Department of Orthopaedics and Traumatology, The University of Hong Kong, Pok Fu Lam.
Department of Orthopaedics and Traumatology, Duchess of Kent Children's Hospital, Sandy Bay, Hong Kong SAR.
J Pediatr Orthop. 2022 Jan 1;42(1):e72-e77. doi: 10.1097/BPO.0000000000001961.
Cerebral palsy patients are at risk of hip instability, to which various soft tissue and bony surgeries are performed should conservative management fail. We aim to identify factors associated with treatment failure to guide surgical management.
Cerebral palsy patients treated at 2 university-affiliated tertiary pediatric orthopaedic referral centers with hip stabilization surgery performed for subluxation in 1998 to 2015 with minimum of 5 years follow-up were reviewed. Failure was defined as reoperation to the same hip because of recurrent subluxation. Age, sex, Gross Motor Function Classification System level, tone abnormality, operation type, Reimer's migration index (RMI), and acetabular index (AI) were assessed. Cut-off values were identified through Youden index on receiver operating characteristic curve.
Eighty-nine hips from 55 patients with mean follow-up of 12.4 years were analyzed. Revision surgery was performed in 14 hips. Postoperative hip subluxation (P<0.001) and acetabular dysplasia (P=0.001) were predictive of failure, with postoperative RMI conferring an adjusted hazard ratio of 1.13 (95% confidence interval: 1.08-1.19, P<0.001) on multivariable survival analysis. Achieving a postoperative RMI of <27.5% predicts success with 92.9% sensitivity and 72% specificity with area under curve of 0.916 (P<0.001), while postoperative AI of <23.1 degrees predicts success with 92.3% sensitivity and 62.2% specificity with area under curve of 0.796 (P=0.001). In subgroup analysis of soft-tissue-only procedures, RMI >44% preoperative and >32% postoperative were associated with reoperation. In femur-only osteotomies, preoperative RMI >48% and postoperative RMI >28% were associated with failure. In pelvic and combined osteotomies, postoperative RMI >32% and AI >30 degrees were associated with failure. Other factors analyzed were not associated with reoperation.
Patient selection and quality of surgery in terms of residual postoperative hip subluxation and acetabular dysplasia are associated with need for remedial surgery. Soft-tissue-only procedures should aim to correct RMI to <32%. Bony surgery should be considered when preoperative RMI >44%, and pelvic osteotomies if RMI >48%. Pelvic osteotomies should target postoperative RMI <32% and AI <30 degrees.
Level II-prognostic study.
脑瘫患者存在髋关节不稳定的风险，如果保守治疗失败，需要进行各种软组织和骨手术。我们旨在确定与治疗失败相关的因素，以指导手术治疗。
回顾了 1998 年至 2015 年间在 2 所大学附属三级儿科矫形转诊中心接受髋关节稳定手术治疗髋关节半脱位的脑瘫患者。如果因再次出现半脱位而对同一髋关节进行再次手术，则定义为治疗失败。评估的因素包括年龄、性别、粗大运动功能分类系统水平、肌张力异常、手术类型、Reimer 迁移指数（RMI）和髋臼指数（AI）。通过接收者操作特征曲线的约登指数确定临界值。
55 名患者的 89 个髋关节进行了平均 12.4 年的随访分析。14 个髋关节进行了翻修手术。术后髋关节半脱位（P<0.001）和髋臼发育不良（P=0.001）是失败的预测因素，多变量生存分析显示术后 RMI 校正后的危险比为 1.13（95%置信区间：1.08-1.19，P<0.001）。术后 RMI<27.5%可预测手术成功，其敏感性为 92.9%，特异性为 72%，曲线下面积为 0.916（P<0.001），而术后 AI<23.1 度的敏感性为 92.3%，特异性为 62.2%，曲线下面积为 0.796（P=0.001）。在仅软组织手术的亚组分析中，术前 RMI>44%和术后 RMI>32%与再次手术有关。在股骨截骨术中，术前 RMI>48%和术后 RMI>28%与失败有关。在骨盆和联合截骨术中，术后 RMI>32%和 AI>30 度与失败有关。其他分析的因素与再次手术无关。
患者选择和手术质量（残余术后髋关节半脱位和髋臼发育不良）与补救性手术的需要有关。仅软组织手术应将 RMI 纠正至<32%。术前 RMI>44%时应考虑行骨手术，如果 RMI>48%，则应进行骨盆截骨术。骨盆截骨术应将术后 RMI 目标值设定为<32%，AI<30 度。
II 级-预后研究。
