Tripleosteotomie bei Morbus Perthes
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Zusammenfassung Operationsziel Durch die Osteotomie des Ischium‑, Pubis- und Iliumknochens kann das Acetabulum über den Hüftkopf geschwenkt werden, sodass der meist anterolateral vorstehende Anteil des Hüftkopfes wieder überdacht wird. Das Ziel ist der Erhalt des Containments der Hüfte, hiermit ist die Wiederherstellung der Kongruenz zwischen dem lateralisierten Hüftkopf und dem Acetabulum gemeint. Das Acetabulum wirkt so als eine Art Schablone für den Hüftkopf, um eine möglichst sphärische Ausheilung des Hüftkopfes zu erreichen. Indikationen Schwere Morbus-Perthes-Erkrankung mit radiologisch sichtbarer Lateralisation des Hüftkopfes und Head-at-risk-Zeichen. Voraussetzung ist, dass der Hüftkopf sich konzentrisch reponieren lässt (Abduktionsaufnahme oder Arthrographie). Kontraindikationen „Hinged abduction“. Keine konzentrische Reposition des Hüftkopfes möglich. Operationstechnik Arthrographie des Hüftgelenkes zur Bestätigung der Operationsindikation. Darstellung und Osteotomie des Ischiums über einen modifizierten Ludloff-Zugang, Osteotomie des Iliums und Pubis über einen modifizierten Smith-Petersen-Zugang. Verbesserung der Hüftkopfüberdachung durch Schwenken des Acetabulums über den Hüftkopf. Fixation des azetabulären Fragmentes mit Vollgewinde-Kirschner-Drähten oder 3,5-mm-Kortikalisschrauben. Weiterbehandlung Mobilisation an Gehstöcken (kleine Kinder im Rollstuhl). Abstellen des Fußes erlaubt. Teilbelastung für 4 bis 6 Wochen (je nach Alter des Patienten). Danach bei im Röntgen guten Konsolidationszeichen Belastungsaufbau innerhalb 1 bis 2 Wochen. Ergebnisse Sehr gute Ergebnisse hinsichtlich Operationstechnik und Ausheilung in der eigenen Klinik. In einer eigenen noch nicht veröffentlichten Studie mit einem durchschnittlichen Untersuchungszeitraum von 5 Jahren zeigten sich bei 30 Patienten sehr gute klinische und radiologische Ergebnisse nach Tripleosteotomie bei Morbus Perthes.Keywords:
Ischium
Legg-Calve-Perthes disease
[Objective]To observe radiographic morphology of femoral head at skeletal maturity of the Salter innominate osteotomy for treatment of patients with Legg-Perthes disease and evaluate sphericity of the femoral head and congruity of the hip.Based on system review of literatures,thes attempted to determine the indications and methods of treatment.[Method]Sixteen patients of Legg-Perthes disease were treated by Salter innominate osteotomy before 1994.The mean age of patients was six years and seven months at operation.Of them,only were 12 patients followed up 10 years and ten months avergely and mean ages of patients were 17 years and 2 months at last follow-up.Growth of plate of femoral head and Y cartilage of acetabulum was closed,indicating skeletal maturity.[Result]According to Stulberg classification of outcome,there were four cases in Stulberg class Ⅰ and six patient in class Ⅱ and one patient in class Ⅲ and one patients in class Ⅳ and no case in class Ⅴ.Lower limb of shortening was averagely 1.5 cm(ranged 0.8~2.0 cm)and the range of motion of hips was almost normal and no abnormal gait was observed.[Conclusion]The Salter innominate osteotomy could keep sphericity of the femoral head and congruity with acetabulum of the hip for children with Legg-Perthes disease and also could be in aid of preventing premature arthritis of hip.
Legg-Calve-Perthes disease
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The material of prospective study involving 57 surgically treated hips in 55 patients suffering with a severe form of Legg-Calvé-Perthes disease (LCPD) was analysed by the use of statistical methods to depict the influence of age, of sex, of the amount of head involvement on the outcomes of surgical treatment by rotational acetabular osteotomy (Salter or Steel osteotomy from 9 years of age).During the period 1990-2000 rotational acetabular osteotomy for Legg-Calvé-Perthes disease was performed totally in 124 patients. Excluded were cases, in which the operation was done for residual subluxation as a definitive outcome of former LCPD, cases which did not return for controls, cases with not yet completed consolidation after surgery and cases operated by me abroad. Totally were analysed stastistical sheets from 57 rotational acetabular osteotomies, including basis dates from medical history, clinical and x-ray examinations. Special concern was given to the evaluation of remodellation of the affected femoral head chronologically.All patients were operated by the group of three senior orthopaedic surgeons. Indication for surgery was based on the evidence of the progressive collapse of the femoral head issuing in the lateral and anterior head extrusion. As the Mose as well as Stulberg classification are showing inter-rater discrepancies, authors measured as well head-neck index, epiphyseal index and acetabulum-head index to eliminate subjectives errors.Age at operation and sex did not affect the results expressed in epiphyseal quotient and acetabulum-head index. With the increasing age the head-neck index dropped down depicting the progressive shortening of the femoral neck the older kids. The periods from the operation till the consolidation of the lateral pillar of the femoral head were longer in younger than in older children. Although the evaluation of results in Mose classification showed poorer results generally and also specifically in relation to the increasing age, distribution of results in Stulberg classification showed excellent and fair results in almost 90% of all treated patients.Prospective study based on the use of rotational osteotomy, avoiding the routine combination with varisation of the proximal femur in older kids using in them Steel triple osteotomy, showed promising results especially in Stulberg classification. Contrary to Salter and others prerequisiting for the indication of operation only slight deformity of the affected femoral head, many of the enrolled cases appeared with the remarkable deformity of the femoral head before the operation. Rotational acetabular osteotomy showed its potential to involve the enlarged head and follow-up depicted its subsequent slow remodellation.Submitted study was prepared to be matched nextly with the conservative group, which will be published in another publication. Internal analysis of the presented cohort disclosed that presented surgical treatment (Salter or Steel osteotomy respectively) assured, that irrespective of higher age, the important parameters like epiphyseal quotient and acetabulum-head index did not become worse than in younger groups. Even in the group over 9 years of age, 87.5% were categorised like excellent and fair results in Stulberg classification.
Legg-Calve-Perthes disease
Subluxation
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Abstract The periacetabular osteotomy (PAO) is a powerful tool to delay the progression of hip arthritis by reorienting the acetabulum. This study aimed to use three-dimensional (3D)-printed models of the pelvis, reconstructed from the computed tomography (CT) scans of patients, to model how the level of dysplasia and its location ilium osteotomy affect radiographic outcomes following PAO. This pilot study aims to determine if preoperative 3D printing/planning can assist in predicting radiographic outcomes. We performed a retrospective review of five patients with differing levels of hip dysplasia for whom we had obtained CT scans before PAO surgery. For each patient, we printed two pelvis models that would undergo standardized cuts of the PAO procedure, with variations only in the distance of the ilium start point (one-third of the distance between the anterior superior iliac spine and anterior inferior iliac spine [AIIS] vs. two-thirds of the distance). We then mobilized the acetabular fragment into eight reproducible positions in space by moving the ilium cut a combination of 0, 1, or 2 cm anterior/lateral. Each position of the newly realigned acetabula was examined under fluoroscopy to obtain a standardized anteroposterior view, and to obtain standardized radiographic measurements in the form of lateral center edge angle (CEA), acetabular depth, Tonnis angle, and acetabular inclination. We performed 80 simulations of the PAO with varying degrees of acetabular mobilization. On average, in the models where the supra-acetabular cut was closer to the AIIS, we found more significant degrees of radiographic correction, regarding Tonnis angles (12.91 vs. 7.95, p = 0.0175), acetabular inclination (20.25 vs. 9.875, p = 0.027), and lateral CEA (11.75 vs. 2.5, p = 0.061). Patients who had greater dysplasia also had more significant degrees of radiographic Tonnis angle correction with the same mobilization movements of the acetabula (p = 0.005). When utilizing 3D printing to model PAO in dysplasia pelvises, we found that both a higher level of preoperative dysplasia and starting the supra-acetabular osteotomy closer to the AIIS were associated with more powerful corrections following smaller manipulations.
Hip Dysplasia
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Ischium
Pubic symphysis
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False profile radiography (FPR), as proposed by Lequesne and de Sèze, depicts the pathology on the anterolateral acetabular wall and femoral head. A study was conducted to find out the differences between normal anteroposterior radiography and FPR. Twenty-seven patients with Legg-Calvé-Perthes disease who had not been operated on previously and 50 recruits without any pathology were studied for the acetabulum-head index of Heyman-Herndon (HHI) and center-edge angles (CEs) in antero-posterior radiographs and VCA angles in FPR. The VCA angle is most useful to detect anterolateral coverage of the femoral head in lateral pillar C hips. FPR is an easy, reliable and cheap technique to evaluate the anterolateral parts of the femoral head, and the acetabulum.
Legg-Calve-Perthes disease
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A retrospective study of 17 Chiari osteotomies performed on patients with Perthes disease who were followed until the end of growth is presented. The average age at operation was 8 years 9 months. Catterall grading was mainly group IV. Chiari osteotomy provided satisfactory femoral head coverage with a decreased acetabular index and a 19.6 degrees improvement of the Wiberg angle. Good femoral coverage was related to age at operation and the site of the osteotomy on the upper rim of the acetabulum. The postoperative result was less successful on younger patients or when the osteotomy was performed higher. At follow-up, the results of femoral head sphericity studied by Mose measurements were favorable under Catterall grading.
Legg-Calve-Perthes disease
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The optimal time and type of the varus-innerrotation femoral osteotomy in the treatment of Legg-Calvé-Perthes disease (LCPD) was evaluated on the basis of 53 hips having early operations and 14 hips having late operations and also on the basis of the previous observations on the disturbed venous drainage in various stages of LCPD. The operation should be done as early as possible in the cases in which it is indicated. Both the operative results in the present series and the theoretical background based on the severe disturbances of venous circulation in the initial phases justify an early intervention. The anatomic results of the early operated-on hips (74% good, 17% fair, and 9% poor) were related to the degree of the varusation and to the postoperative uncovering of the head. In the good results, the attained varusation was greater and the positioning of the head within the acetabulum deeper than in the fair or poor results. Accordingly, in "risk" cases, the optimal angle of the neck immediately after the varusation should be 100--100 degrees. With such varusation, it is possible to obtain good containment and a remarkable relief of the load against the femoral head during walking and running.
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