Bernese髋臼周围截骨术治疗成人髋臼发育不良

髌臼发育不良引起病理性关节负重,是造成继发性髋关节炎最常见的原因之一。据报道,50岁时患髋关节骨性关节炎者25％～50％是由髋臼发育不良引起的。髋关节发育不良的基本病理改变是股骨头髋臼覆盖的减少,结果导致股骨头的不稳定及前外侧移位,在髋臼边缘形成了慢性剪力。剪力长期作用,最终将形成髋臼唇缘的变性,导致髋关节的骨性关节炎。Bernese髋臼周围截骨术可以纠正异常的解剖结构,减少髋关节的负重,改善相对年轻患者髋关节骨性关节炎的预后。     

髋臼周围截骨治疗重度髋臼发育不良

重度髋臼发育不良的治疗方法目前还存在争论。作者采用Bernese髋臼周围截骨治疗16例，其中8例合并髋关节半脱位，8例合并继发性髋臼。6例同时行股骨近端截骨。术后摄片分析畸形矫正程度、截骨愈合和骨关节炎的发生情况。结果显示髋臼畸形矫正满意，所有截骨完全愈合。Harris评分从73．4分提高至91．3分。主要并发症为：1例髋臼固定失败需重新手术固定，     

成人先天性髋臼发育不良全髋置换术中髋臼重建

目的探讨全髋关节置换治疗成人先天性髋臼发育不良术中髋臼的重建方法。方法对24例32髋成人先天性髋臼发育不良继发骨性关节炎患者进行了全髋关节置换术,21髋行自体股骨头及髂骨移植重建髋臼,11髋单纯行髋臼加深重建髋臼。术后以Harris评分、放射学改变、步态、肢体长度、Trendelenburg征评定治疗效果。结果所有患者均获得随访,时间6个月~5年。Harris评分由术前平均48.2分恢复到术后平均86.4分,X线片显示,自体股骨头及髂骨移植重建髋臼病例所有移植骨块均愈合良好。旋转中心平均下降55mm(37~69 mm)。29髋疼痛消失,3髋术后有轻微疼痛。1例术后Trendelenburg征持续阳性。结论根据术前评估,选择合适的髋臼重建方法进行全髋关节置换对成人先天性髋臼发育不良可获得较好疗效。     

经髋臼缘截骨术治疗成人髋臼发育不良(附56例报告)

目的：探讨手术治疗成人髋臼发育不良的一种新方法。方法：在Chiari骨盆内移截骨的基础上，于髋臼缘上3～mm处进行骨盆截骨；截骨远端内移后，可使畸形半脱位的股骨头，通过关节囊与髂骨近端对股骨头产生良好的覆盖和承重，股骨头覆盖面积明显加大。结果：平均随访25个月，疼痛缓解、髋关节功能优良率达87．5％，X线摄片示股骨头的覆盖率术前为70％，术后上升到95％。结论：经髋臼缘截骨术是治疗成人髋臼发育不良的有效方法。     

基于三维CT重建的计算机模拟技术在伯尔尼髋臼周围截骨术中的应用

目的评估基于三维CT重建的计算机模拟设计在Bernese髋臼周围截骨术的术前评估、手术设计以及术后效果分析的可行性。方法从2004年7月至2006年4月，16例（18髋）的Bernese髋臼周围截骨术使用基于三维CT重建的计算机模拟技术。男1例（2髋），女15例（16髋）；手术时年龄为14-42岁，平均24岁。术前行髋关节螺旋CT扫描并进行三维重建，使用“Top View”技术及Azuma分级对股骨头覆盖程度进行评估。通过该程序对Bernese髋臼周围截骨术进行模拟操作，记录模拟手术中髋臼截骨块向外侧和前方旋转的角度，作为实际手术的参考。术后复查髋关节CT及三维重建对术后效果进行分析。结果18髋术前外侧CE角平均为2．94^o（-14^o-22^o），臼顶倾斜角平均为27．7^o（12^o-40^o），前方CE角平均为8．94^o（-10^o-18^o），Top View的股骨头覆盖率平均为63．5％（50％-77％）。术后平均外侧CE角为30．1^o（13^o-47^o），臼顶倾斜角平均为5．5^o（-13^o-18^o），前方CE角为26．9^o（15^o-38^o），Top View的股骨头覆盖面积平均为92．5％（84％-100％）。术后14髋（77．8％）的Azuma分级与模拟设计的分级相符，3髋前覆盖矫正过多，1髋前覆盖矫正稍不足。结论基于三维CT重建的计算机模拟技术能够直观、立体地再现髋臼发育不良的畸形特点，与二维图像可互为补充，通过模拟截骨操作可使术者了解合适的截骨位置和旋转角度，以指导实际的截骨手术。     

髋臼周围截骨术治疗髋臼发育不良

目的探讨髋臼周围截骨术治疗髋臼发育不良的方法及疗效。方法对36例髋臼发育不良患者(43髋)行手术治疗,通过髋臼周围截骨、旋转髋臼向前外侧移位恢复髋臼的正确位置,并增加髋臼覆盖面。结果 36例均获随访,时间6个月～3年。术后髋痛、跛行完全消失或有明显改善,髋关节活动范围基本正常。CE角和Sharp角均基本恢复正常。结论髋臼周围截骨术可有效改善临床症状,恢复髋关节的生物力学特点,是治疗髋臼发育不良的有效方法。     

髋臼旋转截骨术治疗髋臼发育不良

目的：报告1组成年人髋臼发育不良(DDD)患者行髋臼旋转截骨术(RAO)的疗效。方法：采用王金成改良Ollier髋外侧入路，行大粗隆截骨，截骨块连同臀中肌一起向近端反转，在关节囊外距髋臼骨性边缘约1．5cm处做穹隆状截骨，将整个髋臼以球形方式截断并向前、外、下方旋转，覆盖股骨头。结果：12例患者经平均2．5年的随访，疗效满意。结论：RAO手术是治疗成年人DDD行之有效的方法，可有效改善临床症状，恢复髋关节的生物力学及生理特点，明显降低患髋的病残率。     

成人髋臼发育不良生物力学改变及治疗现状

成人髋臼发育不良是指髋臼与股骨头之间失去正常匹配关系 ,导致髋关节生物力学破坏 ,是成年人继发性骨关节炎的主要病因之一。1　影像学变化在普通X线平片上衡量髋臼发育不良的参数很多 ,其中最常用AI与CE角 ,AI值 >3 0°及 (或 )CE角 <2 0°既可诊断为髋臼发育不良。无论是AI值增大 ,还是CE角减小 ,都是以髋臼变浅及髋臼对股骨头包容不良等变化为基础的。以上各种参数只能用来衡量髋臼深浅或上外侧的发育情况。Murphy等对 2 0例患髋及 49例正常髋臼进行CT和MR三维扫描发现正常髋臼是完美的半球形 ,向前倾 2 0° ,外翻 5 3°。发育…     

髋臼翻转造盖术治疗成人髋臼发育不良的生物力学研究

目的探讨髋臼翻转造盖术治疗成人髋臼发育不良的力学机理。方法收集适宜行髋臼翻转造盖术的成人髋臼发育不良12例的术前术后X线片,建立有限元网格,分析其力学变化并与正常髋关节进行对照研究。结果术后与术前各部位受力明显改变具有显著性差异(P<0·01),其中术前髋臼应力集中于外上缘,术后髋臼应力分布于臼顶,应力分散,与正常髋臼受力接近。结论髋臼翻转造盖术可明显改善髋臼局部受力情况,使成人髋臼发育不良术后髋关节受力趋于正常。     

Bernese髋臼周围截骨术治疗成人髋臼发育不良

发育性髋臼发育不良是导致髋关节骨性关节炎(osteoarthritis,OA)的主要发病原因之一,宜早期手术治疗.自2003年6月～2005年3月采用Bernese手术治疗成人髋臼发育不良14例,效果满意,报告如下.     

Gelenkerhaltende Hüftchirurgie im Erwachsenenalter

Deformity and malposition of the acetabulum can occur during the development of the hip. Developmental hip dysplasia and acetabular retroversion are possible causes of osteoarthritis in the young adult. Surgical management with reorientation of the acetabulum allows causal therapy of the deformity and preservation of the native hip joint. Established techniques are the Bernese periacetabular osteotomy (PAO) and the T?nnis and Kalchschmidt triple osteotomy of the pelvis. Both techniques permit three-dimensional correction of the position of the acetabulum. Advantages and disadvantages of each technique must be considered and are summarized in the present paper. If performed early (osteoarthritis grade T?nnis 0 and 1) with correct indication and proper technique, good results can be expected.     

伯尔尼髋臼周围截骨术对严重髋臼发育不良的治疗

目的 研究和分析使用伯尔尼髋臼周围截骨术治疗严重髋臼发育不良的中期临床和影像学结果.方法 1997年10月至2002年12月对18例(20髋)严重髋臼发育不良(Severin分级Ⅳb级)的患者接受了伯尔尼髋臼周围截骨术.患者手术时平均年龄21岁,平均随访时间6.2年.本组患者术前患髋均已出现疼痛,术前功能位片显示关节面吻合.术后影像学评价畸形的矫正范围,截骨处的愈合情况及关节炎的进展.临床结果和髋关节功能由Harris评分进行评价,术前Harris评分平均78.5分.结果 比较术前和术后X线片,外侧中心边缘角(CE角)、前方CE角和臼顶倾斜角均有显著改善.所有髂骨截骨均愈合.患者术后末次随访Harris评分平均91.1分.18例患者中的14例对手术效果表示满意.20髋中16髋临床结果优.但有5髋存在畸形矫正不足.结论 伯尔尼髋臼周围截骨术是治疗严重髋臼发育不良的有效术式.这一截骨术可以在各个平面对严重的骨缺损进行矫正,中期临床结果令人满意.     

Periazetabuläre Osteotomie nach Ganz

The Bernese periacetabular osteotomy (PAO) is a surgical technique for the treatment of (1) hip dysplasia and (2) femoroacetabular impingement due to acetabular retroversion. The aim of the surgery is to prevent secondary osteoarthritis by improvement of the hip biomechanics. In contrast to other pelvic osteotomies, the posterior column remains intact with this technique. This improves the inherent stability of the acetabular fragment and thereby facilitates postoperative rehabilitation. The birth canal remains unchanged. Through a shortened ilioinguinal incision, four osteotomies and one controlled fracture around the acetabulum are performed. The direction of acetabular reorientation differs for both indications while the sequence of the osteotomies remains the same. This surgical approach allows for a concomitant osteochondroplasty in the case of an aspherical femoral head-neck junction. The complication rate is relatively low despite the complexity of the procedure. The key point for a successful long term outcome is an optimal reorientation of the acetabulum for both indications. With an optimal reorientation and a spherical femoral head, the cumulative survivorship of the hip after 10 years is 80–90?%. For the very first 75 patients, the cumulative 20-year survivorship was 60?%. The preliminary evaluation of the same series at a 30-year follow-up still showed a survivorship of approximately 30?%. The PAO has become the standard procedure for the surgical therapy of hip dysplasia in adolescents and adults.     

Pre- and postoperative three-dimensional computed tomography analysis of triple innominate osteotomy for hip dysplasia

Traditional methods of analysis and surgical techniques for hip dysplasia concentrate on frontal-plane analysis of the hip. More recent studies on imaging and operative correction of hip dysplasia recommend three-dimensional (3D) analysis, and some have mentioned but not emphasized the importance of transverse-plane acetabular anatomy (anteversion/retroversion). In this study we found that failure to analyze and understand transverse-plane acetabular anatomy can contribute to complications after triple innominate osteotomy (TIO). A subset of seven patients (eight hips) who were treated with TIO for deficient acetabular coverage resulting from hip dysplasia or Legg-Calvé-Perthes disease had both pre- and postoperative 3D computed tomography (CT) studies. Most of the postoperative studies were obtained to analyze complications (external limb rotation, nonunion). Analysis of the 3D CT studies showed a change in the position of the acetabular fragment after osteotomy into greater adduction, anterior rotation (extension), and external rotation, improving femoral head coverage. All of the hips had increased external rotation of the acetabulum after TIO. Excessive external rotation (>10 degrees) was noted in five hips, and these included two hips with pubic osteotomy nonunion, two with ischial nonunion, and one with marked external rotation of the lower limb. External rotation of the acetabular fragment during redirectional pelvic osteotomy can result in (a) excessive external rotation of the lower limb, (b) decreased posterior coverage, (c) increased gaps at the pubic and/or ischial osteotomy sites with resultant higher rates of nonunion, and (d) lateralization of the joint center. The surgical technique for TIO should be designed to avoid excessive external rotation of the acetabular fragment.     

Surgical correction of acetabular dysplasia in the adult. A Boston experience.

Acetabular redirection surgery is the mainstay of treatment for the symptomatic, dysplastic hip. The authors' experience with the Salter innominate osteotomy, Wagner spherical acetabular osteotomy and the modified Bernese periacetabular osteotomy shows that major acetabular redirection surgery can reliably improve the structure of the dysplastic hip and delay or prevent secondary osteoarthrosis. The limited correction achieved by the Salter innominate osteotomy suggests this procedure generally should be reserved for younger patients with mild dysplasia. The modified Bernese periacetabular osteotomy is the authors' current preferred method of treating acetabular dysplasia, even in the presence of mild to moderate secondary osteoarthrosis.     

Efficiency and Accuracy of Bernese Periacetabular Osteotomy for Adult Hip Dysplasia

Bernese periacetabular osteotomy (PAO) has several advantages dealing with adolescents and adults acetabular dysplasia. The authors introduced the details and steps performing PAO, with attached video and schematic diagram which demonstrates a perfect PAO in efficiency and accuracy. The patient is an 18‐year‐old girl, complaining hip pain on the left side for 6 months. Physical examination shows normal gait and range of motion (ROM) of the left hip. Pelvic anteroposterior X‐ray shows acetabular dysplasia on the left, and post operation on the right. She is very satisfied with the PAO on the right one year before, so we recommend PAO for the left hip dysplasia again. The key point of PAO includes 4 cuts: ischial cut, pubic cut, acetabular roof cut, and quadrilateral bone cut, and the four cuts should be accomplished accurately. Then the acetabular fragment should be turned to ideal position with the lateral CE angle (LCE) > 25°, the Tönnis acetabular angle 0°, the anterior CE angle (ACE) > 20°, good congruence joint space, and with the hip center medialized slightly. At lastly the acetabular fragment is fixed with proper nails and instruments. The patient is very happy to the surgery with no hip pain, with normal gait, ROM, and Harris hip scores (HHS). In summary, PAO is a relative new and efficient procedure for adult hip dysplasia, requiring accurate techniques. Cadaveric practice and familiar with the local anatomy can help the surgeon overcome the learning curve quickly.     

Computer-assisted periacetabular triple osteotomy for treatment of dysplasia of the hip

AIM: Besides general risks, reorienting periacetabular osteotomies include the risks of over- or under-correction. Therefore, intraoperative computer-assisted control of the pelvic fragment may allow for precise reorientation of the acetabulum in all planes. METHODS: The advantages and problems of a computer assisted periacetabular osteotomy are demonstrated in a 19 year old female with spastic paresis and severe secondary dysplasia of the hip over a postoperative follow up period of 2 years. Because of progressive subluxation of the left femoral head with initial degenerative changes of the hip joint a pelvic triple osteotomy as described by T?nnis and an intertrochanteric derotation-varus osteotomy were performed. The intraoperative control of the acetabular position was optimized by CT based navigation. To compare and evaluate the pre- and postoperative clinical and functional outcome, X-rays, CT scans and a gait analysis were applied. RESULTS: The computer assisted orthopedic surgery (CAOS) technique allows for precise intraoperative control following reorientation of the acetabular fragment in all three planes. The pre- and postoperative clinical and radiological findings were compared and the result was classified as good. CONCLUSION: Although the costs and logistics for pelvic osteotomies are increased by CAOS technology, the authors favor this technique for corrective surgery of complex acetabular deformities, although individual parameters need to be considered in each patient.     

Spontaneous fusion of 'os acetabuli' after triple pelvic osteotomy

In acetabular dysplasia, an overloading of the acetabular rim can cause a stress fracture, creating an 'os acetabuli', or a lesion of the acetabular labrum. At puberty, the os acetabuli seems to be the epiphysis of the os pubis. We present the case of a 14-year-old girl with acetabular dysplasia and spontaneous fusion of an 'os acetabuli' after biomechanical correction by triple pelvic osteotomy. Our report supports the correctness of the biomechanical principle: reorientation of the acetabulum results in a better coverage of the femoral head, reduces the stress at the acetabular rim, shifts the os acetabuli out of the stress region, and may allow union of the bony fragment with the acetabulum.     

Surgical management of the problematic hip in adolescent and young adult patients

Surgical management of the problematic hip in adolescent and young adult patients can be challenging. In many of these patients, hip arthrosis and pain occur secondary to hip dysplasia associated with chronic instability, whether the result of prior treatment or chronic unmanaged acetabular dysplasia. Surgical techniques such as the Bernese periacetabular osteotomy are performed to correct acetabular deficiency, restore hip joint stability, and eliminate pain. Patients with previous Legg-Calvé-Perthes disease or slipped capital femoral epiphysis frequently note onset of symptomatic hip arthrosis and pain in adolescence or young adulthood. Pain occurs secondary to pathologic impingement of the deformed proximal femur against the anterolateral acetabulum (ie, femoroacetabular impingement). The recent successful innovation of the transtrochanteric surgical hip dislocation approach provides complete access to the hip and offers the potential for comprehensive correction of both the often severe proximal femoral deformity and associated labral chondral disease secondary to Legg-Calvé-Perthes disease and slipped capital femoral epiphysis. Restoration of more normal proximal femoral morphology results in marked improvement in functional outcome. Effective orthopaedic management requires an understanding of the mechanisms of hip disease as well as surgical expertise.     

Acetabular blood flow during Bernese periacetabular osteotomy: an intraoperative study using laser Doppler flowmetry.

BACKGROUND: The blood flow to the acetabular fragment is of some concern in juxtaarticular pelvic osteotomies used for the treatment of hip dysplasia. No direct measurements have determined the effect of the Bernese periacetabular osteotomy (PAO) on acetabular perfusion. METHODS: Acetabular perfusion was measured by means of laser Doppler flowmetry in 10 patients undergoing a PAO for symptomatic acetabular dysplasia. During the surgical procedure, the intraosseous high energy laser Doppler reliably depicts dynamic changes of small vessel blood flow. Measurements were performed after defined surgical steps to obtain sequential information on the blood perfusion of the acetabular fragment. RESULTS: After complete separation of the acetabular fragment, nine out of 10 patients had pulsatile signals, but the blood flow (BF) significantly decreased by 77%. Corrective positioning of the fragment induced no further drop of the BF signal but a loss of pulsatility in six patients. After a recovery period of about 30 min following preliminary fixation of the fragment, reestablishment of the pulsatile signal and an increase of the BF signal was seen. At termination of the surgical procedure, five out of eight patients, who could be followed throughout the whole procedure, showed a clear pulsatile signal in the supraacetabular area. Bleeding of the supraacetabular cancellous surface could be observed in all acetabula. CONCLUSION: Despite careful preservation of soft tissues during the surgical procedure, a significant reduction of the blood flow in the supraacetabular region has been observed. Nevertheless, a pulsatile signal in more than 60% of the fragments after fragment correction and an increasing signal during the recovery period showed ongoing blood perfusion indicating reversible changes in the measured supraacetabular area. All osteotomies healed within eight weeks without showing signs of necrosis during a minimum follow up of 1 year.