Bypass of epiphyseal fragmentation following early Salter innominate osteotomy and its clinical relevance in Legg-Calve-Perthes disease.
Bypass of epiphyseal fragmentation following early Salter innominate osteotomy and its clinical relevance in Legg-Calve-Perthes disease.
复制标题
早期 Salter 无名截骨术后骨骺碎片的旁路及其在 Legg-Calve-Perthes 病中的临床相关性。
DOI：
10.1097/bpo.0000000000002089
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发表时间：
2022
期刊：
影响因子：
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通讯作者：
Kitoh H
中科院分区：
文献类型：
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作者：
Mishima K;Kamiya Y;Matsushita M;Imagama S;Kitoh H
背景：已有研究表明，早期股骨内翻截骨术（FVO）更有可能跳过或中断骨骺碎裂，从而缩短了legg - calv<s:1> - perthes病活跃期髋关节碎裂期的长度。这种“旁路现象”被认为对疾病严重程度或结果的影响较小，然而这种现象是否仅针对早期FVO仍有待阐明。我们试图调查在无血管坏死或早期骨折期行盆腔截骨术后“旁路现象”的存在和特征，以及其与疾病严重程度和影像学结果的相关性。方法：回顾性分析1987年至2015年诊断的79例单侧legg - calv<s:1> - perthes病患者的资料，这些患者在6.0 ~ 12.0岁的无血管坏死期或骨折早期接受了Salter无名截骨术（SIO），并随访至骨骼成熟。根据前人的研究，骨骺断裂分为4种类型。我们比较了有无分流碎裂期患者的侧柱组和Stulberg分级。结果：手术时平均年龄8.1岁，随访时间7.9岁。手术中60个髋关节处于Waldenström I期，19个髋关节处于IIa期。在I期接受SIO的髋关节，碎片期的平均持续时间为276天。典型的碎裂型有40髋，流产型有17髋，非典型的水平裂型有3髋。碎裂流产的患者在骨骼成熟时经历了更少的严重侧柱受损伤和更有利的Stulberg结果。结论：28%的患者在缺血性坏死期进行早期SIO手术后发现骨骺碎片不完全搭桥。与FVO相比，没有患者完全绕过碎片化。与未行旁路手术的患者相比，行不完全旁路手术的患者出现较轻髋关节的比例明显更高，且与良好的影像学结果相关的概率也明显更高。证据等级：iv级——治疗性研究。legg - calv<s:1> - perthes病（LCPD）是一种发生在成长中的儿童的特发性股骨头缺血性坏死，其影像学发展经历4个阶段，即初始或缺血性坏死、碎裂、再骨化和愈合。虽然LCPD被认为是一种自愈疾病，但如果不治疗或忽视，受影响的股骨头会不同程度地扩大和变形，导致髋关节非球形不一致，但一些学龄前患者除外。2由于骨折期髋臼覆盖率下降和股骨头的机械强度迅速恶化，在骨折早期应采用手术或非手术方法对髋关节进行围护。除了诊断时的年龄外，骨骺外侧1 / 4处的残余高度已经被认为是一个公认的预后指标，称为侧柱（LP）分类，它是根据碎片化中期的x线表现来确定的。从临床的角度来看，虽然适当的治疗方案的选择应该基于几个离散的预测因素，但使用LP分类的治疗决策受到从初始阶段到中期等待期间骨骺塌陷的限制。
Background:It has been demonstrated that early femoral varus osteotomy (FVO) produces a greater probability of skipping or interruption of epiphyseal fragmentation, thereby shortening the length of fragmentation stage for hips in the active stage of Legg-Calvé-Perthes disease. This “bypassing phenomenon” is thought to effect less disease severity or outcome, whereas it remains to be elucidated whether this phenomenon is specific to early FVO. We sought to investigate the presence and characteristics of the “bypassing phenomenon” following pelvic osteotomy performed in the avascular necrosis or early fragmentation stage as well as its correlation with disease severity and radiographic outcomes.Methods:A retrospective review of data was conducted for 79 patients with unilateral Legg-Calvé-Perthes disease who had been diagnosed from 1987 to 2015, undergone the Salter innominate osteotomy (SIO) during the stage of avascular necrosis or in the early part of the fragmentation stage between 6.0 and 12.0 years of age, and followed up until skeletal maturity. Epiphyseal fragmentation was classified into 4 patterns according to a previous study. We compared lateral pillar groups and Stulberg grades between patients with and without bypass of the fragmentation stage.Results:The mean age at surgery and follow-up period was 8.1 and 7.9 years, respectively. Sixty hips were in the Waldenström stage I and 19 hips in stage IIa at the surgery. In hips receiving SIO during stage I, the mean duration of the fragmentation stage was 276 days. The fragmentation pattern was typical for 40 hips, abortive for 17 hips, and atypical with horizontal fissure for 3 hips. Patients whose fragmentation was aborted experienced significantly less severe lateral pillar involvement and more favorable Stulberg outcomes at skeletal maturity.Conclusions:Incomplete bypass of epiphyseal fragmentation was observed in 28% of patients following early SIO performed in the avascular necrosis stage. In contrast to FVO, no patient bypassed fragmentation completely. Patients with incomplete bypass had a significantly higher proportion of less severe hips and a significantly greater probability of being associated with favorable radiographic outcomes compared with those without bypass.Level of Evidence:Level IV—therapeutic study.Legg-Calvé-Perthes disease (LCPD) is idiopathic avascular necrosis of the femoral head in growing children that evolves through 4 radiographic stages, namely initial or avascular necrosis, fragmentation, reossification, and healed. 1 Although LCPD has been considered as a self-healing condition, if untreated or neglected, an affected femoral head becomes enlarged and deformed to a varying degree, resulting in a non-spherical incongruent hip joint except ones of some preschool-aged patients. 2 As decreased acetabular coverage and mechanical strength of the affected femoral head rapidly deteriorate during the fragmentation stage of the disease, containment of the hip with a surgical or nonsurgical method should be undertaken by the early fragmentation stage. 3 In addition to age at diagnosis, residual degrees of height at the lateral one-fourth of the epiphysis have been known to be an established prognosticator called the lateral pillar (LP) classification, determined based on the radiographic appearances in the mid-fragmentation stage. 4 From a clinical standpoint, although the choice of an appropriate treatment option should be made based on several discrete predictors, treatment decision making using the LP classification has been limited by concerns about epiphyseal collapse during the waiting period from the initial stage to the mid …