Luhmann S J, Schoenecker P L, Anderson A M, Bassett G S
Shriners Hospital for Children, St. Louis Unit, Missouri 63131, USA.
J Bone Joint Surg Am. 1998 Dec;80(12):1719-27. doi: 10.2106/00004623-199812000-00001.
Ischemic necrosis of the femoral head occurring after the treatment of congenital dysplasia of the hip can negatively affect the long-term prognosis of the involved hip. Some investigators have suggested that the presence of the ossific nucleus of the femoral head at the time of closed or open reduction is associated with a lower rate of ischemic necrosis. This finding, if verified, could lead to a delay in the treatment of a dislocated hip until ossification of the femoral head has begun, which may be well after the age when the patient has started to walk. We conducted a computerized search of the medical records at our two tertiary-care children's hospitals to identify all patients with congenital dysplasia of the hip who had had a closed or open reduction between January 1, 1979, and December 31, 1993. One hundred and twenty-four patients (153 hips) who satisfied the criteria for inclusion were identified. The ossific nucleus was present in ninety hips and absent in sixty-three. Closed reduction was used in 112 hips and open reduction, in forty-one. Ischemic necrosis was identified in five hips (3 percent): four (6 percent) of the sixty-three hips that did not have an ossific nucleus and one (1 percent) of the ninety hips that had an ossific nucleus at the time of the reduction. With the numbers available for study, we could not detect a difference between these two groups. The age at reduction (p > 0.99), the method of reduction (p = 0.611), previous treatment with a Pavlik harness (p = 0.592), the use of preliminary traction (p = 0.602), concomitant procedures (p > 0.99), and a failure of the primary closed reduction (p = 0.579) were not associated with the development of ischemic necrosis after reduction. In our analysis of patients who were managed over a fifteen-year period, the data did not support the hypothesis that the presence of an ossific nucleus at the time of reduction of a congenitally dislocated hip is associated with a lower prevalence of ischemic necrosis of the femoral head. Sound operative principles dictate that operative reduction of a congenitally displaced hip should be performed when the child can be safely placed under anesthesia and without regard to the presence or absence of the ossific nucleus.
先天性髋关节发育不良治疗后发生的股骨头缺血性坏死会对受累髋关节的长期预后产生负面影响。一些研究者认为，闭合或切开复位时股骨头骨化中心的存在与较低的缺血性坏死发生率相关。这一发现若得到证实，可能会导致脱位髋关节的治疗延迟至股骨头开始骨化，而这可能在患儿开始行走后的年龄很久之后才会发生。我们对两家三级儿童专科医院的病历进行了计算机检索，以确定1979年1月1日至1993年12月31日期间所有接受过闭合或切开复位的先天性髋关节发育不良患者。确定了124例（153髋）符合纳入标准的患者。90髋存在骨化中心，63髋不存在骨化中心。112髋采用了闭合复位，41髋采用了切开复位。发现5髋（3%）发生了缺血性坏死：63髋中无骨化中心的4髋（6%），复位时存在骨化中心的90髋中的1髋（1%）。基于可用于研究的病例数量，我们未检测到这两组之间存在差异。复位时的年龄（p>0.99）、复位方法（p=0.611）、先前使用 Pavlik 吊带治疗（p=0.592）、使用初步牵引（p=0.602）、伴随手术（p>0.99）以及初次闭合复位失败（p=0.579）均与复位后缺血性坏死的发生无关。在我们对15年期间管理的患者进行的分析中，数据不支持先天性脱位髋关节复位时骨化中心的存在与股骨头缺血性坏死较低发生率相关的假设。合理的手术原则要求，当患儿能够安全接受麻醉时，应进行先天性移位髋关节的手术复位，而无需考虑骨化中心的有无。
