髋关节发育不良保髋截骨手术远期效果 (2)：髋关节撞击严重影响DDH髋臼周围截骨术后10年的生存期

髋关节发育不良保髋截骨手术远期效果 (2)：髋关节撞击严重影响髋关节发育不良髋臼周围截骨术后10年的生存期

矫正不足定义为LCEA ＜ 22°，据报道，矫正不足与至少10年随访中的PAO失败有关。

作者：Goro Motomura

作者单位: Department of Orthopedic Surgery, Inselspital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.

译者：陶可（北京大学人民医院骨关节科）

摘要

背景：尽管髋臼周围截骨术(PAO)治疗发育性髋关节发育不良(DDH)与其他截骨术相比具有概念优势，并且据报道20年内关节生存率可达60%，但适当的髋臼重新定位、同时进行的关节切开术和股骨头颈offset对10年髋关节生存率的有无影响仍不清楚。

问题/目的：我们提出了以下问题：(1) PAO后髋关节的10年生存率是否会因适当的髋臼重新定位和球形股骨头而改善；(2) Merle d‘Aubigné-Postel评分是否有所改善；(3)髋关节骨关节炎(OA)的进展能否减缓；以及(4)哪些因素可预测转换为THA、OA进展或Merle d‘Aubigné-Postel评分低于15分？

方法：我们回顾性分析了147名接受165次PAO治疗DDH的患者，分为两组：第I组（正确重新定位和球形股骨头）和第II组（不正确重新定位和非球形股骨头）。我们比较了两组的Kaplan-Meier存活率、Merle d‘Aubigné-Postel评分和OA进展。进行了Cox回归分析（终点：THA、OA进展或Merle d‘Aubigné-Postel评分低于15分）以检测预测失败的因素。最短随访时间为10年（中位数为11年；范围为10-14年）。

结果：I组的存活率增加。Merle d‘Aubigné-Postel评分无差异。I组的OA进展比II组慢。预测失败的因素包括：年龄较大、术前Merle d‘Aubigné-Postel评分较低、存在Trendelenburg征、非球形头、OA、半脱位、术后髋臼后倾、髋臼前倾过度和覆盖不足。

结论：适当的髋臼重新定位和球形股骨头的形成可提高DDH患者的长期存活率并减缓OA进展。

Fig. 1A–C The current technique of periacetabular osteotomy is shown. (A) Typically, dysplastic hips present with an aspherical femoral head (asterisk). Before PAO, this decreased head-neck offset is compensated by the diminished anterior acetabular coverage. (B) After proper reorientation, femoroacetabular impingement may become apparent in deep flexion and internal rotation (arrow). Iatrogenic acetabular overcoverage can increase this conflict. (C) Through an intraoperative arthrotomy, the FAI conflict can be assessed. If necessary, a concomitant osteochondroplasty of the femoral neck can be performed.

图1A–C 显示了髋臼周围截骨术的当前技术。（A）通常，发育不良的髋关节会出现非球形股骨头（星号）。在PAO之前，这种减小的头颈offset通过减少的髋臼前覆盖来补偿。（B）经过适当的（截骨）重新定位后，股骨髋臼撞击可能在极度屈曲和内旋时变得明显（箭头）。医源性髋臼过度覆盖会增加这种问题。（C）通过术中关节切开术，可以评估FAI问题。如有必要，可以同时进行股骨颈骨软骨成形术。

Fig. 2 The definition of differing degrees of acetabular coverage is shown. The total femoral coverage is defined as the craniocaudal coverage of the femoral head by the acetabular rim (A). The anterior acetabular coverage is defined as the amount of coverage of the femoral head by the anterior acetabular wall in the AP direction (B). The posterior acetabular coverage is defined as the amount of coverage of the femoral head by the posterior acetabular wall in the posteroanterior direction (C).

图2 显示了不同程度的髋臼覆盖的定义。总的股骨覆盖定义为髋臼缘对股骨头的整体覆盖（A）。髋臼前覆盖定义为AP方向上髋臼前壁对股骨头的覆盖量(B)。髋臼后覆盖定义为髋臼后壁在后前方向上对股骨头的覆盖量(C)。

Fig. 3 The Kaplan-Meier survivor analysis is shown for both groups with the end points defined as a conversion to THA, progression of OA, or a Merle d’Aubigné-Postel score of less than 15. Group I was comprised of all the hips with optimal acetabular reorientations and corrected or a priori spherical femoral heads. Group II was comprised of the hips with suboptimal acetabular reorientations and/or aspherical heads.

图3 显示了两组的Kaplan-Meier生存分析，终点定义为转换为THA、OA进展或Merle d’Aubigné-Postel评分小于15。第I组包括所有髋臼（截骨）重新定位最佳且股骨头经过矫正或先验为球形的股骨头。第II组包括髋臼（截骨）重新定位次优和/或股骨头为非球形的髋臼。

Fig. 4A–D The radiographs of a 24-year-old woman from Group I (optimal acetabular retroversion and spherical femoral head) are shown. (A) The preoperative AP radiograph showed deficient lateral coverage. (B) Femoral head-neck offset was decreased in the preoperative crosstable view. At the 10-year followup the patient presented with a Merle d’Aubigné-Postel score of 17 points. (C) The AP radiograph showed sufficient lateral coverage and corrected version of the acetabulum without signs of progression of OA. (D) The decreased head-neck offset was corrected by performing an osteochondroplasty of the femoral head-neck junction, leading to impingement-free ROM.

图4A–D 显示了第I组（髋臼后倾最佳且股骨头为球形）中一名24岁女性的X线片。(A)术前AP位X线片显示侧向覆盖不足。(B)术前穿桌位视图显示股骨头颈offset减小。10年随访时，患者的Merle d’Aubigné-Postel评分为17分。(C) AP位X线片显示侧向覆盖充分，髋臼矫正，无OA进展迹象。(D)通过对股骨头颈连接处进行骨软骨成形术矫正减小的头颈offset，从而实现无撞击髋关节活动度。

Fig. 5A–F (A) A 32-year-old woman from Group II presented with bilateral hip dysplasia. (B) The preoperative version of both acetabula is correct: the anterior wall (blue) does not cross the posterior wall (red). (C) The postoperative radiograph shows suboptimal acetabular reorientation on both sides (6 months postoperatively). (D) The right hip presents with excessive anteversion while the left hip presents with excessive retroversion. (E) Eight years after surgery, the right hip had severe progression of osteoarthritis. (F) In the left hip, a herniation pit formed as a result of iatrogenic pincer-type femoroacetabular impingement (arrow). The recurrent impingement resulted in joint space narrowing and subluxation of the joint. The patient required THA on the right side 9 years postoperatively and on the left side 12 years after surgery (not shown).

图5A–F (A)一名32岁II组女性，双侧髋臼发育不良。(B)两个髋臼的术前拍照提示无前后壁交叉征：前壁（蓝色）未穿过后壁（红色）。(C)术后X线片显示两侧髋臼重新定位均不理想（术后6个月）。(D)右髋关节前倾过度，左髋关节后倾过度。(E)手术后8年，右髋关节骨关节炎严重发展。(F)左髋关节因医源性钳状股骨髋臼撞击（箭头）而形成突出凹陷。反复撞击导致关节间隙变窄和关节半脱位。患者术后9年右侧需要进行全髋关节置换术，术后12年左侧需要进行全髋关节置换术（未显示）。

Impingement adversely affects 10-year survivorship after periacetabular osteotomy for DDH.

Abstract

Background: Although periacetabular osteotomy (PAO) for developmental dysplasia of the hip (DDH) provides conceptual advantages compared with other osteotomies and reportedly is associated with joint survivorship of 60% at 20 years, the beneficial effect of proper acetabular reorientation with concomitant arthrotomy and creation of femoral head-neck offset on 10-year hip survivorship remains unclear.

Questions/purposes: We asked the following questions: (1) Does the 10-year survivorship of the hip after PAO improve with proper acetabular reorientation and a spherical femoral head; (2) does the Merle d‘Aubigné-Postel score improve; (3) can the progression of osteoarthritis (OA) be slowed; and (4) what factors predict conversion to THA, progression of OA, or a Merle d‘Aubigné-Postel score less than 15 points?

Methods: We retrospectively reviewed 147 patients who underwent 165 PAOs for DDH with two matched groups: Group I (proper reorientation and spherical femoral head) and Group II (improper reorientation and aspherical femoral head). We compared the Kaplan-Meier survivorship, Merle d‘Aubigné-Postel scores, and progression of OA in both groups. A Cox regression analysis (end points: THA, OA progression, or Merle d‘Aubigné-Postel score less than 15) was performed to detect factors predicting failure. The minimum followup was 10 years (median, 11 years; range, 10-14 years).

Results: An increased survivorship was found in Group I. The Merle d‘Aubigné-Postel score did not differ. Progression of OA in Group I was slower than in Group II. Factors predicting failure included greater age, lower preoperative Merle d‘Aubigné-Postel score, and the presence of a Trendelenburg sign, aspherical head, OA, subluxation, postoperative acetabular retroversion, excessive acetabular anteversion, and undercoverage.

Conclusions: Proper acetabular reorientation and the creation of a spherical femoral head improve long-term survivorship and decelerate OA progression in patients with DDH.

文献出处：Christoph E Albers, Simon D Steppacher, Reinhold Ganz, Moritz Tannast, Klaus A Siebenrock. Impingement adversely affects 10-year survivorship after periacetabular osteotomy for DDH. Clin Orthop Relat Res. 2013 May;471(5):1602-14.doi: 10.1007/s11999-013-2799-8.