本文選題：發(fā)育性髖關(guān)節(jié)脫位　切入點(diǎn)：Dega截骨術(shù)　出處：《山東大學(xué)》2017年碩士論文

【摘要】：研究背景:發(fā)育性髖關(guān)節(jié)脫位(Developmental Dislocation of Hip,DDH)是小兒骨科中的常見(jiàn)畸形,在我國(guó)平均發(fā)病率約3.9‰,南方發(fā)病率較北方為低,習(xí)慣背嬰兒的民族發(fā)病率相對(duì)較低。該疾病的發(fā)生與分娩方式、生后搶救方法和襁褓措施密切相關(guān)。對(duì)于6個(gè)月以內(nèi)的Ortolani征陽(yáng)性嬰兒,常以Pavlik吊帶治療。0.5～1.5歲或2歲的嬰兒,可根據(jù)具體情況行髖關(guān)節(jié)閉合或切開(kāi)復(fù)位+石膏外固定術(shù)治療,必要時(shí)可術(shù)前牽引或輔助長(zhǎng)收肌松解,石膏固定3個(gè)月后更換外展支具繼續(xù)固定3個(gè)月。1.5～2歲以上的患兒,保守治療效果較差,往往需要截骨手術(shù)干預(yù)。用于治療學(xué)齡前(18個(gè)月～72個(gè)月)兒童DDH的髖臼成形術(shù)較多,其中以Pemberton術(shù)式和Dega術(shù)式最為常用,相關(guān)報(bào)道較多。但是所有這些報(bào)道都是針對(duì)某一術(shù)式的療效分析,并未論及不同髖臼形態(tài)與術(shù)式選擇和細(xì)節(jié)操作之間的關(guān)系,也即沒(méi)有論述基于髖臼自身形態(tài)的、針對(duì)性的截骨術(shù)應(yīng)用指征。同心圓復(fù)位是髖臼成形術(shù)的前提,但復(fù)位后應(yīng)用成形術(shù)是為了塑造怎樣的髖臼?這個(gè)問(wèn)題至今無(wú)人回答。我們回顧性分析獲得隨訪的接受Dega術(shù)式治療的學(xué)齡前兒童DDH病例,嘗試對(duì)以上2個(gè)問(wèn)題進(jìn)行回答。研究目的:分析Dega截骨術(shù)治療學(xué)齡前(1.5～6歲)兒童DDH的療效,總結(jié)髖臼成形術(shù)的個(gè)性化應(yīng)用體會(huì)。研究?jī)?nèi)容:回顧性分析獲得隨訪的行Dega術(shù)式治療的學(xué)齡前DDH患兒28例共34髖,手術(shù)時(shí)年齡28± 10個(gè)月(18～72個(gè)月)。34髖均為完全脫位。根據(jù)術(shù)前X線片上假臼形態(tài)分為4組,A組3例3髖,曾行保守治療,無(wú)明顯假臼形成;B組7例7髖,未行保守治療,無(wú)明顯假臼形成;C組6例9髖,假臼明顯,壓迫侵蝕真臼;D組12例15髖,真假臼廣泛融合(融合臼)。分析手術(shù)前后髖關(guān)節(jié)形態(tài)的變化、功能的改善。討論股骨頭缺血性壞死(AVN)的發(fā)生情況。研究結(jié)果:·術(shù)后隨訪67士 14個(gè)月(48～96個(gè)月),末次隨訪時(shí)患兒年齡95±15個(gè)月(73～126個(gè)月)。髖臼指數(shù)由45° ±6。(32～57°)改善至10° ±7。(-6～27°),Reimer 指數(shù)由 0.95±0.12(0.53～1)改善至0.15±0.11(-0.2～0.42),術(shù)后中心邊緣角23° ±7°(11～43°),所有差異均有統(tǒng)計(jì)學(xué)意義(p0.01)。術(shù)前34髖Shenton線均不連續(xù),隨訪時(shí)31髖恢復(fù)連續(xù)性,2髖仍中斷,1髖反向不連續(xù)。根據(jù)改良Severin影像學(xué)分類,Ⅰ類20髖、Ⅱ類12髖、Ⅲ類2髖,優(yōu)良率94%。根據(jù)KalamchiMacEwen股骨頭缺血性壞死分型,Ⅱ型9髖,余25髖無(wú)壞死,壞死率26%。根據(jù)改良McKay臨床功能分級(jí),優(yōu)29髖、良4髖、可1髖,優(yōu)良率97%。綜合A、C組病例行高水平Dega術(shù)式的5髖均未發(fā)生AVN,而行低水平Dega術(shù)式的7髖中5髖發(fā)生AVN,發(fā)生率71%(p=0.028)。綜合B、D組病例行高水平Dega術(shù)式的3髖均發(fā)生AVN,而行低水平Dega術(shù)式的19髖中僅1髖發(fā)生AVN,發(fā)生率5%(p=0.003)。差異均有統(tǒng)計(jì)學(xué)意義(p0.05)。研究結(jié)論:Dega截骨術(shù)治療學(xué)齡前兒童DDH療效顯著,值得臨床推廣應(yīng)用。高水平Dega術(shù)式鉸鏈位置高、截骨遠(yuǎn)端下壓幅度小,適用于矯正保守治療后的殘留髖臼發(fā)育不良和假臼形成明顯的病例;低水平Dega術(shù)式鉸鏈位置低,下壓幅度大,適用于真臼或融合臼的矯正。獲取滿意的覆蓋并打造臼頭匹配性包容是髖臼成形術(shù)的基本要求,個(gè)性化治療DDH必須針對(duì)不同的髖臼形態(tài)選擇相應(yīng)術(shù)式;不同術(shù)式各有適用范圍,不應(yīng)混用。研究意義:本研究是針對(duì)不同的髖臼形態(tài),而非針對(duì)脫位程度進(jìn)行療效評(píng)價(jià),分析的是基于髖臼形態(tài)的手術(shù)療效,因而對(duì)不同術(shù)式適應(yīng)證之間相互聯(lián)系和區(qū)別進(jìn)行探索,是其意義所在。
[Abstract]:Background: the developmental dislocation of the hip (Developmental Dislocation of Hip, DDH) is common in pediatric department of orthopedics deformity, in our country the average incidence rate of about 3.9 per thousand, the incidence is relatively low in the south, the habit of carrying a baby's national incidence is relatively low. The occurrence and mode of delivery of the disease, after the rescue methods and measures are closely related. The baby within 6 months of the positive Ortolani sign baby, often Pavlik sling for the treatment of.0.5 ~ 1.5 or 2 year old baby, according to the specific circumstances of hip joint closed or open reduction and plaster external fixation, when necessary preoperative traction or assisted long adductor muscle relaxation, 3 months after the plaster fixation replacement abduction brace fixed to 3 months.1.5 to children over the age of 2, conservative treatment is poor, often need osteotomy for the treatment of preschool intervention. (18 ~ 72 months) children DDH acetabuloplasty more, The Pemberton operation and Dega operation is most commonly used, reported more. But all of these reports are the effectiveness of an operation, and the relationship between form and not different type selection and operation of acetabular details of the operation is not discussed based on their morphology for acetabular osteotomy, application of indications. Concentric reduction is a prerequisite for arthroplasty, but the reduction after the application of angioplasty is how to shape the acetabulum? This problem has no answer. We retrospectively analyzed and followed up by Dega treatment of preschool children DDH cases, try to answer the above 2 questions. The purpose of the study is to analysis Dega osteotomy for the treatment of preschool (1.5 ~ 6) effect in children with DDH, summarize the experience of the application of personalized acetabuloplasty. Research contents: a retrospective analysis was performed Dega surgical treatment and follow-up of preschool DDH patients 鍎，

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