儿童特发性股骨头坏死：Perthes病：诊断和治疗新进展——2019年最新进展

Perthes病：诊断和治疗新进展

译者：陶可（北京大学人民医院骨关节科）

摘要：

诊断：Perthes病仍然是小儿骨科医生的一个挑战。X线成像仍然是诊断和后续随访检查的首选方法。Waldenström的更详细分类法，尤其是在碎裂早期和晚期，可能与优化覆盖手术的时机有关。“高级MRI”成像可能比传统X线成像更早地发现有潜在患病风险的患者，这可能有助于及早的手术干预。

治疗：目前没有可用的治疗方法可以改善Perthes病的骨质变化。根据症状或临床发现，使用止痛药和/或消炎药等非手术治疗（如改善髋关节活动范围以及减轻股骨头负荷）仍然是治疗的基本标准。如果（髋臼）失去覆盖（股骨头的）能力，尤其是6岁以上的儿童，则需要手术治疗。目前，存在一种趋势，即倾向于采用髋臼重新定位技术，尤其是三联截骨术，因为其不会像股骨内翻截骨术那样额外破坏（髋臼与股骨头的）生物力学关系。

文献出处：B Westhoff, C Ledere, R Krauspe. Perthes disease-news in diagnostics and treatment. Orthopade. 2019 Jun;48(6):515-522.

Perthes disease-news in diagnostics and treatment

Abstract

Diagnostics: Perthes disease remains a challenge for paediatric orthopedic surgeons. X‑ray imaging is still the method of choice for diagnostics and follow-up examination. A more detailed differentiation of Waldenström's classification, especially in early and late fragmentation stages, might be relevant to optimize timing of containment surgery. So-called "advanced MRI" imaging might help to detect patients at risk earlier than conventional x‑ray imaging, which could lead to earlier surgical intervention.

Treatment: Currently there is no treatment modality available which would improve the bone changes in Perthes disease. Non-operative treatment like improving hip range of motion as well as unloading is still the basic standard of care, with analgesic and/or anti-inflammatory medication, according to symptoms or findings. In the case of loss of containment, especially in children older than 6 years, surgery is indicated. Currently, there is a trend favoring acetabular reorientation techniques-especially the triple osteotomy, since the biomechanical relations would not be additionally impaired as in case of femoral varus osteotomy.

Abb. 1 DifferenzierungdesM.Perthes inStadium2Aund2B.a Typ2A–derHüftkopfhatdeutlichan Höhe abgenommenundist sklerotisch;medial zeigt sicheine kleine Fissur.bTyp 2B –fortgeschrittene Fragmentierung

Fig. 1 Differentiation of M. Perthes in stages 2A and 2B.a type 2A - the femoral head has clearly decreased in height and is sclerotic; a small fissure can be seen medially.b type 2B - advanced fragmentation

图1. Perthes病在2A和2B期的区分。a 2A型-股骨头高度明显降低且硬化。内侧可见小裂缝。b 2B型-晚期碎裂。

Abb. 2 Morbus Perthes in der Kernspintomographie. a Übergreifendes Labrumauf der erkrankten Seite. b Horizontalisierung des Labrums auf der erkrankten Seite

Fig. 2 Perthes' disease on magnetic resonance imaging. a Overarching labrum on the diseased side. b Horizontalization of the labrum on the diseased side

图2 磁共振成像中的Perthes病。a 患病一侧的总体盂唇过度覆盖。b 患侧盂唇水平化。

Abb. 3 Containment-Wiederherstellung mit Beckenosteotomie; a 8-jähriger Jungemit schweremM. Perthes und Containment-Verlust; der Kopf steht lateralisiert und ist nicht vollständig von der Pfanne überdacht, die Shenton-Menard-Linie ist unterbrochen und der Abstand zwischen Tränenfigur und Epiphyse ist imVergleich zur gesunden Gegenseite verbreitert. bWiederherstellung des Containmentsmit einer Triple-Osteotomie sowie einer intramuskulären Verlängerung des M. iliopsoas. c 2 Jahre postoperativ gute Konsolidierung sämtlicherOsteotomien; gutes Containment

Fig. 3 Restoration of containment with pelvic osteotomy; a 8-year-old boy with severe M. Perthes and Containment Loss; the head is lateralized and is not completely covered by the socket, the Shenton-Menard line is interrupted and the distance between the teardrop figure and the epiphysis is widened compared to the healthy opposite side. b Restoration of the containment with a triple osteotomy and intramuscular lengthening of the iliopsoas muscle. c 2 years postoperatively good consolidation of all osteotomies; good containment

图3 用骨盆截骨术恢复（髋臼对股骨头）覆盖。a 一个8岁的男孩，患有严重的Perthes病和覆盖缺失；与健康侧相比，股骨头变扁平且没有完全被髋臼覆盖，Shenton-Menard线中断，泪滴与干骨骺之间距离变宽。b 通过三联截骨术和髂腰肌肌瓣延长术恢复（髋臼对股骨头）覆盖。c 术后2年所有截骨处均良好愈合；（髋臼对股骨头）覆盖良好。

Abb. 4 Containment-WiederherstellungmitkombinierteBecken-undFemurosteotomie;a7-jährigerJungemit schwerem M. Perthes und Lateralisation desHüftkopfs. bWiederherstellung des Containmentsmit einer Triple-Osteotomie, Rotations-(15°), Varisations- (10°) und Verkürzungsosteotomie (5mm) sowie einer intramuskulären Verlängerung des M. iliopsoas. Bei derMetallentfernungwurde zusätzlich eine Trochanterapophyseodese durchgeführt. c Im Alter von 15 Jahre sphärisches Gelenk.

Fig. 4 Restoration of containment with combined pelvic and femoral osteotomy; a 7-year-old boy with severe Perthes muscle and lateralization of the femoral head. b Restoration of the containment with a triple osteotomy, rotation (15 °), varization (10 °) and shortening osteotomy (5mm) as well as an intramuscular lengthening of the iliopsoas muscle. In addition, a trochanteric apophysodesis was performed for the metal removal. c At the age of 15 years spherical joint.

图4 结合骨盆和股骨截骨术恢复（髋臼对股骨头）覆盖。a 一个7岁男孩，患有严重Perthes病且股骨头外移。b 用三联截骨术，旋转（15°），内翻（10°）和短缩截骨术（5mm）及髂腰肌肌瓣延长术恢复（髋臼对股骨头）覆盖。另外，进行了转子粗隆的植骨术以去除金属内固定物。c 15岁时（髋关节）为球形关节。