2010年9月15日 星期三

先天性髖關節脫臼

概述
發育性髖關節脫位Developmental Dysplasia of the Hip指患兒出生時或在發育過程中髖臼變淺或股骨頭脫出髖臼之外的現象。又叫先天性髖關節發育不良,先天性髖關節脫位。Developmental dysplasia of the hip (DDH) is a condition which defines any abnormality of a child’s proximal femur or acetabulum. Most commonly this refers to neonatal hip
instability, but also may describe a stable hip with an underdeveloped or shallow acetabulum. A full spectrum of disease may be seen—from the newborn with an irreducible dislocated hip, to the adolescent with hip pain secondary to a mild “uncovering” of the femoral head. Natural history studies suggest a significant relationship between DDH and early onset degenerative hip disease. Thus, early diagnosis and management are extremely important in order to help prevent early onset arthritis and pain in the older patient.近十年來,國外學者註意到,有患兒在出生時髖關節是正常的,但隨著生長發育逐漸出現髖臼發育不良或髖臼發育不良伴股骨頭的半脫位或全脫位。因此,1991年美國骨科學會(AAOS)和北美小兒骨科學會(POSNA)建議將先天性髖關節脫位(CDH, Congenital Dislocation of the Hip)更名為發育性髖關節異常(DDH),它包括患兒出生時就已存在的髖臼發育不良、股骨頭的半脫位或全脫位,也包含了生長發育逐漸出現髖臼發育不良或髖臼發育不良伴股骨頭的半脫位或全脫位。由CDH變為DDH,反映了人們對DDH的病理改變、自然史的認識更加深入。由於DDH的名稱尚未列入WHO的“疾病分類”中,仍有學者在臨床實踐中將其稱為先天性髖關節脫位.

估計我國的發生率大概為1‰。約20%的先髖脫位有家族史;80%的先髖脫位是第一胎;我國統計男女之比為1:4.75. 喜歡用捆綁方法的民族,使新生兒髖關節固定於伸展、內收位,其發生率明顯增高,臀位產發生先髖脫位較頭位產高10倍;剖腹產發生先髖脫位較***產高,
1、單純性先天性髖脫位 
   (1)髖關節發育不良:又稱為髖關節不穩定,X線片常以髖臼指數增大為特點,多數采用髖關節外展位而隨之自愈,約1/10將來發展為先天性髖脫位,還有少數病例持續存在髖臼發育不良,年長後出現癥狀。 
   (2)髖關節半脫位:X線片有髖臼指數增大,髖臼覆蓋著部分股骨頭,這是一種獨立的類型,可長期存在而不轉化為全脫位。 
   (3)髖關節全脫位:股骨頭完全脫出髖臼,根據股肌頭脫位的高低可分為四度: 
    Ⅰ度:股骨頭僅向外方移位,位於髖臼同一水平; 
    Ⅱ度:股骨頭向外、上方移位,相當於髖臼外上方水平; 
    Ⅲ脫出的股骨頭位於髂骨翼的部位; 
    Ⅳ脫出的股骨頭上移達骶髂關節水平。 
2、畸形型先天性髖脫位 
    典型者呈雙髖脫位,雙膝關節處於伸直位僵硬,不能屈曲,兩足平足呈外旋位,還常合並上肢畸形。
 
診斷
新生兒及嬰兒先天性髖脫位的特點是什麽? 
   1、先天性髖脫位在新生兒期診斷較為困難,一旦確診治療容易,且會獲得理想的治療效果。因為新生兒期病理改變最輕,易於矯正;生後第一年骨盆發育最快,尤其在新生兒期更快。 
   2、臨床癥狀 
   外觀:大腿、小腿與對側不對稱,可表現為增粗變短或變細、外旋(單側);臀部增寬(雙側)。 
   皮紋:臀部、腹股溝與大腿皮紋增多、增深和上移不對稱。 
   肢體活動:患肢活動少,在換尿布時最易發現。 
   3、體征 
   患肢股動脈減弱或消失; 
   內收肌緊張痙攣; 
   Barlow試驗陽性  Ortolani征或外展試驗陽性,此2法僅用於3月齡之內。 
   4、X線檢查 
   Von-Rosen位骨盆平片:正常延長線經髖臼外緣相交於腰5與骶1的平面以下; 
   骨盆平片:髖臼指數 正常為20-25°,至12歲時基本恒定於15°,異常為>30°; 
   Perkin's方格 正常位於內下象限 
   Shenton氏線 Nelaton線征破壞。
   測量 Hilgenereiner股骨幹骺端頂點至水平線的距離為H,正常為10mm;股骨幹骺端頂點至髖臼最內緣的距離為d,正常以12 mm為標準。當H值小於10 mm或d距離大於12 mm應懷疑髖發育不育。 
   Bertol測量法:(P30圖4-4)正常上方間隙a為9.5 mm,內側間隙b為4.3 mm。若a小於8.5 mm,b大於5.1 mm應懷疑髖脫位。若a小於7.5 mm,b大於6.1 mm可診斷為髖脫位。
幼兒及兒童期發育性髖脫位的特點?
臨床癥狀:走路較晚,步態異常:開始走路時步態不穩呈蹣跚、搖擺或搖動步故態(單側);雙側者為鴨行步態,肢體不等長,軀幹呈代償性側彎 
   (2)、體征: Allis征陽性(單側) 
   Ortolani征或外展試驗陽性 
   Nelaton線征破壞 
   Trendelenburg征陽性 
   (3)、X線檢查 
   髖臼指數 
   CE角:正常值4歲+15°以上,15歲為+20°以上 
   Perkin's方格 
   Shenton氏線 
   Sharp角:該角>40°即表示髖臼發育不良。 
   股骨頸前傾角的測量:X線雙平片 
   頭臼指數(AHI):由股骨頭內緣到髖臼外緣的距離A比股骨頭的橫徑B,表示股骨頭的大小與髖臼深度不相稱的狀態。其特點是隨年齡的增長而頭臼指數隨之下降,一般正常值在84-85左右。其計算公式為AHI=A/B×100。 
   髖關節間隙:與正常側相比較,雙側患者與同年齡髖關節進行比較。測定股骨頭最高點的面與髖臼軟骨底面的距離,分為5級,4級為正常間隙,3級較正常窄1/4,2級較正常窄1/2,1級較正常窄3/4,0級關節間隙完全消失。用以判斷有無創傷性關節炎的標準。 
   (4)、其它檢查:關節造影、CT、MRI均能對先天性髖脫位有其診斷價值。
髖關節脫位Crowe分類法?Crowe分類法即根據X線片測量股骨頭移位距離與股骨頭及骨盆高度的比例將其分為四型:Ⅰ型:股骨頭移位占股骨頭高度不到50%,或骨盆高度不到10%;
Ⅱ型:股骨頭移位占股骨頭高度的50%~75%,或骨盆高度的10%~15%;
Ⅲ型:股骨頭移位占股骨頭高度的75%~100%,或骨盆高度的15%~20%;
Ⅳ型:股骨頭移位超過股骨頭高度的100%,或骨盆高度的20%。 

參考資源:http://www.dxy.cn/bbs/actions/archive/post/7789456_1.html

DDH的診斷由哪三個主要階段?
1.第一階段:大約從1920年到1950年。在這一階段新生兒的DDH普查項目尚未引入,這時期所診斷患者的年齡差別大,制訂的標準不統一,所報道的數據中差異很大以至於數據之間可比性很差。在這段時期,DDH的發病率大約為0~20%。
2.第二階段:從1950年到1980年,在這一段時間裏引入了新生兒普查。在此階段DDH病例數據主要是基於臨床物理檢查提示的髖不穩,這就導致了很多患者的過度診斷(overdiagnosis)和過度治療(overtreatment)。
3.第三階段:1980年以後,奧地利醫生Graf率先報道運用超聲波檢查技術診斷新生兒和小嬰兒發育性髖關節異常。DDH的發病率則降為0.5%到6.18%。由於超聲的高靈敏性,使得超聲能檢測出臨床上未被發現的異常髖關節(靜止的病理髖。

超聲波在早期診斷DDH中的價值是什麽?
超聲波髖關節檢查技術在很多醫學發達國家和地區被公認為早期診斷DDH的首選方法,成為當前早期發現和幹預治療兒童DDH的重要手段。
超聲波具有穿透軟骨的特性,特別適合在股骨頭尚未出現骨化的新生兒和嬰兒中施行檢查。隨著股骨頭骨化中心的形成和增大,超聲波的作用也將下降。超聲波髖關節檢查具有很高的靈敏度和精確性表現在發現髖臼形態變化的能力上比X線片測量髖臼指數(AI)更為精確,它發現盂唇和園韌帶變化的能力與髖關節造影相當Graf指出:超聲波提供了早期鑒別髖關節成熟的可能,選擇最佳治療方法並實施監視的可能。 
國際上常用的方法是Graf法:探頭置大轉子上,縱軸和軀幹縱軸平行,前後平行移動探頭,以獲得較清晰的髖額狀斷面聲像,測得α、β角。再根據α、β角的大小將髖關節分為4型。Ⅰ型α>60°、β<55°,屬正常髖關節,骨性髖臼發育良好:Ⅱ型:α43°~60°,β55°~77°,即髖關節發育不良;Ⅲ型:<43°,β>77°,半脫位;Ⅳ型:完全脫位。α角(骨頂角)是指由骨頂線(BD)和基線(AB)相交而成的夾角;β角(軟骨頂角):由軟骨頂線(BC)和基線(AB)相交而成的夾角
治療
新生兒組(0-6月)Ortolani和Barlow試驗陽性的患兒,治療的目的是穩定髖關節,對於有輕中度內收肌攣縮的患兒治療目的是髖關節復位。應用Pavlik 挽具(Pavlik harness)治療成功率為85%,但是應用連衣挽具後做Barlow試驗確定髖關節穩定性,然後俯臥位觸摸雙側大粗隆不對稱說明仍有脫位,拍片證實股骨頸正對著Y形軟骨。但是隨著患兒年齡的增長,軟組織攣縮的出現以及髖臼的繼發改變,連衣挽具的治療成功率逐漸下降。應用連衣挽具後根據脫位類型確定治療方案:向上脫位增加屈髖;向下脫位減少屈髖;向外脫位持續觀察;向後脫位常常伴有內手肌緊張,在後側觸摸到大粗隆可以作出診斷。改為其他方法。全天佩戴挽具的時間為髖關節穩定後再加2個月,挽具治療有缺血性股骨頭壞死潛在並發癥。必須對髖關節脫位方向、穩定性和復位的可能性作出判斷,如果屬於畸胎性脫位、不能復位、或者髖臼覆蓋小於20%則不能使用連衣挽具。
牽引復位法:適用於6個月以內的患兒,也有人用於1歲以內的患兒。內收肌切斷閉合復位法:主張用於2歲以內的患兒,保守治療一般頭三個月用石膏固定,以後改用支架固定,保持髖關節的有限制動;固定時間一般為就診月齡時間或加3個月,一般每三個月復查一次並復查骨盆平片進行監測.
石膏固定為何選用人字位而不是蛙式位?主張采用人位固定(Human Position)而不用Lorenz體系的蛙式位,其理由如下: 蛙式位是股骨頭遭受髖臼壓力最大的體位,尤其是對6個月以內的嬰兒; 蛙式位時經過內收長肌與髂腰肌之間的旋股內側動脈遭受壓迫,將直接影響股骨頭的血運; 蛙式位時,增大的盂唇可以壓迫骺間溝,致使股骨頭發育受到影響,甚至產生畸形。 
 
影響復位的因素有哪些?  髂腰肌的攣縮; 盂唇過大,阻塞了髖臼而影響股骨頭的復位; 頭、臼不稱,通常是髖臼過小過淺; 其它:如髖臼內脂肪過多,圓韌帶過長、增寬在臼內形成阻塞,關節囊的攣縮等。
髖關節發育的基本條件是什麽?保持頭、臼同心是髖關節發育的基本條件。
幼兒或兒童組(3-8歲)DDH是否需要骨牽引?術前不應該再做骨牽引,因為:術前骨牽引發生股骨頭缺血性壞死和再脫位的發生率分別是54%、31%,而切開復位加股骨短縮截骨發生率分別是8%、0% 參考資源:坎貝爾骨科手術學,2005第十版第二卷,1045.The management of untreated congenital dislocation of the hip in a child older than 3 years of age is difficult. By this age, adaptive shortening of the periarticular structures and structural alterations in the femoral head and the acetabulum have occurred. Dislocated hips in this age group require open reduction. Preoperative skeletal traction should not be used. Schoenecker and Strecker reported a 54% incidence of osteonecrosis and a 31% incidence of redislocation after the use of skeletal traction in patients older than 3 years. Open reduction combined with femoral shortening resulted in no osteonecrosis and an 8% incidence of redislocation. Coleman reported an 8% incidence of osteonecrosis in his series of femoral shortening. At an almost 7-year average follow-up, Vallamshetla et al. reported only one patient with osteonecrosis in 18 hips treated with one-stage femoral shortening and acetabuloplasty in patients 4 to 11 years old. Excellent results were obtained in 12 hips and good results in six; however, leg-length discrepancies of 1.5 cm or less occurred in eight patients with unilateral dislocations. Two hips required additional surgery because of resubluxation (6 weeks after surgery) and inadequate correction of anteversion (6 years after surgery). Although femoral shortening aids in the reduction and decreases the potential for complications, it is technically demanding, as is treatment of the dislocated hip, in this older age group.參考資源:坎貝爾骨科手術學(英文版),第11版,第二卷.
發育性髖關節脫位常用的骨盆截骨方式有哪些(坎貝爾)單純骨盆截骨或者與切開復位聯合應用是增加或者保持術後髖關節穩定的措施,骨盆截骨包括:1 Salter髂骨截骨; 2 Pemberton髖臼成形術;3 遊離髖臼截骨(Steel三相截骨或者轉盤式髖臼截骨適用於7歲以上,髖臼發育極度不良者);4 Staheli造架術; 5 Chiari髖臼內移截骨 ;參考資源:坎貝爾骨科手術學;2005第十版第二卷,1049改良沙拉尼契克手術(Zahradnick):是一次性髖臼、股骨頸、股骨幹成形術,使其恢復解剖關系和功能,這種手術適用於3-7歲手術法失敗或發現較晚7歲以內的兒童。手術成功率是很高的,但其並發癥有可能影響關節活動功能。應強調年齡越小手術效果越好,並發癥越少。 Gill手術。
Salter骨盆截骨術的手術適應癥、註意事項?  手術適應癥:年齡在1.5-6歲的先天性髖關節脫位患兒,髖臼指數在45°以下,股骨頭大小與髖臼基本適應者。  手術前準備:必須進行牽引,可行皮牽引或骨牽引,牽引時間不應少於3-4周,必須使股骨頭達到髖臼Y形軟骨線水平。 術中註意事項: 手術時對內收肌和髂腰肌均應切斷,在關節囊外分離髂腰肌至股骨小轉子處應註意保護股神經;髖臼內的脂肪組織和圓韌帶均應清除,特別註意要切斷髖臼橫韌帶;作髂骨截骨時應用線鋸鋸斷而不應用骨刀,理想的截骨應是在髂骨上、下棘之間,保持內低外高,後低前高;髂骨遠端應以恥骨聯合為軸心,向前、下、外方向牽引旋轉,改變髖臼的方向;註意保持不能造成髂骨截骨後方張開,這樣達不到髂骨充分旋轉。  6-8周折石膏並可拔出固定鋼針; 三個月後開始下地行走。
 髂骨截骨由Salter倡導應用,僅適用於1.5-6歲的髖關節能夠同心圓復位者。術中整個髖臼、恥骨、坐骨作為一個單位一並向前外旋轉,恥骨聯合起鉸鏈作用。嚴重的髖臼發育不良和髖關節未中心性復位者是該手術的禁忌癥。
Salter髂骨截骨手術成功的前提:股骨頭位於髖臼水平;必須松解攣縮的髂腰肌、內收肌;必須使股骨頭中心性和完全性復位,切除髖臼內軟組織(不包括臼唇);髖關節必須匹配;髖關節活動特別是外展、內旋和屈曲必須在正常範圍內。
Salter骨盆截骨容易損傷的組織有:股外側皮神經、坐骨神經、股神經、閉孔神經、闊筋膜張肌的營養血管
手術體位:仰臥位患側胸部髖部墊高
先期經皮或者切開松解內收肌,手術切口:起自髂脊前中1/3向前延長至髂前下棘,繼續沿腹股溝韌帶延長至於起止點; 鈍性分離闊筋膜張肌與縫匠肌、股直肌間隙,顯露髂前上棘後,銳性分離股直肌及深面的關節囊,切斷股直肌直頭及反折頭
沿髂脊從前中1/3向前切開髂脊骨骺,至於前方的髂前下棘;將髂脊骨骺的外側半連同骨膜,從髂骨外板上行骨膜下連續剝離,前方剝離到髖臼上緣,後方至於坐骨切跡;分離關節囊與髂骨外板及假臼的粘連,顯露前方的關節囊,並鈍性分離關節囊與外側臀肌的間隙;用大塊紗布充填已經分離的間隙控制出血並增加骨膜與坐骨切跡之間的距離,如果股骨頭不能進入髖臼實現中心性復位,與髖臼下方1cm並與髖臼平行切開前上方關節囊;如果圓韌帶肥厚應該切除,再輕柔的把股骨頭復位入髖臼,切勿切除盂唇;T形切開關節囊把所形成的外下方的三角形關節囊瓣切除,試驗髖關節的穩定性,如果髖關節內收時,股骨頭自髖臼向上方移位,髖關節伸直或者外旋時,股骨頭則向前移位,應該作骨盆截骨;從髂脊的前部剝離髂脊內側半骨骺,並骨膜下剝離髂骨內板的後下部分,顯露髂骨內板和坐骨切跡,填塞紗布控制止血,增加骨膜與髂骨間隙,顯露髂腰肌的腱性部分,用剪刀把腱性部分從肌肉上分離,切斷腱性部分,但需要保護肌肉。把一直角鉗從髂骨外板深入坐骨切跡,夾住線鋸一端使之通過坐骨切跡。將髂骨內外板兩側的組織牽開,用線鋸把髂骨從坐骨切跡到髂前上下棘之間直線截斷。從髂脊前部切除用於植骨的全厚髂骨塊將其修剪成楔形,基底寬度相當於髂前上下棘之間的距離。用數把巾鉗夾住截斷的髂骨兩端,繼之把一彎形骨膜起子插入坐骨切跡,向前方翹起截骨兩端,同時牽拉夾住截骨遠端的巾鉗,使截骨遠端向前、外下方移動,並使截骨兩端在前外側張開形成間隙,但要保證截骨兩端的後方緊密接觸,把楔形植骨塊嵌入截骨間隙。(若把患肢置於做4字試驗的位置,可使截骨遠端的移位更加容易,切記不要向頭側牽拉截骨近端的巾鉗,避免造成骶髂關節脫位);用一根螺紋克氏針從截骨近端的髂骨近端的髂骨,經植骨塊進入截骨遠端,避免鉆入髖臼,然後平行鉆入第二根螺紋針;再次把股骨頭復位進入髖臼,重新試驗其穩定性,此時,髖關節在內收及輕度外旋位也應該很穩定,閉合切口時,助手擡起下肢,保持膝關節屈曲、髖關節輕度屈曲、外展和內旋,縫合關節囊;在保持髖關節內旋位時,把遠端外側關節囊瓣拉向內側並越過髂前下棘,間斷縫合修復關節囊;縫合縫匠肌、股直肌到原來的位置,再把髂脊骨骺的內外側半於髂脊上縫合。剪除螺紋克氏針一端埋於皮下脂肪內,皮內連續縫合切口,術後單髖人字石膏固定。術後處理:術後8-12周拆除石膏,在局麻或者全麻下取出克氏針, 參考資源:坎貝爾骨科手術學,2005第十版第三卷,1050-1051

Pemberton髖臼成形術的手術適應征、註意事項?
    手術適應征: 年齡在2歲以上,髖臼發育不良,髖臼角大於45°以上,頭臼比例不適合髖臼不能包容股骨頭者;手法或手術復位後,經一定時間觀察,髖臼仍發育不佳或未發育,股骨頭仍處於半脫位或全脫位;年齡超過7歲以上,恥骨聯合軟骨已愈合,雖髖臼指數未超過45°者也適應此術式。  用髖人字石膏,外展、外旋0度位。或應用矯形支具,固定角度可以調整。術後6-8周折石膏; 術後3-6個月下地行走。
  
先髖脫位遠期療效如何評價? 
    1、本評價標準適用於手術或保守治療之後的各年齡組的先天性髖脫位的療效評定;對療效的評定時間至少在治療後2年以上方可評定,時間過短意義不大;本標準既可反應出隨訪的結果也可判斷預後,具有使用簡便,判斷容易,評價較準確的特點。 
    2、本標準由兩大部組成,均以評分方式進行,總計30分。 
    ⑴ 臨床功能評價(15分):主觀感覺和臨床檢查 
    ⑵ X線攝片檢查評價(15分): 
    3、評價方法: 
    4、評定: 
     30-26分……優 
     25-21分……良 
     20-16分……可 
     <15分 ……差
先髖進展
Developmental Dysplasia of the Hip (DDH). Developmental dysplasia of the hip represents a spectrum of abnormalities relating to the growth and development of the hip joint. Risk factors include family history, breech, oligohydramnios, female, and first-born.
Diagnosis. Tests for neonatal instability include the Ortolani and Barlow maneuvers. The Barlow maneuver is a stress test in which gentle posterior pressure is exerted with the hip in adduction. A positive test indicates that the hip is subluxatable or dislocatable, indicative of significant neonatal laxity. The Ortolani maneuver assesses whether a dislocated hip is reducible, and involves gentle abduction of the hip coupled with anterior translation of the head of the femur. Physical findings in older infants with a subluxated or dislocated hip may include limited passive abduction (adduction contracture), positive Galeazzi sign (difference in knee heights when both hips are flexed to 90 degrees and held together), and asymmetric thigh folds. The femoral capital epiphysis appears by 3 to 6 months and interpreting radiographs of hips becomes easier at this time. Prior to this, ultrasound is the best way to diagnose this condition. Graf classified the dislocation in four types on the basis of alpha angle obtained on static ultrasound (Fig. 2.10 AB). The normal angle is greater than 60 degrees and anything less than 43 degrees is classified as dislocation. The dynamic ultrasound is performed in coronal plane while maneuvering the hip as in the Barlow test. Ultrasound not only assists diagnosis but also is useful to confirm reduction and assess the reduction in follow-up. Plain radiographs are useful once the ossific nucleus has appeared. The femoral head or metaphyseal beak should lie in the inner and lower quadrant formed by Perkins line and Hilgenreiner line (Fig. 2.10 C). An arthrogram is more useful for assessment of reduction of hip following examination under anesthesia. It also allows interpreting the structures obstructing the reduction of the hip.P.106

 
FIGURE 2.10 (A) Images of normal ultrasound of an infant. (B) Schematic ultrasound image to demonstrate the alpha and beta angles in the hip. (
A and B from Herring J. Tachdjian's Pediatric Orthopedics. Philadelphia: WB Saunders, 2001
.) (C) Radiographic lines used in diagnosis of DDH. Acetabular index, Hilgenreiner, Perkins, and Shenton, lines.
Treatment. The aim of treatment is a stable and concentrically reduced hip. The type of treatment depends on age and ease of achieving reduction. Most patients presenting during the first few months of life may be managed with a Pavlik harness. Ultrasound is useful in confirming and following up the reduction while in the harness. The treatment continues until the hip is stable and the radiographic appearance is satisfactory. The weaning period for the harness is double the time it was worn full time. The hip that fails to reduce concentrically in the acetabulum will be complicated with inferior dislocation as the hip is flexed beyond 90 degrees in a Pavlik harness. If reduction is not achieved by 2 to 3 weeks, then alternative methods of treatment should be considered. Those presenting after 6 months of age and irreducible hips are treated with closed reduction under general anesthesia. The use of traction prior to closed reduction remains controversial. In presence of tight adductors, an adductor tenotomy is recommended in order to improve the safe zone. While an exam under anesthesia is required to document the arc of stability, the typical position for immobilization in a hip spica cast is flexion (90 to 100 degrees) and abduction. Care should be taken to stay within the safe zone of abduction, and to avoid hyperabduction (beyond 60 degrees), which increases the risk of
P.107

avascular necrosis. Intraoperative arthrogram is useful to assess the reduction and any obstructing structures. Postoperatively, the reduction should be assessed by computed tomography (limited study with cuts through the acetabulum) or by magnetic resonance imaging, as a posterior subluxation or dislocation may not be apparent on plain radiographs. The initial hip spica is replaced under anesthesia after 6 weeks, and often removed after an additional 6 weeks, depending upon the age of the patient. The total duration of casting is 3 to 4 months for most patients. Open reduction is performed when closed reduction fails, or in older patients, generally more than 18 months of age. Obstacles to closed reduction include an hourglass constriction of the capsule by the iliopsoas tendon, inverted labrum, hypertrophic ligamentum teres, and pulvinar (fibrofatty tissue). The most common surgical approach is anterolateral, however a medial approach may also be used in younger patients. The medial approach allows one to remove the obstacles to reduction, but does not provide access to perform a capsulorrhaphy.
Osteotomies. A subset of patients may require an osteotomy during treatment for DDH. In infants/toddlers who have a developmentally dislocated hip and are undergoing an open reduction, depending upon age and tension when the hip is reduced, a femoral shortening osteotomy is commonly performed to reduce the risks of avascular necrosis. In older patients with untreated dislocation, or in those with persistent dysplasia, a femoral and/or pelvic osteotomy may be recommended. Bony abnormalities in children with hip dysplasia commonly include increased femoral anteversion (variable) and acetabular dysplasia (deficiency is commonly anterior and lateral). A concentric reduction is a prerequisite for these osteotomies. Femoral osteotomies commonly involve shortening and derotation, and varus is infrequently required. A variety of pelvic osteotomies may be performed, depending upon the age of the child and the specific pathology being treated. While most osteotomies aim to cover the femoral head with healthy articular cartilage (reconstruction), several others are useful for salvage. For toddlers and children with acetabular dysplasia, a Salter innominate osteotomy (redirectional) or a Pemberton (volume reducing, hinges down the acetabular roof through the triradiate cartilage) may achieve the desired degree of coverage. In older children and adolescents, these procedures are more limited in their ability to provide the desired degree of realignment, and options for redirecting the acetabulum in this age group include the double innominate osteotomy (Sutherland), the triple innominate osteotomy (Steele), the Ganz osteotomy, and others. In many cases, a CT scan with three-dimensional reconstructions may help to better define the acetabular anatomy, and a CT scan can also be used to quantify the degree of femoral version. For patients with an incongruent joint, or in whom symptomatic degenerative changes are present, options to improve coverage of the femoral head include the Shelf procedure and the Chiari osteotomy. In the former, bone grafts are used to enlarge the size of the acetabulum and therefore improve coverage. In the latter, a medial displacement osteotomy is performed, which not only improves coverage of the femoral head, but also medializes the hip, which reduces the joint reactive force.
 參考資源:Chin, Kingsley R.; Mehta, Samir。 Orthopaedic Key Review Concepts, 1st Edition,2008 Lippincott Williams & Wilkins,105-109

 http://www.jst-hosp.com.cn/yqzt.files/yqzt-gk3.htm 大齡兒童髖部脫位治療又有新思路(積水潭)觀點是年齡>10歲,雙側高位脫位者,手術切開復位要慎重。12歲以上的脫位,不強求中心復位。
 http://www.greenstick.net/index.php/action-viewnews-itemid-432527髖臼坐骨切跡周圍骨盆截骨術"治療兒童發育性髖關節脫位
小兒先髖,請大俠評價一下手術 http://www.dxy.cn/bbs/actions/archive/post/7072915_1.html
 【讀片】這個小兒有沒有先髖  http://www.dxy.cn/bbs/actions/archive/post/7824611_1.html
雙側先髖術後,現行走不能 http://www.dxy.cn/bbs/actions/archive/post/2110427_1.html
 很容易漏診的一例髖臼發育不良(CE角)  http://www.dxy.cn/bbs/actions/archive/post/2108244_1.html

 1 平臥位先行內收肌切斷,縱切口
2 健側正側臥位,以大轉子頂點下2cm為中心的Y切口
3 分層顯露,切開闊筋膜,顯露大轉子及其附著扇形肌群,大轉子處薄層軟骨截骨
4 剝離關節囊外層,切開囊,繼續向髖臼方向止真臼處,切除多余的關節囊
5 清理臼及周圍
6 股骨後正中肌肉外緣骨膜下剝離,股骨後正中線放鋼板,近端打入3枚螺釘,線鋸截骨2cm,前傾角約75度,股骨遠端向外旋轉直至足尖朝前,前傾角約15度,螺釘固定鋼板,先縫合肌層(不能縫合骨膜)蓋住鋼板
7 距離臼上緣1.5cm處髖臼周圍截骨,骨鑿留在原位固定,向下翻轉植入取下的骨塊(未用內固定)周圍放入明膠海綿,固骼生粉及止血膜,檢查股直肌較緊張,松解之
8 10號絲線修復關節囊(最後一起打結)
9 7號絲線縫合大轉子骨骺
10 4號線縫皮下,0號縫前層, 0號可吸收縫線縫合皮內,不放引流條
11 腹部及患肢套入粗棉布套,5卷樹脂石膏髖人字固定至足底,屈髖30屈膝17外展自旋轉中立位。
12石膏固定4周(一般6周)提前活動

 【發育性髖脫位進展要點】
1.以步行前後(1.5歲)作為手法復位與手術治療的年齡界限,同時對年齡在1.5-3歲間,脫位在一度,髖臼指數<35°復位穩定者,也可以考慮手法復位。月齡組閉合復位年齡越大,病理改變越重,復位成功率越低,並發癥越多,療效越差,手法復位失敗率與年齡成正比,1歲以下者為8.8%,1.5-2歲為19%,37-44月高達44%,年齡越小髖關節發育和塑性能力越大。
2.新生兒篩查用Ortonlani試驗,推廣B超檢查。對以下高位嬰兒進行篩查
有家族史的女孩,高發地區,大腿皮紋不對稱,臀位產、剖腹產,關節松弛癥,存在其他先天性畸形。
3.6個月以下嬰兒用Pavlik支具,每月檢查一次,3月以下固定3月,3月以上固定4月。
4,7-18月手法復位人位石膏或者改良蛙式位石膏固定6月,

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