背景:在接受改良Dunn手术治疗的不稳定滑脱的股骨骨epi(SCFE)中,发生血管坏死(AVN)的风险尚不清楚。此外,因为据报道,不稳定的Loder分类不同于实际的术中观察到的不稳定(即,股骨头骨phy端和近端股骨干端之间的不连续性),发展AVN的总体风险,以及用改良的Dunn手术治疗这些患者的潜在并发症,是未知的。
目的:评估改良的Dunn程序用于治疗骨phy端-干phy端不连续性的患者,我们问:(1)10年时无AVN的生存率是多少?(2)10年时无后续手术和/或并发症的生存率是多少?(3)临床和患者报告的结果评分是多少?
方法:在回顾性分析中,我们确定了在1998年至2020年期间接受改良Dunn手术治疗SCFE的159例患者(159髋),其中97%(159例中的155例)有关于术中观察到的骨phy端-干meta端稳定性的文献.其中,据记录,37%(155例中的58例)的患者在术中观察到骨phy端-干phy端不连续性,并被认为符合纳入条件。而63%(155例中的97例)记录了骨phy-干phy端稳定性,并被排除.在最低2年之前,没有患者失去随访。对所有患者进行生存评估,但7%(58例中的4例)没有填写我们的结局评分问卷.这导致93%(58个中的54个)的患者可用于结果评分评估。此外,50%(58例中的29例)的患者在过去5年内没有就诊;但我们注意到他们的地位存在不确定性。手术时的中位(范围)年龄为13岁(10至16岁),性别比例为60%(58例中的35)男性和40%(58例中的23)女性。64%(58例中的37例)的患者被归类为慢性急性,17%(58例中的10例)的患者被归类为急性。根据影像学分类,47%(58例中的27例)的患者出现严重滑脱,43%(58例中的25例)的患者出现中度滑脱。所有患者均采用改良的Dunn手术进行手术髋关节脱位,以纠正滑脱畸形并提供稳定。从电子病历的审查中评估并发症和再次手术,并使用Kaplan-Meier估计量来估计10年无并发症和再手术的生存率。在至少2年的随访中评估临床检查结果和问卷答复。
结果:10年无AVN的Kaplan-Meier生存率为93%(95%CI87%至100%)。10年无任何再次手术的存活率为75%(95%CI64%至88%)。此外,没有并发症的幸存者,定义为AVN的发展,再操作,或II级或更高的水槽并发症,10年时为57%(95%CI45%至73%)。对于未发生AVN的患者,MerleD\'AubignePostel评分中位数(范围)为18(14至18),4例发生AVN的患者为12例(6至16)(p<0.001)。非AVN队列的Harris髋关节评分中位数为100(74至100),AVN队列为65(37至82)(p=0.001)。非AVN队列中的HOOS总分中位数为95(50至100),AVN队列中的HOOS总分中位数为53(40至82)(p=0.002)。
结论:尽管改良的Dunn程序在技术上具有挑战性,这项研究表明,在有经验的手中,表现为骨-干phy端不连续性的患者可以在低风险的AVN和后续手术的情况下进行治疗.建议将这些患者转诊给在此过程中具有丰富专业知识的专家,以改善患者的预后。前瞻性,长期观察性研究将帮助我们在术前识别这些高危患者,并确定该手术的长期成功与否.
方法:四级,治疗性研究。
BACKGROUND: The risk of developing avascular necrosis (AVN) in the setting of an unstable slipped capital femoral epiphysis (SCFE) that is undergoing treatment with the modified Dunn procedure is not well understood. In addition, since the Loder classification of unstable is reportedly different than actual intraoperatively observed instability (that is, discontinuity between the femoral head epiphysis and proximal femoral metaphysis), the overall risk of developing AVN, as well as the potential complications of treatment of these patients with the modified Dunn procedure, are unknown.
OBJECTIVE: To evaluate the modified Dunn procedure for the treatment of patients with epiphyseal-metaphyseal discontinuity, we asked: (1) What was the survivorship free from AVN at 10 years? (2) What was the survivorship free from subsequent surgery and/or complications at 10 years? (3) What were the clinical and patient-reported outcome scores?
METHODS: In a retrospective analysis, we identified 159 patients (159 hips) treated with a modified Dunn procedure for SCFE between 1998 and 2020, of whom 97% (155 of 159) had documentation about intraoperatively observed epiphyseal-metaphyseal stability. Of those, 37% (58 of 155) of patients were documented to have intraoperatively observed epiphyseal-metaphyseal discontinuity and were considered eligible for inclusion, whereas 63% (97 of 155) had documented epiphyseal-metaphyseal stability and were excluded. No patients were lost to follow-up before the 2-year minimum. All patients were assessed for survival, but 7% (4 of 58) did not fill out our outcomes score questionnaire. This resulted in 93% (54 of 58) of patients who were available for outcome score assessment. Additionally, 50% (29 of 58) of patients had not been seen within the last 5 years; they are included, but we note that there is uncertainty about their status. The median (range) age at surgery was 13 years (10 to 16), and the sex ratio was 60% (35 of 58) male and 40% (23 of 58) female patients. Sixty-four percent (37 of 58) of patients were classified as acute-on-chronic, and 17% (10 of 58) of patients were classified as acute. Forty-seven percent (27 of 58) of patients presented with severe slips and 43% (25 of 58) of patients with moderate slips based on radiographic classification. All patients underwent surgical hip dislocation with the modified Dunn procedure to correct the slip deformity and provide stabilization. Complications and reoperations were assessed from a review of electronic medical records, and a Kaplan-Meier estimator was used to estimate survivorship free from complications and reoperations at 10 years. Clinical examination results and questionnaire responses were evaluated at minimum 2-year follow-up.
RESULTS: Kaplan-Meier survivorship free from AVN was 93% (95% CI 87% to 100%) at 10 years. Survivorship free from any reoperation was 75% (95% CI 64% to 88%) at 10 years. In addition, survivorship free from complications, defined as development of AVN, reoperation, or a Sink Grade II complication or higher, was 57% (95% CI 45% to 73%) at 10 years. The median (range) Merle D\'Aubigne Postel score was 18 (14 to 18) for the patients who did not develop AVN, and 12 (6 to 16) for the four patients who developed AVN (p < 0.001). The median modified Harris hip score was 100 (74 to 100) in the non-AVN cohort and 65 (37 to 82) in the AVN cohort (p = 0.001). Median HOOS total score was 95 (50 to 100) in the non-AVN cohort and 53 (40 to 82) in the AVN cohort (p = 0.002).
CONCLUSIONS: Although the modified Dunn procedure is technically challenging, this study shows that in experienced hands, patients with who have demonstrated epiphyseal-metaphyseal discontinuity can be treated with a low risk of AVN and subsequent surgery. Referral of these patients to specialists who have substantial expertise in this procedure is recommended to improve patient outcomes. Prospective, long-term observational studies will help us identify these high-risk patients preoperatively and determine the long-term success of this procedure.
METHODS: Level IV, therapeutic study.