Dujardin F, Matsoukis J, Duparc F, Biga N, Thomine J M
Clinique Chirurgicale Orthopédique et Traumatologique, Hôpital Charles Nicolle, Rouen.
Rev Chir Orthop Reparatrice Appar Mot. 1994;80(6):485-92.
In cases of severe hip osteoarthritis in young patients, the intertrochanteric osteotomy can delay total hip arthroplasty. The main advantage of the osteotomy is to preserve the bone stock. The main disadvantages are the lasting postoperative invalidity and the varying longterm success rate. Our aim was to quantify these disadvantages using survivorship analysis.
The study included 64 patients (65 osteotomies) ranging from 16 to 68 years. The osteotomies were performed between 1975 and 1987. The osteoarthritis was stage III or IV, with a joint space less than 50 per cent. Osteoarthritis was primitive in 25 cases and secondary in the others. The osteotomy always included a medial displacement of the shaft according to the principle of Mac Murray's procedure, but also 22 cases (33.8 per cent) had a varus angulation and 19 (29.2 per cent) a valgus angulation. The preoperative pain score according to the Merle d'Aubigné (MDA) grading was 2.6 (1 to 4) and the global functional score was 11.1 (5 to 15). The patients were reviewed in 1991 and examined clinically and radiographically.
The results of the 65 cases were distributed into 3 groups: -29 cases having reached the follow-up without difficulty, -7 patients were lost for follow-up examination, 6 of these latter than 9 years, -29 patients taking osteotomy failure as a pain lesser than the 3 MDA score. The postoperative delay to obtain the best functional result was 6 to 24 months (mean: 13.65). This result ranged from 5 to 17 MDA score (mean: 15) with pain ranging from 2 to 6 (mean: 5). The survivorship analysis curve showed 67.5 +/- 19.5 per cent survival for all osteotomies to the interval of 9-10 years. There were 3 types of results: -3 early failures (4.6 per cent) one because of a deep infection, -in 7 cases, after a short initial functional improvement, there was a progressive degradation leading to failure in 3.7 years (2 to 6 years), -55 cases with a lasting period of functional improvement, 26 osteotomies leading to failure in 3.5 to 15 postoperative years and, 29 cases having reached the follow-up (7 to 16 years mean 10 years). There was radiographic improvement of the osteoarthritis increasing the joint space in 59 cases (90.7 per cent). There was no radiographic improvement in the 6 other cases, including the 2 functional failures. The functional degradation appeared parallel to the radiographic degradation leading to a decrease of joint space to 90 per cent. We tested differences between various groups using Log Rank test. We found no difference in survival between the 3 different types of osteotomy.
The results of this study can help to choose between intertrochanteric osteotomy and THA in the case of severe osteoarthritis. The best functional result of the osteotomy is in one postoperative year, with a mean MDA score of 15 and a mean pain score of 5. It appears that we do not predict the duration of functional improvement, the patient has 2/3 chances that this improvement reaches 10 years.
对于年轻患者的重度髋骨关节炎病例，转子间截骨术可延迟全髋关节置换术。截骨术的主要优点是保留骨量。主要缺点是术后长期功能丧失以及长期成功率各异。我们的目的是通过生存分析对这些缺点进行量化。
该研究纳入了64例患者（65次截骨术），年龄在16至68岁之间。截骨术于1975年至1987年间进行。骨关节炎为III期或IV期，关节间隙小于50%。25例为原发性骨关节炎，其余为继发性。截骨术始终包括根据麦克默里手术原则进行的骨干内侧移位，但也有22例（33.8%）存在内翻成角，19例（29.2%）存在外翻成角。根据默尔·德·奥比涅（MDA）分级，术前疼痛评分为2.6（1至4分），整体功能评分为11.1（5至15分）。1991年对患者进行了复查，并进行了临床和影像学检查。
65例患者的结果分为3组：-29例顺利完成随访，-7例失访，其中6例失访时间超过9年，-29例因疼痛评分低于MDA 3分而视为截骨术失败。术后获得最佳功能结果的延迟时间为6至24个月（平均：13.65个月）。该结果的MDA评分为5至17分（平均：15分），疼痛评分为2至6分（平均：5分）。生存分析曲线显示，所有截骨术至9至10年的生存率为67.5±19.5%。有3种结果类型：-3例早期失败（4.6%），1例因深部感染，-7例在最初功能短暂改善后，出现渐进性退化，在3.7年（2至6年）内导致失败，-55例有持久的功能改善期，26例截骨术在术后3.5至15年内导致失败，29例完成随访（平均10年，7至16年）。59例（90.7%）骨关节炎的影像学有改善，关节间隙增加。其他6例，包括2例功能失败，影像学无改善。功能退化与影像学退化平行，导致关节间隙减小至90%。我们使用对数秩检验测试了不同组之间的差异。我们发现3种不同类型的截骨术在生存率上没有差异。
本研究结果有助于在重度骨关节炎病例中选择转子间截骨术和全髋关节置换术。截骨术的最佳功能结果在术后1年，平均MDA评分为15分，平均疼痛评分为5分。似乎我们无法预测功能改善的持续时间，患者有2/3的机会使这种改善达到10年。
