Lamplot Joseph D, Schoenecker Perry L, Pascual-Garrido Cecilia, Nepple Jeffery J, Clohisy John C
Department of Orthopaedic Surgery, Washington University, St Louis, MO.
J Pediatr Orthop. 2020 Mar;40(3):120-128. doi: 10.1097/BPO.0000000000001192.
Osteochondritis dissecans (OCD) is estimated to occur in 2% to 7% of patients with Legg-Calvé-Perthes disease (LCPD). Unstable osteochondral fragments secondary to LCPD may produce mechanical symptoms requiring surgical intervention. Reattachment of the fragment with open reduction and internal fixation (ORIF) may provide good clinical outcomes. The purpose of this study is to report short-term clinical and radiographic results of ORIF for the treatment of symptomatic osteochondral lesions resulting from LCPD.
Clinical data including patient demographics and patient-reported outcome scores were collected prospectively. All patients underwent preoperative radiographs and magnetic resonance imaging confirming an unstable OCD fragment as well as postoperative radiographs at regular intervals. Indications for ORIF of the OCD fragment were hip pain and mechanical symptoms with radiographic evidence of LCPD and a magnetic resonance imaging demonstrating an OCD fragment of the femoral head. Osteochondral fragment instability was confirmed intraoperatively. Preoperative and postoperative physical examination findings were documented. All patients failed a course of nonsurgical treatment (activity modification, anti-inflammatories, and physical therapy).
From a total of 64 consecutive patients treated with hip preservation surgery for LCPD, 7 patients with symptomatic OCD secondary to LCPD were treated with surgical hip dislocation and ORIF of the femoral head osteochondral fragment. OCD size lesion ranged from 200 to 625 mm. All patients reported marked clinical improvement, with resolution of both pain and mechanical symptoms. Radiographs at final follow-up demonstrated complete osteochondral fragment healing without implant failure. Mean follow-up was 4.6 years (range, 1.1 to 7.4 y). There was a significant postoperative improvement in measured internal rotation in flexion (5.0±5.0 to 16.4±9.8; P=0.02). Modified Harris Hip Score markedly improved from baseline to final follow-up (47.8 to 82.7; [INCREMENT]34.9; minimal clinically important difference, 11; P=0.002), with all patients meeting minimal clinically important difference for modified Harris Hip Score. There were no complications and no progression of osteoarthritis in all patients at final follow-up.
We have demonstrated both predictable radiographic healing and marked clinical improvement following ORIF of symptomatic post-Perthes OCD lesions. We advocate ORIF for symptomatic osteochondral lesions as a first-line surgical treatment for these patients due to the advantages of native osteochondral tissue preservation, predictable healing, and marked clinical improvement.
Level IV-case series.
据估计，在Legg-Calvé-Perthes病（LCPD）患者中，剥脱性骨软骨炎（OCD）的发生率为2%至7%。LCPD继发的不稳定骨软骨碎片可能产生需要手术干预的机械性症状。通过切开复位内固定（ORIF）使碎片重新附着可能会带来良好的临床效果。本研究的目的是报告ORIF治疗LCPD所致有症状骨软骨病变的短期临床和影像学结果。
前瞻性收集包括患者人口统计学资料和患者报告的结局评分在内的临床数据。所有患者均接受术前X线片和磁共振成像检查，以确认存在不稳定的OCD碎片，并定期进行术后X线片检查。OCD碎片进行ORIF的指征为髋部疼痛和机械性症状，伴有LCPD的影像学证据，以及磁共振成像显示股骨头有OCD碎片。术中确认骨软骨碎片不稳定。记录术前和术后的体格检查结果。所有患者均经过一个疗程的非手术治疗（活动调整、抗炎药和物理治疗）但效果不佳。
在总共64例接受LCPD保髋手术治疗的连续患者中，7例继发于LCPD的有症状OCD患者接受了手术性髋关节脱位及股骨头骨软骨碎片的ORIF治疗。OCD病变大小范围为200至625mm。所有患者均报告临床症状明显改善，疼痛和机械性症状均消失。末次随访时的X线片显示骨软骨碎片完全愈合，且植入物无失败情况。平均随访时间为4.6年（范围为1.1至7.4年）。术后屈曲内旋测量值有显著改善（从5.0±5.0至16.4±9.8；P=0.02）。改良Harris髋关节评分从基线到末次随访有显著改善（从47.8至82.7；增加34.9；最小临床重要差异为11；P=0.002），所有患者的改良Harris髋关节评分均达到最小临床重要差异。所有患者在末次随访时均无并发症，且无骨关节炎进展。
我们已经证明，对有症状的Perthes病后OCD病变进行ORIF后，在影像学上有可预测的愈合，临床症状也有显著改善。由于保留了天然骨软骨组织、愈合可预测且临床症状有显著改善，我们主张将ORIF作为这些患者有症状骨软骨病变的一线手术治疗方法。
IV级——病例系列。
