摘要
目的探讨发育性髋关节发育不良(developmental dysplasia of the hip,DDH)经闭合复位石膏裤治疗后发生股骨头坏死(avascular necrosis,AVN)的危险因素。方法回顾性分析2016年1月至2017年12月接受闭合复位人类位石膏裤固定治疗的DDH患者,纳入年龄≥6个月、闭合复位成功、资料齐全且随访超过2年的病例48例54髋,其中男2例,女46例;单侧41例41髋,双侧7例13髋(1例双侧脱位单侧复位成功);治疗时年龄(16.4±3.8)个月(范围6~24个月);随访(2.9±1.8)年(范围2.3~4.1年),末次随访时年龄(4.2±1.8)岁(范围3.4~5.8岁)。吸入麻醉下行闭合复位后给予石膏裤固定,记录石膏裤外展角度。术中复位稳定性以Ramsey安全区评估,包括复位最大外展及再脱位外展角度;复位质量评估包括术中造影及术后MRI测量的关节内侧间隙及股骨头进入深度;每年复查摄骨盆正位X线片,根据Salter标准评估是否发生AVN。采用单因素及二分类Logistic回归模型分析AVN发生的危险因素。结果54髋中12髋发生AVN,发生率22.2%。单因素分析中国际髋关节发育不良协会(International Hip Dysplasia Institute,IHDI)分度及Ramsey安全区复位后最大外展减石膏裤外展的差值(最大-石膏外展差)与AVN发生有关:AVN组与无AVN组的IHDI分度的差异有统计学意义(χ^(2)=8.857,P=0.014),其中IHDI 4度AVN发生率(42.9%,9/21)高于IHDI 3度(9.7%,3/31),差异有统计学意义(χ^(2)=6.007,P=0.018),而IHDI 3度AVN发生率与IHDI 2度(0%,0/2)的差异无统计学意义(χ^(2)=0.000,P=1.000)。AVN组最大-石膏外展差为-0.7°±5.9°,无AVN组为6.1°±7.6°,差异有统计学意义(t=2.125,P=0.038)。多因素分析中,IHDI分度(OR=8.256,P=0.015)和最大-石膏外展差(OR=0.832,P=0.047)是AVN发生的独立危险因素。结论DDH闭合复位石膏裤治疗后AVN主要发生在IHDI 4度脱位患者。治疗过程中人类位石膏裤固定的外展角度与AVN发生无关,但石膏裤外展接近或超过复位最大外展将增加AVN发生的风险。安全的石膏裤固定必须避免极度外展体位,石膏裤外展应小于最大外展5°~10°以上。
Objective To analyze the risk factors of avascular necrosis(AVN)after closed reduction and spcia casting in treating developmental dysplaisa of the hip(DDH).Methods The patients with DDH who received closed reduction in our department from January 2016 to December 2017 were retrospectively reviewed.The inclusion criteria included aged at reduction≥6 months,achieving successful reduction,having complete data with more than 2 years follow-up.A total of 48 cases with 54 hips were included in the present study.Among them,there were 2 males and 46 females,41 unilateral hips and 13 bilateral hips.The mean age at closed reduction was 16.4±3.8 months(range 6-24 months).The mean follow-up duration was 2.9±1.8 years(range 2.3-4.1 years).Closed reduction was conducted under general anesthesia followed with a spcia cast immobilization.The abduction angle of the cast was recorded.The stability of reduction was evaluated by Ramsey safety zone.The maximum abduction and re-dislocation abduction were recorded.The quality of reduction was evaluated by the medial gap and femoral head coverage on intraoperative arthrography and post-reduction MRI.AVN was diagnosed according to Salter criteria.The risk factors of AVN were analyzed by univariate and binary logistic regression analysis.Results AVN occurred in 12 hips(22.2%)of 54 hips.International Hip Dysplasia Institute(IHDI)grade and the difference between maximum abduction and cast abduction(Max-Cast abduction)were related to the occurrence of AVN in univariate analysis.The incidence of AVN in hips of IHDI grade 4(42.9%,9/21)was significantly higher than that in hips of IHDI grade 3(9.7%,3/31)(χ^(2)=6.007,P=0.018).However,the hips of IHDI grade 3 and 2(0%,0/2)presented a similar incidence of AVN(χ^(2)=0.000,P=1.000).The Max-Cast abduction was-0.7°±5.9°in the AVN group and 6.1°±7.6°in the AVN group(t=2.125,P=0.038).Finally,IHDI grade(OR=8.256,P=0.015)and Max-Cast abduction(OR=0.832,P=0.047)were both independent factors of AVN in multivariate analysis.Conclusion Most of the hips with AVN are IHDI grade 4 after closed reduction for DDH.The abduction angle in a spica cast could not be significantly related to the occurrence of AVN.However,the risk of AVN might be increased when the cast abduction is close to or beyond the maximum abduction.Safe abduction in the cast should be 5 to 10 degrees less than maximum abduction at least.
作者
付喆
王侃
邓书贞
陈兆强
张华东
曲大伟
杨建平
张中礼
Fu Zhe;Wang Kan;Deng Shuzhen;Chen Zhaoqiang;Zhang Huadong;Qu Dawei;Yang Jianping;Zhang Zhongli(Department of Pediatric Orthopaedics,Tianjin Hospital,Tianjin 300211,China)
出处
《中华骨科杂志》
CAS
CSCD
北大核心
2021年第14期992-1000,共9页
Chinese Journal of Orthopaedics
关键词
髋脱位
先天性
骨牵引复位法
石膏
外科
手术
股骨头坏死
Hip dislocation,congenital
Skeletal tracting reposition
Casts,surgical
Femoral head necrosis
