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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2022, Vol. 16 ›› Issue (01) : 8 -15. doi: 10.3877/cma.j.issn.1674-134X.2022.01.002

临床论著

Bernese髋臼周围截骨术早期手术效果的影响因素分析
顾言阁1, 石志伟1, 段续东2, 殷鲁旭3, 张业勇3, 孙华强3, 李树锋3, 闫新峰4,†()   
  1. 1. 250012　济南，山东大学齐鲁医学院
    2. 710048　西安交通大学医学部
    3. 250014　济南，山东第一医科大学第一附属医院（山东省千佛山医院）骨外科，山东省风湿免疫病转化医学重点实验室
    4. 250012　济南，山东大学齐鲁医学院；250014　济南，山东第一医科大学第一附属医院（山东省千佛山医院）骨外科，山东省风湿免疫病转化医学重点实验室
  • 收稿日期:2021-01-26 出版日期:2022-02-01
  • 通信作者: 闫新峰
  • 基金资助:
    山东省自然科学基金资助项目(ZR2019MH130)

Analysis of influencing factors of early surgical results of Bernese periacetabular osteotomy

Yan′ge Gu1, Zhiwei Shi1, Xudong Duan2, Luxu Yin3, Yeyong Zhang3, Huaqiang Sun3, Shufeng Li3, Xinfeng Yan4,†()   

  1. 1. Cheeloo College of Medicine, Shandong University, Jinan 250014, China
    2. Xi′an Jiaotong University Health Science Center, Xi′an 710048, China
    3. Department of Orthopedic Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Jinan 250014, China
    4. Cheeloo College of Medicine, Shandong University, Jinan 250014, China; Department of Orthopedic Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Jinan 250014, China
  • Received:2021-01-26 Published:2022-02-01
  • Corresponding author: Xinfeng Yan
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引用本文：

顾言阁, 石志伟, 段续东, 殷鲁旭, 张业勇, 孙华强, 李树锋, 闫新峰. Bernese髋臼周围截骨术早期手术效果的影响因素分析[J]. 中华关节外科杂志(电子版), 2022, 16(01): 8-15.

Yan′ge Gu, Zhiwei Shi, Xudong Duan, Luxu Yin, Yeyong Zhang, Huaqiang Sun, Shufeng Li, Xinfeng Yan. Analysis of influencing factors of early surgical results of Bernese periacetabular osteotomy[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2022, 16(01): 8-15.

目的

探讨Bernese髋臼周围截骨术(PAO)术后功能恢复及疼痛的影响因素。

方法

对2017年1月至2019年11月接受改良Smith-Peterson入路Bernese髋臼周围截骨术治疗的发育性髋关节发育不良患者进行回顾性研究。纳入标准为在此期间接受PAO治疗的所有DDH患者。排除标准：髋关节外伤史，现有神经肌肉或结缔组织疾病，既往有髋关节手术史，影像资料不全者，髋臼后倾(交叉征阳性)，采用髂腹股沟入路的PAO和失访者。测量术前和术后的影像学指标，观察了髋臼顶倾斜角，外侧中心边缘角，髋臼外展角，股骨头超出指数，股骨头球度指数，Shenton线，骨关节炎Tonnis分级，头臼匹配度，p/a比值，髋臼前倾角，西安大略和麦克马斯特大学骨关节炎指数(WOMAC)疼痛评分和改良Harris髋关节评分(MHHS)等因素，使用logistic回归分析确定术后功能及疼痛的影响因素。

结果

在此期间共有75名患者接受Bernese髋臼周围截骨术，排除髂腹股沟入路16例，失访5例，影像资料不全者8例，术前髋臼后倾2例，最终有44名患者纳入此次研究，术后随访时间平均(2.1±1.4)年。患者MHHS从术前70(55，84)分提高到术后91(88，91)分(Z＝-7.067, P< 0.01)，WOMAC疼痛评分从术前4(1，8)分降至术后0分(Z＝-4.920, P< 0.01)。根据logistic回归分析，术前外侧中心边缘角每增加一个单位，术后MHHS被归类为优秀的几率是原来的1.2倍[比值比(OR)＝1.183，95%置信区间(CI)(1.077，1.299)，P<0.01]。年龄每增加一个单位，术前疼痛程度增加一级的可能性是原来的1.1倍[OR＝1.090，95%CI(1.018，1.157)，P＝0.012]。身体质量指数每增加一个单位，术前疼痛程度增加一级的可能性是原来的1.2倍[OR＝1.244，95%CI(1.050，1.474)，P＝0.011]。其它因素与术前疼痛及术后功能评分之间不存在有统计学意义的相关性。

结论

Bernese髋臼周围截骨术后患者功能评分显著提高，疼痛症状显著减轻。术前外侧中心边缘角较大的患者术后将获得更佳的关节功能，年龄及身体质量指数较大的患者疼痛程度更重。

关键词: 髋脱位，先天性, 骨疾病，发育性, 截骨术
Objective

To explore the influencing factors of postoperative functional recovery of Bernese periacetabular osteotomy(PAO) and influencing factors of pain degree.

Methods

A retrospective study was conducted on the patients with developmental dysplasia of the hip (DDH) who underwent Bernese periacetabular osteotomy with a modified Smith-Peterson approach between January 2017 and November 2019. The inclusion criteria was all the DDH patients who received PAO during this period. Exclusion criteria: history of hip joint trauma, existing diseases of nerve, muscle or connective tissue, history of hip surgery, incomplete image data, acetabular retroversion (positive cross sign), the iliac-inguinal approach patients, and the patients who were lost during the follow-up. The preoperative and postoperative imaging indicators were measured. The acetabular top tilt angle, lateral central edge angle, acetabular abduction angle, femoral head extrusion index, sphericity index of femoral head, Shenton line, Tonnis grade of osteoarthritis, joint congruency, p/a ratio, acetabular anteversion angle, Western Ontario and McMaster Universities osteoarthritis index (WOMAC) pain score and modified Harris hip score (MHHS) were measured and recorded. Multiple regression analysis was applied to determine the preoperative pain degree and postoperative function influencing factors.

Results

A total of 75 patients underwent Bernese PAO. Among them, 16 cases using the iliac-inguinal approach were excluded, five cases were lost during follow-up, eight cases had incomplete imaging data, and there were two cases of acetabular retroversion. Eventually the study was conducted on 44 patients. The follow-up time was (2.1±1.4) years on average. The MHHS increased from 70(55, 84) points before the surgery to 91(88, 91) points after the surgery (Z=-7.067, P <0.01), WOMAC pain score decreased from 4(1, 8) points before surgery to zero after the surgery (Z=-4.920, P<0.01). According to the logistic regression analysis, for every unit increased in the lateral center-edge angle, the postoperative modified Harris score was 1.2 times more likely to be classified as excellent[odds ratio(OR)=1.183, 95%confidence interval(CI)(1.077, 1.299), P<0.01]. For each increase of age by one unit, the probability of preoperative pain level increasing by one level was 1.1 times higher [OR=1.090, 95%CI(1.018, 1.157), P=0.012]. For each increase in body mass index by one unit, the probability of preoperative pain level increasing by one level was 1.2 times higher [OR=1.244, 95%CI(1.050, 1.474), P=0.011]. Regression analysis of other factors showed no significant correlation with preoperative pain and postoperative functional score.

Conclusions

The overall function score of patients after Bernese periacetabular osteotomy is significantly improved, and the pain symptoms are significantly reduced. The patients with larger lateral center-edge angle may have better joint function after surgery, while the patients with elder age and lager body mass index may suffer more severe pain.

Key words: Hip dislocation, congenital, Bone diseases, developmental, Osteotomy
图1 手术示意图。图A为手术切口；图B为切开阔筋膜，在阔筋膜深层向内侧分离至阔筋膜张肌和缝匠肌间隙，同时保护股外侧皮神经；图C为分离股直肌和髂腰肌，显露关节囊，通过关节囊、髂腰肌及股骨近端内侧建立坐骨截骨通道
图2 p/a比值的测量方法[10]。图A示p/a比值是用p除以a，两者都是在髋臼外缘与前下缘连线的垂直平分线上测量的；图B示当垂直平分线位于髋臼窝时，将髋臼关节面作为圆的一部分来作出最佳拟合圆，以圆的轨迹与该线的交点作为p和a的近点注：p为从髋臼关节面到髋臼后壁边缘的距离；a为从髋臼关节面到髋臼前壁边缘的距离
图3 DDH(发育性髋关节发育不良)患者术前、术后及随访时的双髋关节正位X线影像。图A为术前双髋关节正位X线，示股骨头向髋臼外上方移位，为半脱位状态；图B为术后双髋关节正位X线示各项影像学指标较术前改善，LCEA(外侧中心边缘角)增加，ABA(髋臼外展角)降低，Tonnis角减小，EI(股骨头超出指数)减小，p/a比值及对应的髋臼前倾角减小，髋关节中心向内侧移动；术后髋关节的头臼匹配度优于术前；图C为DDH患者术后随访时影像，示骨块无移位、愈合良好
表1 患者术前术后的X线表现
影像学参数 术前 术后 统计值 P值
LCEA [°，(±s)] 10.7±7.2 34.8±7.1 t＝-16.630 <0.01
ABA[°，M(P25，P75)] 48.0(44.3，51.0) 38.0(34.3，41.0) Z＝-5.780 <0.01
EI [%，(±s)] 28.4±9.5 10.5±5.4 t＝11.980 <0.01
Tonnis分级占比(%)        
  0级 22.8% 20.4%    
  1级 72.7% 77.3% χ2＝2.000 0.368
  2级 4.5% 2.3%    
  3级 - -    
Tonnis角[°，M(P25，P75)] 23.0(19.0，24.8) 9.5(6.0，12.0) Z＝-5.690 <0.01
p/a比值[M(P25，P75)] 2.3(1.8，3.3) 1.6(1.4，2.0) Z＝-5.271 <0.01
髋臼前倾角[°，M(P25，P75)] 21.9(17.1，31.7) 15.3(13.0，18.6) Z＝-5.298 <0.01
Shenton线连续(%) 68.2 75   0.648*
Shenton线不连续(%) 31.8 25    
头臼匹配度占比(%)        
  优 29.5 81.9    
  良 52.4 13.6   0.031*
  一般 13.6 4.5    
  差 4.5 0    
髋关节中心位置[mm，M(P25，P75)] 10.8(9.0，13.4) 8.5(6.2，9.6) Z＝-3.875 <0.01
图4 术前术后MHHS(改良Harris髋关节评分)对比
表2 术后MHHS评分的单因素分析
变量 β值 Wald值 OR值 95%CI P值
手术时年龄 -0.033 0.580 0.968 (0.949，1.125) 0.447
随访时间 -0.226 0.915 0.797 (0.502，1.268) 0.339
性别 -2.526 4.078 0.080 (0.004，1.818) 0.113
身体质量指数 -0.068 0.272 0.934 (0.722，1.208) 0.602
左右侧 0.571 0.525 1.769 (0.378，8.284) 0.469
股骨头球度指数 0.036 0.412 1.037 (0.929，1.157) 0.521
术前髋臼顶倾斜角 -0.058 0.659 0.944 (0.821，1.085) 0.417
术前外侧中心边缘角 0.111 0.062 1.117 (0.990，1.261) 0.073
术前髋臼外展角 -0.051 0.076 0.950 (0.819，1.102) 0.497
术前股骨头超出指数 2.821 0.468 0.972 (0.897，1.054) 0.491
术前shenton线 0.310 0.145 1.364 (0.276，6.737) 0.704
术前骨关节炎Tonnis分级 -1.025 1.285 0.359 (0.061，2.111) 0.257
术前头臼匹配度 -0.603 0.485 0.547 (0.211，1.417) 0.214
术前P/A比值 -0.360 0.259 0.698 (0.420，1.160) 0.165
术前髋臼前倾角 -0.037 1.913 0.963 (0.914，1.016) 0.167
术后髋臼顶倾斜角 -0.036 0.177 0.965 (0.817，1.140) 0.674
术后外侧中心边缘角 0.046 0.756 1.047 (0.944，1.162) 0.385
术后髋臼外展角 -0.050 0.779 0.951 (0.850，1.063) 0.377
术后股骨头超出指数 -0.055 0.633 0.947 (0.827，1.083) 0.426
术后Shenton线 1.421 2.983 4.143 (0.826，20.790) 0.084
术后骨关节炎Tonnis分级 -1.435 1.504 0.238 (0.024，2.359) 0.220
术后头臼匹配度 -0.595 0.365 0.551 (0.080，3.800) 0.546
术后p/a比值 0.786 0.523 2.195 (0.260，18.508) 0.470
术后髋臼前倾角 -0.081 0.513 0.922 (0.739，1.151) 0.474
表3 术前WOMAC疼痛级别的单因素分析
变量 β值 Wald值 OR值 95%CI P值
手术时年龄(岁) 0.083 6.943 1.087 (1.021，1.156) 0.008
随访时间(年) 0.140 0.531 1.150 (0.790，1.674) 0.466
性别 -0.935 0.990 0.393 (0.062，2.480) 0.320
身体质量指数(kg/m2) 0.133 2.893 1.142 (0.980，1.332) 0.089
左右侧 -1.094 3.580 0.335 (0.108，1.040) 0.058
股骨头球度指数 0.001 0.001 1.001 (0.930-1.079) 0.969
术前髋臼顶倾斜角(°) 0.004 0.009 1.004 (0.921，1.095) 0.923
术前外侧中心边缘角 -0.016 0.182 0.984 (0.914，1.060) 0.669
术前髋臼外展角(°) -0.027 0.259 0.973 (0.877，1.080) 0.611
术前股骨头超出指数 -0.035 1.463 0.966 (1.096，1.022) 0.227
术前Shenton线 0.458 0.614 1.581 (0.503，4.963) 0.433
术前骨关节炎Tonnis分级 1.296 0.748 3.655 (0.194，68.855) 0.387
术前头臼匹配度 0.306 1.372 1.358 (0.092-20.005) 0.823
术前p/a比值 -0.022 0.001 0.978 (0.257，3.725) 0.974
术前髋臼前倾角(°) 0.043 4.062 1.044 (1.001，1.088) 0.044
表4 术后改良Harris髋关节评分的多元logistic回归分析结果
变量 β值 Wald值 OR值 95%CI P值
术前LCEA 0.168 12.401 1.183 (1.077，1.299) <0.01
术后Shenton线 -0.812 1.076 0.444 (0.096，2.059) 0.300
表5 术前WOMAC疼痛分级的有序logistic回归分析结果
变量 β值 Wald值 OR值 95%CI P值
手术时年龄 0.082 6.297 1.090 (1.018，1.157) 0.012
身体质量指数 0.218 6.404 1.244 (1.050，1.474) 0.011
左右侧 -1.265 3.963 0.282 (0.081，1.020) 0.052
术前髋臼前倾角 0.044 3.640 1.045 (1.000，1.092) 0.056
[1]
Chen M, Shang XF. Surgical treatment for young adult hip dysplasia: joint-preserving options[J]. Int Orthop, 2016, 40(5): 891-900.
[2]
Hernandez PA, Wells J, Usheva E, et al. Early-Onset osteoarthritis originates at the chondrocyte level in hip dysplasia[J]. Sci Rep, 2020, 10(1): 627. DOI: 10.1038/s41598-020-57431-x.
[3]
Schmitz MR, Murtha AS, Clohisy JC, et al. Developmental dysplasia of the hip in adolescents and young adults[J]. J Am Acad Orthop Surg, 2020, 28(3): 91-101.
[4]
宋永兴，曾忠友，陈晓东，等．髋臼周围截骨术治疗中青年髋关节发育不良[J]．中国矫形外科杂志，2018，26(10): 878-882.
[5]
Beaulé PE, Dowding C, Parker G, et al. What factors predict improvements in outcomes scores and reoperations after the Bernese periacetabular osteotomy？[J]. Clin Orthop Relat Res, 2015, 473(2): 615-622.
[6]
王恒，弋石泉，殷勇，等．Bernese髋臼周围截骨治疗成人髋臼发育不良的初步探讨[J]．双足与保健，2018，27(3): 138-139.
[7]
Steppacher SD, Tannast M, Werlen S, et al. Femoral morphology differs between deficient and excessive acetabular coverage[J]. Clin Orthop Relat Res, 2008, 466(4): 782-790.
[8]
Clohisy JC, Carlisle JC, Beaulé PE, et al. A systematic approach to the plain radiographic evaluation of the young adult hip[J]．J Bone Joint Surg Am, 2008, 90 Suppl 4(Suppl 4): 47-66.
[9]
Wells J, Schoenecker P, Duncan S, et al. Intermediate-term hip survivorship and patient-reported outcomes of periacetabular osteotomy: The Washington University Experience[J]. J Bone Joint Surg Am, 2018, 100(3): 218-225.
[10]
Koyama H, Hoshino H, Suzuki D, et al. New radiographic index for evaluating acetabular version[J]. Clin Orthop Relat Res, 2013, 471(5): 1632-1638.
[11]
Abraham CL, Knight SJ, Peters CL, et al. Patient-specific chondrolabral contact mechanics in patients with acetabular dysplasia following treatment with peri-acetabular osteotomy[J]. Osteoarthritis Cartilage, 2017, 25(5): 676-684.
[12]
Wyles CC, Statz JM, Hevesi M, et al. Incidence and risk factors for hardware removal following periacetabular osteotomy and its association with clinical outcomes[J]. Hip Int, 2021, 31(3): 410-416.
[13]
Gaffney BM, Clohisy JC, Van DR, et al. The association between periacetabular osteotomy reorientation and hip joint reaction forces in two subgroups of acetabular dysplasia[J/OL]. J Biomech, 2020, 98：109464. DOI: 10.1016/j.jbiomech.2019.109464.
[14]
Thomas-Aitken HD, Goetz JE, Dibbern KN, et al. Patient age and hip morphology alter joint mechanics in computational models of patients with hip dysplasia[J]. Clin Orthop Relat Res, 2019, 477(5): 1235-1245.
[15]
Luo D, Zhang H, Zhang W. Comparison of three approaches of Bernese periacetabular osteotomy[J]. Ther Clin Risk Manag, 2016, 12(12): 67-72.
[16]
Albers CE, Steppacher SD, Ganz RA, et al. Impingement adversely affects 10-year survivorship after periacetabular osteotomy for DDH[J]. Clin Orthop Relat Res, 2013, 471(5): 1602-1614.
[17]
Novais EN, Duncan S, Nepple J, et al. Do radiographic parameters of dysplasia improve to normal ranges after bernese periacetabular osteotomy？[J]. Clin Orthop Relat Res, 2017, 475(4): 1120-1127.
[18]
Kralj M, Mavcic B, Antolic V, et al. The bernese periacetabular osteotomy: clinical, radiographic and mechanical 7-15-year follow-up of 26 hips[J]. Acta Orthop, 2005, 76(6): 833-840.
[19]
Fujii M, Nakashima Y, Noguchi Y, et al. Factors associated with severity of intra-articular lesions in patients with severe hip dysplasia[J]. Arthroscopy, 2016, 32(8): 1581-1589.
[20]
Petrie JR, Novais EN, An TW, et al. What is the Impact of periacetabular osteotomy surgery on patient function and activity levels? [J] J Arthroplasty，2020，35(6S): S113-S118.
[21]
Larsen JB, Mechlenburg I, Jakobsen SS, et al. 14-year hip survivorship after periacetabular osteotomy: a follow-up study on 1，385 hips[J]. Acta Orthop, 2020, 91(3): 299-305.
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