Gourineni Prasad V, Valleri Durga Prasad, Chauhan Prakash, Watkins Summer
Advocate Christ Medical Center, Oak Lawn, USA.
Department of Pediatric Orthopaedics Surgery, Amara Hospital, Karakambadi, Tirupati, Andhra Pradesh 517520 India.
Indian J Orthop. 2023 Apr 28;57(7):1112-1117. doi: 10.1007/s43465-023-00895-6. eCollection 2023 Jul.
Relative femoral neck lengthening (RNL) is a newer technique to correct coxa breva and coxa vara to relieve a femoro-acetabular impingement and improve hip abductor function without changing the position of the head on the shaft. Proximal femoral osteotomy (PFO) changes the position of the femoral head relative to the shaft. We studied the short-term complications of procedures that combined RNL with PFO.
All hips that underwent RNL and PFO using a surgical dislocation and extended retinacular flap development were included. Hips that were treated only with intra-articular femoral osteotomies (IAFO) were excluded. Hips that underwent RNL and PFO, with IAFO and/or acetabular procedures were included. Intra-operative evaluation of the femoral head blood flow was performed with the drill hole technique. Clinical evaluation and hip radiographs were obtained at 1 week, 6 weeks, 3 months, 6 months, 12 months and 24 months.
Seventy two patients (31 males, 41 females, 6-52 years of age) underwent 79 combined RNL and PFO. 22 hips underwent additional procedures like head reduction osteotomy, femoral neck osteotomy, and acetabular osteotomies. There were 6 major and 5 minor complications noted. Two hips developed non-unions, both with basicervical varus-producing osteotomies. Four hips developed femoral head ischemia. Two of these hips avoided collapse with early intervention. One hip had persistent abductor weakness requiring hardware removal and three hips, all in boys developed symptomatic widening of the hip on the operated side from varus-producing osteotomy. One hip had asymptomatic trochanteric non-union.
RNL is routinely performed by releasing the short external rotator muscle tendon insertion from the proximal femur to raise the posterior retinacular flap. Though this technique protects the blood supply from direct injury, it seems to stretch the vessels with major corrections in the proximal femur. We recommend evaluating the blood flow intraoperatively and postoperatively and taking necessary steps early to decrease the stretch on the flap. It may be safer to avoid raising the flap for major extra-articular proximal femur corrections.
The results of this study suggest ways to improve the safety of procedures that combine RNL and PFO.
相对股骨颈延长术（RNL）是一种较新的技术，用于矫正髋内翻和髋外翻，以缓解股骨髋臼撞击并改善髋外展肌功能，同时不改变股骨头在股骨干上的位置。股骨近端截骨术（PFO）会改变股骨头相对于股骨干的位置。我们研究了将RNL与PFO相结合的手术的短期并发症。
纳入所有采用手术脱位和扩展支持带瓣技术进行RNL和PFO的髋关节。仅接受关节内股骨截骨术（IAFO）治疗的髋关节被排除。纳入接受RNL和PFO以及IAFO和/或髋臼手术的髋关节。采用钻孔技术对股骨头血流进行术中评估。在术后1周、6周、3个月、6个月、12个月和24个月进行临床评估并拍摄髋关节X线片。
72例患者（31例男性，41例女性，年龄6 - 52岁）接受了79例RNL与PFO联合手术。22个髋关节还接受了其他手术，如股骨头复位截骨术、股骨颈截骨术和髋臼截骨术。共记录到6例主要并发症和5例次要并发症。2个髋关节出现骨不连，均为基底部内翻截骨所致。4个髋关节出现股骨头缺血。其中2个髋关节通过早期干预避免了塌陷。1个髋关节持续存在外展肌无力，需要取出内固定物，3个髋关节（均为男孩）因内翻截骨导致手术侧髋关节出现有症状的增宽。1个髋关节出现无症状的转子间骨不连。
RNL通常通过从股骨近端松解短外旋肌肌腱附着点以掀起后方支持带瓣来进行。尽管该技术可保护血供免受直接损伤，但在股骨近端进行较大矫正时似乎会拉伸血管。我们建议术中及术后评估血流情况，并尽早采取必要措施以减少对支持带瓣的牵拉。对于股骨近端较大的关节外矫正，避免掀起支持带瓣可能更安全。
本研究结果提示了提高RNL与PFO联合手术安全性的方法。
