Evaluation of the efficacy of proximal femoral varus derotational osteotomy in conjunction with modified triple innominate osteotomy for the management of hip dislocation in cerebral palsy
Evaluation of the efficacy of proximal femoral varus derotational osteotomy in conjunction with modified triple innominate osteotomy for the management of hip dislocation in cerebral palsy
目的 评估股骨近端内翻去旋转截骨联合改良骨盆三联截骨术治疗脑瘫髋脱位的临床疗效。 方法 回顾性分析2018年11月至2022年9月接受股骨近端内翻去旋转截骨联合改良骨盆三联截骨术治疗23例（28髋）脑瘫髋脱位患者的病历资料，男17例、女6例，左侧11髋、右侧17髋，手术年龄为7.7（6.9，8.9）岁。术前8髋存在疼痛症状。对患者施行股骨转子下三维截骨矫形并应用儿童髋关节钢板内固定，经Smith-Petersen入路及会阴入路行改良骨盆三联截骨。手术前后完善临床评估，包括髋关节疼痛程度及关节活动度；影像学评估指标包括位移指数（migration percentage，MP）、髋臼指数（acetabular index，AI）、髋臼偏移（acetabular offset，AO）、颈干角（neck shaft angle，NSA）和股骨前倾角（femoral neck anteversion，FNA）。 结果 所有被纳入的病例均得到随访，随访时间为15（12，20）个月。手术时间为6.1（5.5，6.9）h，术中失血量为（400±153）ml（范围200~800 ml）。未观察到坐骨神经损伤、切口或深部感染的病例。术后1周MP为0%（0%，0%），与术前50.5%（38.2%，75.8%）的差异有统计学意义（Z=4.624，P<0.001）；AI为1.0°（-3.3°，11.8°），与术前29.4°（26.3°，38.0°）的差异有统计学意义（Z=4.623，P<0.001）；AO为69.8（66.0，76.0）mm，与术前72.3（69.1，81.1）mm的差异有统计学意义（Z=4.099，P<0.001)；NSA为124.3°（118.7°，129.9°），与术前145.6°（139.6°，153.5°）的差异有统计学意义（Z=4.541，P<0.001）；FNA为13.0°（5.4°，24.1°），与术前33.6°（27.8°，39.8°）的差异有统计学意义（Z=4.407，P<0.001）。术后7髋疼痛症状得到缓解、1髋残留关节疼痛。术后伸髋外展活动度增加、伸髋内旋活动度减小、伸髋外旋和屈髋活动度与术前的差异无统计学意义。2髋（7%）存在髂骨弓状线不愈合。随访期间未观察到股骨头坏死、再脱位和行翻修手术的病例。末次随访时MP为0%（0%，10.0%），与术后1周MP的差异无统计学意义（Z=0.561，P=0.575）。 结论 改良骨盆三联截骨术可有效矫正脑瘫髋脱位的髋臼畸形，联合股骨近端内翻去旋转截骨能有效矫正脑瘫髋脱位、缓解疼痛并保留髋关节活动度。 Objective To assess the effectiveness and postoperative stability of proximal femoral varus derotational osteotomy combined with modified triple innominate osteotomy in treating hip dislocation in cerebral palsy. Methods A total of 28 hips (11 left, 17 right) from 23 patients with cerebral palsy-induced hip dislocation who underwent the said surgical procedures were retrospectively examined between November 2018 and September 2022. The median age at the time of surgery was 7.7 years. Preoperatively, 29% of hips exhibited pain. Intraoperatively, a three-dimensional subtrochanteric osteotomy was performed with internal fixation using a Pediatric Hip Plate, alongside a modified triple innominate osteotomy via the Smith-Petersen and perineal approaches. Clinical assessments included pre- and postoperative evaluations of hip pain and joint mobility, as well as imaging evaluations, including migration percentage, acetabular index, acetabular offset, neck shaft angle, and femoral neck anteversion. Results With a median follow-up of 15 months (range: 12 months to 20 months), all patients were successfully monitored. The median surgery duration was 6.1 hours, with blood loss averaging 400±153 ml (range 200-800 ml). The difference between the median postoperative (1 week after operative) MP 0% (0%, 0%) and the median preoperative MP 50.5% (38.2%, 75.8%) was statistically significant (Z=4.624, P<0.001). The difference between the median postoperative AI 1.0° (-3.3°, 11.8°) and the median preoperative AI 29.4° (26.3°, 38.0°) was statistically significant (Z=4.623, P<0.001). The difference between the median postoperative AO 69.8 (66.0, 76.0) mm and the median preoperative AO 72.3 (69.1, 81.1) mm was statistically significant (Z=4.099, P<0.001). The difference between the median postoperative NSA 124.3° (118.7°, 129.9°) and the median preoperative NSA 145.6° (139.6°, 153.5°) was statistically significant (Z=4.541, P<0.001). The difference between the median postoperative FNA 13.0° (5.4°, 24.1°) and the median preoperative FNA 33.6° (27.8°, 39.8°) was statistically significant (Z=4.407, P<0.001). The pain was relieved postoperatively in 7 hips (88%) and residual hip pain in 1 hip. The postoperative range of motion was preserved. No case of avascular necrosis of the femoral head was observed. There were 2 hips (7%) with nonunion in the iliac arcuate line. No case of redislocation was observed at the last follow-up, and no revision was performed recently. There was no significant difference between the median MP at the last follow-up of 0% (0%, 10.0%) and the median postoperative MP (Z=0.561, P=0.575). Conclusion The modified triple innominate osteotomy proved to be an effective intervention for correcting acetabular deformity in cerebral palsy-induced hip dislocation. The combination of proximal femoral varus derotational osteotomy with the modified triple approach not only significantly corrected hip dislocation but also alleviated pain and maintained joint mobility in pediatric patients with cerebral palsy.
Abstract
Objective To assess the effectiveness and postoperative stability of proximal femoral varus derotational osteotomy combined with modified triple innominate osteotomy in treating hip dislocation in cerebral palsy. Methods A total of 28 hips (11 left, 17 right) from 23 patients with cerebral palsy-induced hip dislocation who underwent the said surgical procedures were retrospectively examined between November 2018 and September 2022. The median age at the time of surgery was 7.7 years. Preoperatively, 29% of hips exhibited pain. Intraoperatively, a three-dimensional subtrochanteric osteotomy was performed with internal fixation using a Pediatric Hip Plate, alongside a modified triple innominate osteotomy via the Smith-Petersen and perineal approaches. Clinical assessments included pre- and postoperative evaluations of hip pain and joint mobility, as well as imaging evaluations, including migration percentage, acetabular index, acetabular offset, neck shaft angle, and femoral neck anteversion. Results With a median follow-up of 15 months (range: 12 months to 20 months), all patients were successfully monitored. The median surgery duration was 6.1 hours, with blood loss averaging 400±153 ml (range 200-800 ml). The difference between the median postoperative (1 week after operative) MP 0% (0%, 0%) and the median preoperative MP 50.5% (38.2%, 75.8%) was statistically significant (Z=4.624, P<0.001). The difference between the median postoperative AI 1.0° (-3.3°, 11.8°) and the median preoperative AI 29.4° (26.3°, 38.0°) was statistically significant (Z=4.623, P<0.001). The difference between the median postoperative AO 69.8 (66.0, 76.0) mm and the median preoperative AO 72.3 (69.1, 81.1) mm was statistically significant (Z=4.099, P<0.001). The difference between the median postoperative NSA 124.3° (118.7°, 129.9°) and the median preoperative NSA 145.6° (139.6°, 153.5°) was statistically significant (Z=4.541, P<0.001). The difference between the median postoperative FNA 13.0° (5.4°, 24.1°) and the median preoperative FNA 33.6° (27.8°, 39.8°) was statistically significant (Z=4.407, P<0.001). The pain was relieved postoperatively in 7 hips (88%) and residual hip pain in 1 hip. The postoperative range of motion was preserved. No case of avascular necrosis of the femoral head was observed. There were 2 hips (7%) with nonunion in the iliac arcuate line. No case of redislocation was observed at the last follow-up, and no revision was performed recently. There was no significant difference between the median MP at the last follow-up of 0% (0%, 10.0%) and the median postoperative MP (Z=0.561, P=0.575). Conclusion The modified triple innominate osteotomy proved to be an effective intervention for correcting acetabular deformity in cerebral palsy-induced hip dislocation. The combination of proximal femoral varus derotational osteotomy with the modified triple approach not only significantly corrected hip dislocation but also alleviated pain and maintained joint mobility in pediatric patients with cerebral palsy.
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