目的 通过临床和X线检查,评估单侧髋脱位联合去旋转截骨术后股骨前倾角的变化,探讨股骨近端横断面上塑形性相关的影响因素,为个体化的手术方案提供参考.方法 按Severin和Mckay优和良的标准,回顾性分析2005 ～2008年作者收治的58例单侧髋脱位患儿临床资料,均接受联合股骨上段去旋转截骨;手术年龄3 ～15 岁,平均(6.11±2.99 )岁,随访时间3.4 ～6.4年,平均(4.74±0.88)年,随访结束时年龄8.2 ～18.9岁,平均(10.8±2.82)岁.术后通过骨盆前后位平片及侧位片,测量股骨颈干角髋臼指数、中心边缘角和股骨头骺板-股骨颈角,并按Ogata方法 测量股骨近端前倾角.随访结束时测量双髋内外旋活动范围.将非手术侧设为对照组.通过SPSS16.0进行统计分析,重复测量方差分析用于术后前倾角的演变趋势;Pearson相关分析和多元线性回归分析用于股骨前倾角塑形能力相关影响因素;髋关节旋转活动范围分析采用配对样本t检验,P<0.05为差异有统计学意义.结果 ①髋脱位联合去旋转截骨术后股骨近端在轴位上存在塑形能力,术后前倾角矫正为21.3±2.13,术后1年逐渐改善至 22.9±1.23,随访结束时前倾角为24.7±1.16.②多种因素影响前倾角的塑形,手术时年龄(β=-0.545,P< 0.05)和术后髋臼指数(β=0.349,P<0.01)与前倾角的塑形呈显著相关,术中去旋转截骨度数(β=-0.050,P>0.05)和术后颈干角 (β=0.039,P>0.05)与之相关性较弱.股骨颈-骺板角以及中心边缘角与股骨前倾角的塑形无明显相关关系.③随访结束时,双侧髋关节内外旋活动范围无显著差异(P>0.05).结论 髋脱位在行一期联合去旋转截骨术后,股骨近端在轴位上有一定的塑形能力,且与手术年龄和术中去旋转角度有密切关系,这为髋脱位术前个体化设计手术方案提供了重要参考.%Objective To explore the related factors of proximal femoral remodeling at axial plane for u-nilateral developmental dislocation of the hip with combined derotational osteotomy of proximal femur according to the evaluation of clinical tests and radiological examination. Methods 58 unilateral developmental dislocation of the hip with combined derotational osteotomy from 2005 ~ 2008 were included in this study. The average age of operation were 6. 11 ±2. 99 yr ( range: 3-15 yr ) and the average age of final follow-up were 10. 8 ± 2. 82 yr ( range: 8. 2 ~ 18. 9 yr ). The average followed-up time was 4. 74 ± 0. 88 year ( range: 3.4 ~ 6. 4 year ). These individuals were all assessed with excellent and good according to the Mckay and Severin criteria of evaluation and included grade I avascular necrosis by criteria of Kalamachi-MacEwen. Meanwhile, femoral anteversion was checked out by Ogata chart according to standard anterior-posterior X-ray of pelvis and lateral X-ray of operated femur, in addition, neck-shaft angle, acetabular index and center-edge angle being obtained from anterior-posterior roentgenogram of pelvis. At final follow-up, internal and external rotation movement of bothsides were measured clinically. The non-operated side was set up as control group. SPSS 16. 0 software was ap-plied for further statistical analysis. Repeated measurement variance was used for changes of postoperative femoral ante version; meanwhile, Pearson correlation and multi linear regression were used for investigation related factors with remodeling of femoral anteversion. Besides that, paired-t test was chosen for analysis of rotational movements of both sides hip joints. P <0. 05 was considered to be significant. Results Firstly, it was indicated that femoral anteversion got remodeling activity postoperatively. Average value was increased from 21. 3 ±2. 13 at post-operation to 22. 9 ± 1. 23 one year after procedure and reduced to 24. 7 ± 1. 16 at final follow-up. The remodeling ability of proximal femur at axial plane was correlated to several factors, which were depicted by a multi linear regression model. In this model, a strong negative correlation between age at operation ( β coefficient = - 0. 545 ; P < 0. 05 ) as well as positive correlation with postoperative acetabular index ( βcoefficient = 0. 349; P < 0. 01 ) and remodeling of femoral anteversion was found, meanwhile, a weak correlation was checked out between degrees of derotation ( β coefficient = - 0. 050; P > 0. 05 ) concomitant of neck-shaft after operation (β coefficient = 0. 039; P > 0. 05 ) and the remodeling ability of femoral anteversion. However, no obvious correlation was present between neck-epiphysis angle well as center-edge angle and remodeling of femoral anteversion. At final follow-up, no significant difference was present at the rotational movements of both sides ( P > 0. 05 for both internal and external rotation respectively ). Conclusion proximal femur has remodeling ability at axial plane after combined derotational osteotomy for developmental dislocation of the hip, and this remodeling is related to not only derotational degrees as well as neck-shaft angle, but also age at operation and postoperative acetabular index. And therefore, these related factors can provide significant reference when individual pre-operative surgical plan is designed.
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