Perthes病：患有双髋Perthes病儿童的临床结果和预后因素：对40名儿童进行5年的前瞻性研究

患有双髋Perthes病儿童的临床结果和预后因素：对40名儿童进行5年的前瞻性研究北京大学人民医院骨关节科陶可

译者：陶可（北京大学人民医院骨关节科）

摘要：

目的：本研究目的是阐述非手术治疗、双髋Perthes病的病程，并确定放射学和临床结果的具体预后因素。

患者和方法：我们确定了40名平均年龄为5.9岁（1.8至13.5岁）的儿童，这些儿童均纳入我们这项对双髋Perthes病进行非手术性治疗的多中心、前瞻性研究中，这包括了挪威所有在1996年至2000年5年内被诊断出患有Perthes病的儿童。所有儿童都进行了五年的随访。髋关节病变严重程度按照Catterall分类法进行分类。一种改良的Stulberg三组分类被用作临床结果的评价，其中，球形股骨头被定义为优良，椭圆形头被定义为尚可，扁平状股骨头被定义为差。

结果：23名儿童可见双髋Perthes病，同时17名儿童在随访中出现双髋Perthes病。后一组第二侧髋关节发病平均延迟1.9年（0.3至5.5年）。五年放射学结果中，30髋优良（39%），25髋尚可（33%）和21髋差（28%）。预后不良的最强预测因素是范围大于50%的股骨头坏死，比值比（OR）为19.6和确诊时年龄=6岁（OR 3.3）。结果差的其他危险因素是疾病发病的时间，即前后连续发生双髋Perthes病的儿童比同时发生双髋Perthes病的儿童风险更高（p = 0.021，卡方检验）。一侧髋关节确诊Perthes病后，有5%的机会对侧髋关节会出现Perthes病。

结论：上述结果表明，我们需要区分同时发病的儿童和前后连续发生双髋Perthes病的儿童，因为预后结果可能不同。之前尚无研究对此进行阐述。双髋同时出现Perthes病儿童的临床结果与之前我们研究的一系列单髋患有Perthes病的儿童相似，而前后连续发生双髋Perthes病的儿童预后较差。对孩子和父母需要注意的是，一侧髋关节出现Perthes病，对侧髋患病风险增加。

文献出处：O Wiig, S Huhnstock, T Terjesen, A H Pripp, S Svenningsen. The Outcome and Prognostic Factors in Children With Bilateral Perthes' Disease: A Prospective Study of 40 Children With Follow-Up Over Five Years. Bone Joint J, 2016 Apr;98-B(4):569-75.

The Outcome and Prognostic Factors in Children With Bilateral Perthes' Disease: A Prospective Study of 40 Children With Follow-Up Over Five Years

Abstract

Aims: The aims of this study were to describe the course of non-operatively managed, bilateral Perthes' disease, and to determine specific prognostic factors for the radiographic and clinical outcome.

Patients and methods: We identified 40 children with a mean age of 5.9 years (1.8 to 13.5), who were managed non-operatively for bilateral Perthes' disease from our prospective, multicentre study of this condition, which included all children in Norway who were diagnosed with Perthes' disease in the five-year period between 1996 and 2000. All children were followed up for five years. The hips were classified according to the Catterall classification. A modified three-group Stulberg classification was used as an outcome measure, with a spherical femoral head being defined as a good outcome, an oval head as fair, and a flat femoral head as a poor outcome.

Results: Concurrent, simultaneous bilateral Perthes' disease was seen in 23 children and 17 had the sequential onset of bilateral disease. The mean delay in onset for the second hip in the latter group was 1.9 years (0.3 to 5.5). The five-year radiographic outcome was good in 30 (39%), fair in 25 (33%) and poor in 21 (28%) of the hips. The strongest predictors of poor outcome were > 50% necrosis of the femoral head, with odds ratio (OR) 19.6, and age at diagnosis > 6 years (OR 3.3). Other risk factors for poor outcome were the timing of the onset of disease, where children with the sequential onset of bilateral disease had a higher risk than those with the concurrent onset of bilateral disease (p = 0.021, chi-squared test). Following a diagnosis of Perthes' disease in one hip, there was a 5% chance of developing it in the contralateral hip.

Conclusion: These results imply that we need to distinguish between children with concurrent onset and those with sequential onset of bilateral Perthes' disease, as the outcomes may be different. This has not been previously described. Children with concurrent onset of bilateral disease had a similar outcome to our previous series of those with unilateral disease, whereas children with sequential onset of bilateral disease had a worse prognosis. The increased risk of developing Perthes' disease in the contralateral hip in those with unilateral disease is important information for the child and parents.

Anteroposterior and Lauenstein radiograph projections of the hips of a 3.5 year old boy with the concurrent onset of bilateral Perthes’ disease, at the time of diagnosis (a). The right hip was classified as Catterall I, the left as Catterall IV. And (b); five years after diagnosis. The right hip was classified as spherical (Stulberg 1) and the left hip as oval (Stulberg 3)

图1. 在确诊时，一个3.5岁男孩的髋关节前后位和Lauenstein位X线片，发现双髋Perthes病（a）右髋被归类为Catterall I型，左髋为Catterall IV型；（b）确诊5年后右髋被归类为球形（Stulberg 1型），左髋被归类为椭圆形（Stulberg 3型）

Anteroposterior and Lauenstein radiograph projections of the hips of a 4.5 years old boy with the sequential onset of bilateral Perthes’ disease, at the time of diagnosis (a) The left hip was classified as Catterall group III. And (b); six months later. The right hip is now also affected, in the initial phase of the disease and classified as Catterall IV when in the fragmentation phase. And (c); When aged ten years with both hips classified as oval (Stulberg 3).。

图2. 在确诊时，一个4.5岁男孩的髋关节前后位和Lauenstein位X线片，提示前后连续发生双髋Perthes病（a）左髋被归类为Catterall III型；（b）6个月后，右髋也受到影响，在疾病的早期并分类为Catterall IV型，碎片阶段；和（c）10岁，双侧髋关节分类为椭圆形（Stulberg 3型）。