Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles.
Keck School of Medicine, University of Southern California, Zonal Avenue, Los Angeles, CA.
J Pediatr Orthop. 2024;44(5):e452-e456. doi: 10.1097/BPO.0000000000002663. Epub 2024 Mar 20.
Of children, 30% to 35% with cerebral palsy (CP) develop hip subluxation or dislocation and often require reconstructive hip surgery, including varus derotation osteotomy (VDRO). A recent literature review identified postoperative fractures as the most common complication (9.4%) of VDROs. This study aimed to assess risk factors for periprosthetic fracture after VDRO in children with CP.
A total of 347 patients (644 hips, 526 bilateral hips) with CP and hip subluxation or dislocation (129 females; mean age at index VDRO: 8.6 y, SD 3.4, range: 1.5 to 17.7; 2 Gross Motor Function Classification System (GMFCS) I, 35 GMFCS II, 39 GMFCS III, 119 GMFCS IV, 133 GMFCS V, 21 unavailable) were included in this retrospective, single-group intervention (VDRO) study at a tertiary referral center. Imaging and clinical documentation for patients age 18 years or younger at index surgery, treated with VDRO were reviewed to determine demographic data, GMFCS level, surgeon, type of hardware implanted, use of anticonvulsants and steroids, type of postoperative immobilization, presence of periprosthetic fractures, fracture location and mechanism, and time from surgery to fracture. Potential determinants of periprosthetic fractures were assessed using mixed effects logistic regression.
Of 644 hips, 14 (2.2%, 95% CI: 1.3%, 3.6%) sustained a periprosthetic fracture, at a median of 2.1 years postoperatively (interquartile range: 4.6 y, range: 1.2 mo to 7.8 y). Patients with a fracture had a median age at index surgery of 7.3 years (interquartile range: 4.3, range: 2.8 to 17.8; 1 GMFCS II, 6 GMFCS IV, 7 GMFCS V). Periprosthetic fractures were not significantly related to age at index surgery ( P = 0.18), sex ( P = 0.30), body mass index percentile ( P = 0.87), surgery side ( P = 0.16), anticonvulsant use ( P = 0.35), type of postoperative immobilization ( P = 0.40), GMFCS level ( P = 0.31), or blade plate size ( P = 0.17). Only surgeon volume significantly related to periprosthetic fracture (odds ratio = 5.03, 95% CI: 1.53, 16.56, P = 0.008), with the highest-volume surgeon also using smaller blade plates ( P < 0.01).
Periprosthetic fractures after VDRO surgery in children with CP are uncommon, and routine hardware removal appears unnecessary. The data suggest that the common dogma of putting in the largest blade plate possible to maximize fixation may increase the risk of periprosthetic fracture. Due to the overall low fracture rate, especially when contextualized relative to the risk of hardware removal, a reactive approach to hardware removal appears warranted.
Level III-retrospective study (targeting varus derotational osteotomies in children with cerebral palsy).
在脑瘫患儿中，30%至 35%的患儿会出现髋关节半脱位或脱位，通常需要进行重建性髋关节手术，包括内翻旋截骨术（VDRO）。最近的文献综述发现术后骨折是 VDRO 最常见的并发症（9.4%）。本研究旨在评估脑瘫儿童行 VDRO 后发生假体周围骨折的危险因素。
本研究共纳入了 347 名（644 髋，526 双侧髋）脑瘫伴髋关节半脱位或脱位的患儿（129 名女性；VDRO 指数年龄：8.6 岁，标准差 3.4 岁，范围：1.5 至 17.7 岁；2 级粗大运动功能分类系统（GMFCS），35 级 GMFCS II，39 级 GMFCS III，119 级 GMFCS IV，133 级 GMFCS V，21 级不可用），这些患儿在三级转诊中心接受 VDRO 治疗。对所有接受 VDRO 手术且年龄在 18 岁以下的患儿的影像学和临床资料进行回顾性分析，以确定人口统计学数据、GMFCS 分级、外科医生、植入的硬件类型、抗惊厥药和类固醇的使用、术后固定类型、假体周围骨折的存在、骨折的位置和机制，以及从手术到骨折的时间。使用混合效应逻辑回归评估假体周围骨折的潜在决定因素。
在 644 髋中，14 髋（2.2%，95%置信区间：1.3%，3.6%）发生了假体周围骨折，术后中位数时间为 2.1 年（四分位距：4.6 年，范围：1.2 个月至 7.8 年）。发生骨折的患儿 VDRO 指数年龄中位数为 7.3 岁（四分位距：4.3 岁，范围：2.8 岁至 17.8 岁；1 级 GMFCS II，6 级 GMFCS IV，7 级 GMFCS V）。假体周围骨折与手术年龄无显著相关性（P = 0.18），与性别（P = 0.30）、体质量指数百分位数（P = 0.87）、手术侧（P = 0.16）、抗惊厥药使用（P = 0.35）、术后固定类型（P = 0.40）、GMFCS 分级（P = 0.31）或刀片板尺寸（P = 0.17）无显著相关性。只有外科医生手术量与假体周围骨折显著相关（优势比=5.03，95%置信区间：1.53，16.56，P = 0.008），且手术量最高的外科医生也使用较小的刀片板（P < 0.01）。
脑瘫儿童行 VDRO 手术后发生假体周围骨折并不常见，且常规去除内固定物似乎没有必要。数据表明，为了最大限度地固定而放置最大刀片板的常见观点可能会增加假体周围骨折的风险。由于总体骨折率较低，尤其是相对于去除内固定物的风险而言，采取被动去除内固定物的方法似乎是合理的。
III 级回顾性研究（针对脑瘫儿童行内翻旋截骨术）。
