股骨颈前倾角数字解剖在发育性髋关节脱位手术中的应用研究
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摘要
目的:利用髋关节的三维CT影像,通过数字化处理,作可视化动画重建,探讨发育性髋关节脱位(developmental dislocation of the hip,DDH)股骨颈前倾角(femoralneck anteversion,FNA)的病理改变,为术式的选择提供依据。
方法:2005年1月～2007年5月间在我院行手术治疗的30例DDH患儿术前进行3DCT研究.患有神经肌肉性疾病、合并有其它先天畸形者被排除在外。男11例,女19例,年龄1.5～13岁(平均7.29岁),其中CroweⅡ6例,CrowemⅢ型10例,CroweⅣ型14例。术前用GE Lightspeed VCT(64排CT,美国GE公司生产)扫描双侧髋关节和双侧股骨髁部,扫描后的图像重建在独立工作站进行,分别对髋臼和股骨头颈部的形态做前方、后方、侧方和仰视位观察,行双侧髋关节薄层平扫+三维重建,测量股骨颈前倾角(FNA),分别计算其FNA,并指导术中股骨旋转截骨,前倾角＞45°作旋转截骨(FNA分别旋转1～6岁为:20.00±2.00,＞6岁为18.00±2.00),术后双侧髋关节再行薄层平扫+三维重建,正常侧髋分别与患侧术前及术后作为比较并作统计学处理,30例30髋获得3个月～2年随访(平均13个月)。
结果:分别对术前、后双侧髋关节股骨颈前倾角行三维空间成像,DDH骨性病理包括髋臼、股骨头颈和两者的对应关系的变化,其中髋臼的病理可以表现为髋臼方向的变化或者是髋臼的骨性缺损(主要表现在外上缘部位),股骨头颈的前倾角变化是DDH的主要病理因素之一。三维CT的观察结果表明18个月～6岁组:正常侧FNA:(21.40°±3.512°);脱位侧术前FNA:(68.45°±12.272°),术后FNA:(20.45°±2.940°);=6岁组正常侧FNA为:(23.44°±3.561°);脱位侧术前FNA:(73.49°±12.678°),术后FNA:(18.28°±1.931°),术后早期均获得满意FNA和头臼对位。统计学分析结果显示,患侧FNA术前较正常侧明显增大(P＜0.05),术前两侧有统计学有明显差异性,术后相统计学上均无显著意义。
结论:螺旋CT的三维重建方法简单、精确、可重复性强。3DCT可以直观地显示股骨近端的结构形态改变,通过多平面重建技术(MPR),可以精确地测量股骨颈前倾角的大小,是测量股骨颈前倾角理想的方法,对DDH的治疗具有很好的指导意义。
Objective:Femoral neck anteversion was one of the main and basical pathological changes,normalizing their hip anantomy might prevent or delay the development of osteoarthrosis.This is the concept of reconstrutive osteotomy,in which the primary aim of the surgical treatment is to improve the longterm prognosisof the hip join to discus the femoral neck anteversion of DDH and to guide operating with visual and digitalizing picture in 3DCT and to provide a reasonablo basis of the examination for clinic analyzing 3DCT findings of the DDH.
Method:During the past three years(1999.6 -2002.6),thirty children with unilateral DDH had been diagnosed and treated with open reduction,nineteen female patients and eleven male patients,age was ranging from 18 months to 13 years old with an average age of 7.29 years old,six of them were gradeⅡ°and 10 were gradeⅢ°and 14 were gradeⅣ°according to Crowe clasification,were analysed using 3DCT,GE Lightspeed VCT Picker)was used for this study.The femoral condyles were scanned and the 3DCT images were constructed at an independent computer workstation,children that FNA exceed 45°received the subtrochanter osteotomy,images from different direction,FNA of hip were measured respectively before and after operation respectively and were measured in normal and abnormal hips respectively,FNA of hip respectively statistical treatment.30 patients(30 hips) were followed up ranging from 3 months to 2 years with mean 13 months.
Result:The bone pathology of DDH included the femoral head and abnormalities of acetabulum,and the congruous relationship between acetabulum and femoral head.FNA abnormality was one of the main elements in the DDH pathology。In group younger than 18 months,the FNA were in normal hips(21.40°±3.512°),in dysplasia hips respectively,the FNA were(68.45°±12.272°),the FNA were measured (20.45°±2.940°) after operation:in group elder than 6 yers,there were significantly statistical differences,the FNA were in normal hips(23.44°±3.561°),in dysplasia hips respectively,the FNA were(73.49°±12.678°),the FNA were measured(18.28°±1.931°) after operation.Clinical assessment was performed according to Mckay'S classification.The satisfactory congruity FNA was achieved in all the cases at the early stage postoperatively.The results showed that.FNA was increased significantly (p＜0.05)as compared with normal group and the overall excellent or good rate was 96.6%.
Conclusion:3D-CT method is a new accurate and convenient and reduplicative method for measuring FNA and 3DCT reonstruction techniques can intuitionistic reveal.The change of structure and shape of femoral head and acetabulum.we can get accurate datum of FNA with MPR.It will be more helpful for related operations when three-dimendional images are considered.
方法:2005年1月～2007年5月间在我院行手术治疗的30例DDH患儿术前进行3DCT研究.患有神经肌肉性疾病、合并有其它先天畸形者被排除在外。男11例,女19例,年龄1.5～13岁(平均7.29岁),其中CroweⅡ6例,CrowemⅢ型10例,CroweⅣ型14例。术前用GE Lightspeed VCT(64排CT,美国GE公司生产)扫描双侧髋关节和双侧股骨髁部,扫描后的图像重建在独立工作站进行,分别对髋臼和股骨头颈部的形态做前方、后方、侧方和仰视位观察,行双侧髋关节薄层平扫+三维重建,测量股骨颈前倾角(FNA),分别计算其FNA,并指导术中股骨旋转截骨,前倾角＞45°作旋转截骨(FNA分别旋转1～6岁为:20.00±2.00,＞6岁为18.00±2.00),术后双侧髋关节再行薄层平扫+三维重建,正常侧髋分别与患侧术前及术后作为比较并作统计学处理,30例30髋获得3个月～2年随访(平均13个月)。
结果:分别对术前、后双侧髋关节股骨颈前倾角行三维空间成像,DDH骨性病理包括髋臼、股骨头颈和两者的对应关系的变化,其中髋臼的病理可以表现为髋臼方向的变化或者是髋臼的骨性缺损(主要表现在外上缘部位),股骨头颈的前倾角变化是DDH的主要病理因素之一。三维CT的观察结果表明18个月～6岁组:正常侧FNA:(21.40°±3.512°);脱位侧术前FNA:(68.45°±12.272°),术后FNA:(20.45°±2.940°);=6岁组正常侧FNA为:(23.44°±3.561°);脱位侧术前FNA:(73.49°±12.678°),术后FNA:(18.28°±1.931°),术后早期均获得满意FNA和头臼对位。统计学分析结果显示,患侧FNA术前较正常侧明显增大(P＜0.05),术前两侧有统计学有明显差异性,术后相统计学上均无显著意义。
结论:螺旋CT的三维重建方法简单、精确、可重复性强。3DCT可以直观地显示股骨近端的结构形态改变,通过多平面重建技术(MPR),可以精确地测量股骨颈前倾角的大小,是测量股骨颈前倾角理想的方法,对DDH的治疗具有很好的指导意义。
Objective:Femoral neck anteversion was one of the main and basical pathological changes,normalizing their hip anantomy might prevent or delay the development of osteoarthrosis.This is the concept of reconstrutive osteotomy,in which the primary aim of the surgical treatment is to improve the longterm prognosisof the hip join to discus the femoral neck anteversion of DDH and to guide operating with visual and digitalizing picture in 3DCT and to provide a reasonablo basis of the examination for clinic analyzing 3DCT findings of the DDH.
Method:During the past three years(1999.6 -2002.6),thirty children with unilateral DDH had been diagnosed and treated with open reduction,nineteen female patients and eleven male patients,age was ranging from 18 months to 13 years old with an average age of 7.29 years old,six of them were gradeⅡ°and 10 were gradeⅢ°and 14 were gradeⅣ°according to Crowe clasification,were analysed using 3DCT,GE Lightspeed VCT Picker)was used for this study.The femoral condyles were scanned and the 3DCT images were constructed at an independent computer workstation,children that FNA exceed 45°received the subtrochanter osteotomy,images from different direction,FNA of hip were measured respectively before and after operation respectively and were measured in normal and abnormal hips respectively,FNA of hip respectively statistical treatment.30 patients(30 hips) were followed up ranging from 3 months to 2 years with mean 13 months.
Result:The bone pathology of DDH included the femoral head and abnormalities of acetabulum,and the congruous relationship between acetabulum and femoral head.FNA abnormality was one of the main elements in the DDH pathology。In group younger than 18 months,the FNA were in normal hips(21.40°±3.512°),in dysplasia hips respectively,the FNA were(68.45°±12.272°),the FNA were measured (20.45°±2.940°) after operation:in group elder than 6 yers,there were significantly statistical differences,the FNA were in normal hips(23.44°±3.561°),in dysplasia hips respectively,the FNA were(73.49°±12.678°),the FNA were measured(18.28°±1.931°) after operation.Clinical assessment was performed according to Mckay'S classification.The satisfactory congruity FNA was achieved in all the cases at the early stage postoperatively.The results showed that.FNA was increased significantly (p＜0.05)as compared with normal group and the overall excellent or good rate was 96.6%.
Conclusion:3D-CT method is a new accurate and convenient and reduplicative method for measuring FNA and 3DCT reonstruction techniques can intuitionistic reveal.The change of structure and shape of femoral head and acetabulum.we can get accurate datum of FNA with MPR.It will be more helpful for related operations when three-dimendional images are considered.
引文
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8.By JohnC.Clohisy,MD,SusanE et al.Periacetabular osteotomy in the treatment of severe acetabular dysplasia[J].Bone Joint Surg Am.2006;88:65-83
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30.Nelitz M,Guenther KP,Gunkel S,Puhl W.Reliability of radiological measurements in the assessment of hip dysplasia in adults.Br J Radiol 1999;72:331-4.
31.Tezeren G,Tukenmez M,Bulut O,Cekin T,Percin S.One-stage combined surgery with or without preoperative traction for developmental dislocation of the hip in older children.J Orthop Surg(Hong Kong) 2006;14:259-64.
32.Vallamshetla VR,Mughal E,O'Hara JN.Congenital dislocation of the hip.A re-appraisal of the upper age limit for treatment.J Bone Joint Surg Br 2006;88:1076-81.
33.Forlin E,Munhoz da Cunha LA,Figueiredo DC.Treatment of developmental dysplasia of the hip after walking age with open reduction,femoral shortening,and acetabular osteotomy.Orthop Clin North Am 2006;37:149-60.
34.马梦然,王建设,张志成.发育性髋关节脱位髂骨截骨术后再脱位的原因分析[J].2005;18(5):357
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36.Jones D,Dezateux CA,Danielsson LG,Paton RW,Clegg J.At the crossroads-neonatal detection of developmental dysplasia of the hip.J Bone Joint Surg[Br]2000;82-B:160-4.
37.Bialik V,Bialik GM,Wiener F.Prevention of overtreatment of neonatal hip dysplasia by the use of ultrasonography.J Paediatr Orthop B 1998;7:39-42.
38.Hakan,Derya,Yucel.A new measurement method for the radiographic assessment of the proximal femur:the center-trochanter distance,Acta Orthop Traumatol Turc 2004;38(4):261-264.
39.Hakan OMEROGLU,Alper KAYA,Berk GUCLU.Evidence-based current concepts in the radiological diagnosis and follow-up of developmental dysplasia of the hip[J].Acta Orthop Traumatol Turc 2007;41 Suppl 1:14-18.
40.韩敦福,杨启友.发育性髋关节脱位治疗后股骨近端影像参数的变化[J].贵阳医学院学报,2004;29(2):132-133,136.
41.[57].Smidt N,Rutjes AW,van der Windt DA,et al.Quality of reporting of diagnostic accuracy studies.Radiology 2005;235:347-353.
42.Bossuyt PM,Reitsma JB,Bruns DE,et al.The STARD statement for reporting studies of diagnostic accuracy:explanation and elaboration.Clin Chem 2003;49:7-18.
43.Whiting P,Harbord R,Kleijnen J.No role for quality scores in systematic reviews of diagnostic accuracy studies.BMC Med Res Methodol 2005;5:19-28.
44.苗武胜,姜海,马强.青少年发育性髋关节脱位的治疗[J].2005;2(24)2266-2267.
45.陈芒 苏琦 周敏,大龄儿童发育性髋关节脱位的手术治疗[J].国际骨科学杂 志2007;28(6):401-402
46.Eva N G Pedersen,Tine Alkjaer,Kjeld Sφballe,et al.Walking pattern in 9 women with hip dysplasia 18 months after periacetabular osteotomy.J Acta Orthopaedica 2006;77(2):203-208
47.Terje Terjesen,Vera Halvorseno Long-term results after closed reduction of latedetectedhip dislocation 60 patients followed up to skeletal maturity J,Acta Orthopaedica 2007;78(2):236-246
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49.Fgen lahgen,aysg ma akturk,ufuk beyazova,et al.Screening for developmental dysplasia of the hip:Results of a 7-year follow-up study J,Pediatrics International(2004)46,162-166
50.Hakan lenaran,h mustafa demir,tun cevat,et al.Value of limited hip abduction in developmental dysplasia of the hip J,Pediatrics International(2004)46,456-458
51.裴生太,张德宏,王想福,等,Pemberton+Salter手术治疗发育性髋关节脱位[J].2006;19(1):79-81
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53.S.C.Wearing,E.M.Hennig,N.M.Byrne,e tal.The impact of childhood obesity on musculoskeletal form J,obesity reviews(2006)7,209-218
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2.Hakan OMEROGLU,Alper KAYA,Berk GUCLU.Evidence-based current concepts in the radiological diagnosis and follow-up of developmental dysplasia of the hip[J].Acta Orthop Traumatol Turc 2007;41 Suppl 1:14-18.
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4.Michael Leunig,Martin Beck,Morteza Kalhor,et al.Fibrocystic changes atanterosuperior femoralneck:Prevalence in hips with femoroacetabular impingement1[J].Radiology 2005;236;237-246.
5.Kate L.Tsai,Keith E.et al.Clinical and genetic assessments of hip joint laxity in theBoykin spaniel[J].The Canadian Journal of Veterinary Research,2006;70:148-150.
6.Wenger DR.Bomar JD.Human hip dysplasia:Evolution of current treatment concepts[J].Orthop Sci.2003,8:264 271.
7.刘复奇,郑志永,薛远亮.发育性髋关节脱位手术截骨中股骨颈前倾角度的选择[J].山东医药,2006,46(20):44-45
8.By JohnC.Clohisy,MD,SusanE et al.Periacetabular osteotomy in the treatment of severe acetabular dysplasia[J].Bone Joint Surg Am.2006;88:65-83
9.李连永,赵群.幼儿发育性髋脱位髋臼病理形态的三维CT研究[J].中华小儿外科杂志,2005,26(11):572-575.
10.Kaj Tallroth1 and Jyri Lepist(o|").Computed tomography measurement of acetabular dimensions[J].Acta Orthopaedica 2006;77(4):598-602.
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29.陈瑶,沈品泉,王秋艳,等.儿童髋臼前倾角的CT测量与分析[J].中华小儿外科杂志,2005;26(2):90-92.
30.Nelitz M,Guenther KP,Gunkel S,Puhl W.Reliability of radiological measurements in the assessment of hip dysplasia in adults.Br J Radiol 1999;72:331-4.
31.Tezeren G,Tukenmez M,Bulut O,Cekin T,Percin S.One-stage combined surgery with or without preoperative traction for developmental dislocation of the hip in older children.J Orthop Surg(Hong Kong) 2006;14:259-64.
32.Vallamshetla VR,Mughal E,O'Hara JN.Congenital dislocation of the hip.A re-appraisal of the upper age limit for treatment.J Bone Joint Surg Br 2006;88:1076-81.
33.Forlin E,Munhoz da Cunha LA,Figueiredo DC.Treatment of developmental dysplasia of the hip after walking age with open reduction,femoral shortening,and acetabular osteotomy.Orthop Clin North Am 2006;37:149-60.
34.马梦然,王建设,张志成.发育性髋关节脱位髂骨截骨术后再脱位的原因分析[J].2005;18(5):357
35.Bialik V,Bialik GM,Blazer S,et al.Developmental dysplasia of the hip:a new approach to incidence.Pediatrics 1999;103:93-9.
36.Jones D,Dezateux CA,Danielsson LG,Paton RW,Clegg J.At the crossroads-neonatal detection of developmental dysplasia of the hip.J Bone Joint Surg[Br]2000;82-B:160-4.
37.Bialik V,Bialik GM,Wiener F.Prevention of overtreatment of neonatal hip dysplasia by the use of ultrasonography.J Paediatr Orthop B 1998;7:39-42.
38.Hakan,Derya,Yucel.A new measurement method for the radiographic assessment of the proximal femur:the center-trochanter distance,Acta Orthop Traumatol Turc 2004;38(4):261-264.
39.Hakan OMEROGLU,Alper KAYA,Berk GUCLU.Evidence-based current concepts in the radiological diagnosis and follow-up of developmental dysplasia of the hip[J].Acta Orthop Traumatol Turc 2007;41 Suppl 1:14-18.
40.韩敦福,杨启友.发育性髋关节脱位治疗后股骨近端影像参数的变化[J].贵阳医学院学报,2004;29(2):132-133,136.
41.[57].Smidt N,Rutjes AW,van der Windt DA,et al.Quality of reporting of diagnostic accuracy studies.Radiology 2005;235:347-353.
42.Bossuyt PM,Reitsma JB,Bruns DE,et al.The STARD statement for reporting studies of diagnostic accuracy:explanation and elaboration.Clin Chem 2003;49:7-18.
43.Whiting P,Harbord R,Kleijnen J.No role for quality scores in systematic reviews of diagnostic accuracy studies.BMC Med Res Methodol 2005;5:19-28.
44.苗武胜,姜海,马强.青少年发育性髋关节脱位的治疗[J].2005;2(24)2266-2267.
45.陈芒 苏琦 周敏,大龄儿童发育性髋关节脱位的手术治疗[J].国际骨科学杂 志2007;28(6):401-402
46.Eva N G Pedersen,Tine Alkjaer,Kjeld Sφballe,et al.Walking pattern in 9 women with hip dysplasia 18 months after periacetabular osteotomy.J Acta Orthopaedica 2006;77(2):203-208
47.Terje Terjesen,Vera Halvorseno Long-term results after closed reduction of latedetectedhip dislocation 60 patients followed up to skeletal maturity J,Acta Orthopaedica 2007;78(2):236-246
48.Yamada N,Maeda S,Fujii G,Kita A,Funayama K,KokubunS.Closed reduction of developmental dislocation of the hip by prolonged traction.J Bone Joint Surg (Br) 2003;85:1173-7.
49.Fgen lahgen,aysg ma akturk,ufuk beyazova,et al.Screening for developmental dysplasia of the hip:Results of a 7-year follow-up study J,Pediatrics International(2004)46,162-166
50.Hakan lenaran,h mustafa demir,tun cevat,et al.Value of limited hip abduction in developmental dysplasia of the hip J,Pediatrics International(2004)46,456-458
51.裴生太,张德宏,王想福,等,Pemberton+Salter手术治疗发育性髋关节脱位[J].2006;19(1):79-81
52.M,P erren SM,e tal.E xtra-articular augmentation for residual hip dysplasia J,Bone Joint Surg 1993,75(B):750-754.
53.S.C.Wearing,E.M.Hennig,N.M.Byrne,e tal.The impact of childhood obesity on musculoskeletal form J,obesity reviews(2006)7,209-218
54.余希临 桂彤 沈先涛,发育性髋关节脱位复位前后关节腔动态测压的临床意义[J].2005;26(3):138-140
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