Lu Xu, Wang Shusen, Fu Jun, Zhang Dongxian, Han, Han, * * *, * * *, * * *, * *, * *, * *, * *, * *, * *Department of joint surgery, Xijing H
Lu Xu, Wang Shusen, Fu Jun, Zhang Dongxian, Han, Han, * * *, * * *, * * *, * *, * *, * *, * *, * *, * *
Department of joint surgery, Xijing Hospital, The Fourth Military Medical University, Shaanxi 710032, China,
[Abstract]: Objective: To investigate the Smith-Peterson and ilioinguinal osteotomy for early treatment of adult hip dysplasia short-term clinical results. Methods: from August 2007 to June 2011 by the Bernese periacetabular osteotomy for the treatment of 19 cases of patients with 22 cases, including 4 cases of male female 15 cases 4 hips, 18 hips with an average age of 26 years (14 ~ 39). Preoperative and postoperative shooting pelvic anteroposterior, hip lateral and hip CT 3D reconstruction, measurement of acetabular CE angle (center edge angle), AC angle (acetabular dome angle), Sharp angle s, and give the hip Harris score. Results: all patients after femoral head coverage was improved significantly, CE angle from 11 degree preoperatively (-7 ~ 22 DEG) increased to an average of 24.4 degrees (16 to 38 degrees), AC angle from 20.6 degree preoperatively (7 to 36 degrees) is reduced to an average of 12.4 degrees (from 4 to 22 s, Sharp ') degree angle from 49.1 degree preoperatively (43 to 59 degrees) is reduced to an average of 40.9 degrees (24 to 50 degrees), hip Harris score from preoperative average of 86 points (80 to 92) for the improvement of an average of 96.9 points (94 to 99). After a mean follow-up of 1.7 years (range, 0.5 to 4 years), hip pain symptoms were relieved or disappeared in 19 patients (22 hips). Conclusion: the Bernese periacetabular osteotomy can significantly improve the acetabular coverage of the femoral head.
Author: Xu Lu (1984-), male, Jiangxi city of Ganzhou Province, postgraduate research direction in reading, joint surgery, Xijing Hospital of The Fourth Military Medical University joint surgery, 710032, Tel: 13572928785, E-mail:firstname.lastname@example.org.
Correspondence Author: Han life, Department of joint surgery, Xijing Hospital, The Fourth Military Medical University, 710032, E-mail: email@example.com
It is an effective and safe surgical method for the treatment of developmental dysplasia of the hip in adults.
[keyword]: hip dysplasia; osteotomy; osteoarthritis; treatment outcome
Treatment of adult developmental dysplasia of the hip with Bernese periacetabular osteotomy LU Xu, WANG Shusen, FU Jun, ZHANG Dongxian, SUN Pengxiao, HAN Yisheng*. Department of Orthopaedics, Xijing Hospital, The Fourth Military Medical University Xi, "an, 710032, China.
Abstract: Objective To report the short-term clinical results of the Bernese periacetabular osteotomy (PAO) which is used to treat adult developmental dysplasia of the hip in the early term through Smith-Peterson and ilioinguinal approaches. Methods Totally 19 cases (22 hips) who s undergone PAO in our "Department between August 2007 and June 2011 were adopted in this study. In this project, there were 4 males (4 hips) and 15 females (18 hips) with a mean age of old. The patients were 26 years required to do radiographic examinations such as AP pelvis, anteroposterior and lateral hip films of affected side, as well as three-dimensional computed tomography. Before and after operation, the X-ray films were respectively measured for CE angle (centre-edge angle), and AC angle (acetabular index angle), as well as Sharp s angle. Harris hip Scores "were recorded before and after surgery. Results The coverage of femoral head of all patients were improved obviously after operation. The mean CE angle was increased from (-7 11 degrees to 22 degrees 24.4 degrees (16 to) to 38 degrees), the mean AC angle was decreased from 20.6 (7 degrees to 36 degrees) 12.4 ~ to (4 ~ 22 degrees), the mean Sharp s angle was decreased from '49.1 degrees (43 to 59 degrees) 40.9 ~ to (24 ~ 50 degrees), and the mean hip Harris scores was improved from 86 (80 ~ 92) to 96.9 (94 ~ 99).The mean follow-up time was 1.7 years (0.5 ~ 4 years). The clinical improvement has happened for all patients. Conclusions The Bernese periacetabular osteotomy Could improve the of head remarkably it is effective and safe surgery to an treat adult DDH. and femoral coverage
Key words: Hip dysplasia; Osteotomy; Osteoarthritis; Clinical results
Hip dysplasia (developmental dysplasia the hip of, DDH) is a common developmental disorder in young adults. In early adulthood, there is a certain relationship between DDH and secondary osteoarthritis of the hip (1). The main pathological features of the patients are the shallow acetabulum and the femoral head displacement. Under normal circumstances, the stress of 30 degrees around the acetabulum is the main stress area, the stress pattern between the acetabulum and the femoral head is a face to face, and is consistent with the trabecular bone (2,3). When the hip dysplasia, acetabular coverage of the femoral head area decreased, the acetabulum and the femoral head local stress increased significantly, even spotty, and the main stress area concentrated on the acetabular rim, thus making the hip joint cartilage damage and accelerated progress of arthritis is osteoarthritis of the hip. Early periacetabular osteotomy can increase the femoral head coverage, ease of acetabulum and femoral head of local stress, improve the symptoms of patients, and to delay or even prevent the development of hip osteoarthritis. Our department from August 2007 to June 2011 by the Bernese periacetabular osteotomy (Bernese periacetabular, osteotomy, PAO) in the treatment of 19 cases of congenital hip dysplasia in patients with a total of 22 hips, 22 hips of 19 cases with satisfactory, report as follows now.
1 clinical data
1.1 general data: a total of 19 cases of hip in this group, including a total of 4 male patients with a total of 4 hips, and a total of 15 female patients with a total of 18 hips, aged from 14 to 39 years, with an average age of 26 years. Standard 4: the 1 symptoms of pain of hip dysplasia in adolescent and adult patients; the lower limit of 2 age by Y cartilage patients is closed; 3 less than 45 years of age, no or only mild hip degeneration (Tö NNIS 1); 4 hip femoral head exhibition in the acetabulum and good tolerance, good range of motion; 5.CE angle less than 25 degrees. Exclusion criteria: severe hip deformity, age greater than 45 years, and severely impaired hip joint activity (Tö NNIS class). There were 8 cases of left hip, right hip in 8 cases, and double hip in 3 cases (n = 6).
1.2 evaluation methods of preoperative and postoperative patients underwent imaging examination (such as radiograph of the pelvis, hip radiographs, hip abduction radiographs, hip joint CT and 3D reconstruction), X-ray measurement in the preoperative and postoperative CE angle, AC angle, Sharp s angle. At the same time, the patients of hip joint was evaluated by Harris score, is divided into the following aspects: pain (0 to 44), functional activities (0 to 47), lower limb deformities (0 ~ 4), the range of motion of hip (0 ~ 5), out of 100 points. Excellent score more than 90 cent; good: 80 ~ 89; benign: 70 ~ 79; difference: < 70.
2.119 patients were followed up for a minimum of 6 months, the longest period of nearly 4 years, with an average of 1.7 years.
2.2 CE angle and AC angle, s angle CE angle Sharp 'results by preoperative mean of 11 degrees (-7 ~ 22 DEG) increased to an average of 24.4 degrees (16 to 38 degrees), AC angle from 20.6 degree preoperatively (7 to 36 degrees) is reduced to an average of 12.4 degrees (4 to 22 degrees). Sharp s angle 49.1 degree preoperatively (43 to 59 degrees) is reduced to an average of 40.9 degrees (24 to 50 degrees). See figure 1.
2.3 patients with Harris score of preoperative average of 86 points (from 80 to 92 points), postoperative average of 96.9 (94 ~ 99). See table 1.
2.4 postoperative complications: postoperative hip joint sciatic nerve incomplete injury in 1 cases, surgical exploration and adjustment of the length of the screw, fully recovered half year after operation; 5 cases of lateral femoral cutaneous nerve injury;
1 cases of fracture of the osteotomy area.
The history of many operation methods in the treatment of DDH, there are a variety of pelvic osteotomy, osteotomy, shelfoperation, proximal femoral osteotomy and arthrodesis 5-8, the acetabular reconstruction is a kind of ideal solution, the reason is that the joint surface between the increase of shares more matching; the bones of tolerance and coverage; stress of the acetabulum and femoral head are relatively more.
The Bernese periacetabular osteotomy, namely Ganz osteotomy, reconstruction of acetabular surgery is a more commonly used, initially by Reinhold Ganz and Jeffrey Mast, the Swiss doctor proposed in 1988 5, polygon periacetabular osteotomy in the acetabular, from the surrounding pelvic in separation, the interception of the acetabulum can be greatly mobile, the coverage of the femoral head were corrected greatly, osteotomy can contact area is conducive to healing, continuous pelvic posterior column, pelvic stability provides the osteotomy, early weight-bearing, acetabular segment cut out large, significantly reduce the risk of ischemic necrosis. The disadvantage is the high technical requirements of the operation, there are a number of complications, including femoral nerve, sciatic nerve palsy, posterior column is not continuous, inadequate or excessive correction, pubic connection, heterotopic ossification. It was first designed to enter from the S-P incision, but the osteotomy of the posterior part of the acetabulum was accomplished by the directional fracture under the condition of non direct vision.
The Bernese periacetabular osteotomy for less than 45 years of age, the epiphyseal line closed, there has been pain, hip abduction of femoral head in the acetabulum and good tolerance, good joint activity, no or only mild hip degeneration (Tö NNIS 1) Adult DDH patients, and for those who have serious hip joint deformity, age more than 50 years and the risk of hip joint activities seriously restricted patients, is not recommended to use the procedure 3. Zhang Hong 9 to ensure that the surgical effect of accurate indications, she proposed indications and contraindications were indications: (1) for patients with hip dysplasia, CE angle, AC angle < 25º > 15º. (2) the patients had hip pain, relieved after rest, and had good joint mobility. (3) the OA of hip joint is lighter, that is, the joint space of hip joint is good, and there is no obvious stenosis. (4) no obvious deformity of hip abduction, radiographs of the femoral head of mortar with good visible. Contraindications: (1) severe joint deformity, femoral head and acetabular articular surface of the relationship cannot restore osteotomy. (2) the degree of hip mobility was significantly limited. If the preoperative hip joint stiffness, postoperative osteotomy will be subject to a large amount of active stress, which results in abnormal activity of the ends of the osteotomy and bone nonunion. (3) the age is too large and heavy OA, patients with postoperative functional recovery, bone remodeling is also poor, will significantly affect the operation effect.
Some scholars believe that 10 patients with hip dysplasia early if not given effective treatment, joint is always in high stress state, the degeneration of cartilage ossification, gradually thinning, the joint contact surface changes, the joint forces to further increase, the cancellous bone trabecular bone collapse, blood supply reduced bone formation of necrosis, X-ray manifestations of hardening zone and if the hardened zone is replaced with fibrous tissue formation of cystic change, further development will become secondary hip osteoarthritis. By Smith-Peterson and ilioinguinal osteotomy through adjusting the acetabular position to increase the coverage area and inclusive of the femoral head, alleviate the local stress of the joint, the high stress state into a balanced state, thus delaying or even prevent the further progression of hip joint osteoarthritis. This procedure has many advantages: 11 1 of this procedure can effectively increase the coverage of femoral head, improve the femoral head before and after the coverage of 2; not significantly alter the shape of the pelvis; 3 to maintain the integrity of pelvic posterior column, which can make patients with early functional exercise; 4 ensure the blood supply of the acetabulum is not affected; 5 women of childbearing age patients can natural childbirth fetal etc..
Burke 12 reported on 79 cases (85 hips) were treated with PAO DDH, the average follow-up time was 59 months (16 to 96 months), patients with Merle-d'Aubign score from preoperative 12.4 points (9 to 14) increased to 16 (from 11 to 18 points), during the follow-up period, 61 patients (63 hips) with no or only mild pain symptoms, 48 patients (52 hips). Hip joint activities without restriction, 4 patients underwent osteotomy in total hip arthroplasty. Matheney 13 of 109 cases (135 hips) treated by PAO DDH with an average of 9 years (9 + 2.2 years) of follow-up, including 102 hips (76%) joint function is preserved, 33 hips (required for correction of failed total hip replacement or WOMAC pain score = 10, 20) patients (20 hips) in the first year after surgery related complications occurred, is one of the most common ipsilateral peroneal nerve paralysis (9 hips, 6.7%), and 2 patients (2 hips) without clinical symptoms of ipsilateral superior ramus of pubis bone nonunion and in 1 patients after February the formation of pelvic abscess, the complications in early postoperative, after treatment to rehabilitation.
Adult hip dysplasia patients are mostly young people, especially women, the majority of patients with rapid progression, speed, great impact on daily life of patients, so early detection and early treatment is especially crucial to 14, by covering the improvement of acetabulum, thus delay or even prevent progression of hip osteoarthritis and improve the quality of life of patients. The Bernese periacetabular osteotomy in the treatment of adult hip dysplasia is an ideal scheme through periacetabular osteotomy to correct the acetabular rotation, hip deformity of the femoral head, so that can get better coverage, reduce the local stress of femoral head 15. From our follow-up results, most of the patients symptoms improved significantly, but there are still some problems: 1 through Smith-Peterson approach for periacetabular osteotomy at the ischial ramus underperforming, ischium osteotomy is not easy to locate, mainly by the surgeon's experience and sense of osteotomy; 2 via ilioinguinal approach the operation requirements of high technology, in early may encounter more serious complications; 3 rotation direction and angle of rotation of the acetabulum when no specific quantitative criteria, to achieve the best coverage of the femoral head. To solve these problems, we think it should be prepared before surgery to improve the preoperative design, the CT three-dimensional reconstruction technique in combination with computer technology to simulate the operation, to determine the direction and angle of the acetabular osteotomy in advance, intraoperative surgical navigation positioning by operating system, so as to improve the accuracy of acetabular osteotomy. In addition, although the preoperative and postoperative observation indicators have different degrees of improvement, but do not know the changes in the coverage area of the femoral head, at present we are also related to the study of the image.
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A: preoperative CE angle =18 degrees, AC angle =20 degrees, Sharp 's angle =44 degrees
B: after CE angle =38 degrees, AC angle =4 degrees, Sharp 's angle =24 degrees
Figure 2 X-ray films before and after operation
Table 1 Harris score of hip joint before and after operation (n=22)