动。长期结果尚不清楚，我们提醒大家，治疗儿童髋关节疾病的后遗症具有挑战性。
IV 级，治疗性研究。
