严重股骨头骺滑脱原位克氏针固定术后患者的髋关节撞击症在三维CT上表现为屈曲位时屈曲度减小及屈曲位强迫外旋减小。
Hip Impingement of severe SCFE patients after in situ pinning causes decreased flexion and forced external rotation in flexion on 3D-CT.
作者信息
Lerch Till D, Kim Young-Jo, Kiapour Ata, Boschung Adam, Steppacher Simon D, Tannast Moritz, Siebenrock Klaus A, Novais Eduardo N
机构信息
Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland.
Department of Orthopaedic surgery, Child and Young Adult Hip Preservation Program at Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
出版信息
J Child Orthop. 2023 Aug 29;17(5):411-419. doi: 10.1177/18632521231192462. eCollection 2023 Oct.
INTRODUCTION
In situ pinning is an accepted treatment for stable slipped capital femoral epiphysis. However, residual deformity of severe slipped capital femoral epiphysis can cause femoroacetabular impingement and forced external rotation.
PURPOSE/QUESTIONS: The aim of this study was to evaluate the (1) hip external rotation and internal rotation in flexion, (2) hip impingement location, and (3) impingement frequency in early flexion in severe slipped capital femoral epiphysis patients after in situ pinning using three-dimensional computed tomography.
PATIENTS AND METHODS
A retrospective Institutional Review Board-approved study evaluating 22 patients (26 hips) with severe slipped capital femoral epiphysis (slip angle > 60°) using postoperative three-dimensional computed tomography after in situ pinning was performed. Mean age at slipped capital femoral epiphysis diagnosis was 13 ± 2 years (58% male, four patients bilateral, 23% unstable, 85% chronic). Patients were compared to contralateral asymptomatic hips (15 hips) with unilateral slipped capital femoral epiphysis (control group). Pelvic three-dimensional computed tomography after in situ pinning was used to generate three-dimensional models. Specific software was used to determine range of motion and impingement location (equidistant method). And 22 hips (85%) underwent subsequent surgery.
RESULTS
(1) Severe slipped capital femoral epiphysis patients had significantly (p < 0.001) decreased hip flexion (43 ± 40°) and internal rotation in 90° of flexion (-16 ± 21°, IRF-90°) compared to control group (122 ± 9° and 36 ± 11°). (2) Femoral impingement in maximal flexion was located anterior to anterior-superior (27% on 3 o'clock and 27% on 1 o'clock) of severe slipped capital femoral epiphysis patients and located anterior to anterior-inferior (38% on 3 o'clock and 35% on 4 o'clock) in IRF-90°. (3) However, 21 hips (81%) had flexion < 90° and 22 hips (85%) had < 10° of IRF-90° due to hip impingement and 21 hips (81%) had forced external rotation in 90° of flexion (< 0° of IRF-90°).
CONCLUSION
After in situ pinning, patient-specific three-dimensional models showed restricted flexion and IRF-90° and forced external rotation in 90° of flexion due to early hip impingement and residual deformity in most of the severe slipped capital femoral epiphysis patients. This could help to plan subsequent hip preservation surgery, such as hip arthroscopy or femoral (derotation) osteotomy.
引言
原位穿针固定术是治疗稳定型股骨头骨骺滑脱的一种公认方法。然而，严重股骨头骨骺滑脱的残留畸形可导致股骨髋臼撞击和强迫性外旋。
目的/问题：本研究的目的是使用三维计算机断层扫描评估原位穿针固定术后严重股骨头骨骺滑脱患者的（1）髋关节在屈曲时的外旋和内旋，（2）髋关节撞击位置，以及（3）早期屈曲时的撞击频率。
患者与方法
一项经机构审查委员会批准的回顾性研究，对22例（26髋）严重股骨头骨骺滑脱（滑脱角>60°）患者在原位穿针固定术后进行术后三维计算机断层扫描。股骨头骨骺滑脱诊断时的平均年龄为13±2岁（58%为男性，4例为双侧，23%为不稳定型，85%为慢性型）。将患者与对侧无症状髋关节（15髋）的单侧股骨头骨骺滑脱患者（对照组）进行比较。原位穿针固定术后的骨盆三维计算机断层扫描用于生成三维模型。使用特定软件确定运动范围和撞击位置（等距法）。22髋（85%）随后接受了手术。
结果
（1）与对照组（122±9°和36±11°）相比，严重股骨头骨骺滑脱患者的髋关节屈曲（43±40°）和90°屈曲时的内旋（-16±21°，IRF-90°）明显降低（p<0.001）。（2）严重股骨头骨骺滑脱患者在最大屈曲时的股骨撞击位于前上前方（3点处27%，1点处27%），在IRF-90°时位于前下前方（3点处38%，4点处35%）。（3）然而，21髋（81%）的屈曲<90°且22髋（85%）的IRF-90°<10°，原因是髋关节撞击，21髋（81%）在90°屈曲时有强迫性外旋（IRF-90°<0°）。
结论
原位穿针固定术后，针对患者的三维模型显示，大多数严重股骨头骨骺滑脱患者由于早期髋关节撞击和残留畸形，导致屈曲和IRF-90°受限，以及90°屈曲时的强迫性外旋。这有助于规划后续的髋关节保留手术，如髋关节镜检查或股骨（去旋转）截骨术。
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