改良Dunn手术对严重青少年股骨头骨骼溶解症患儿脊柱骨盆比值关系的影响

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论证。青少年股骨头骨骺溶解症是儿童髋关节最严重的疾病之一，其特征是股骨近端骨骺出现不同程度的单侧或双侧畸形。根据P. Roussouly的分类法，受影响关节的股骨部分的严重变形会导致骨盆后倾、腰椎前凸减少、胸椎后凸增加，并形成I型（脊柱后凸）垂直姿势，从而导致腰骶椎的退行性萎缩过程。目前，文献中还没有关于手术治疗对这部分患者椎-骨盆正面和矢状面比例的影响的数据。

本研究旨在对改良Dunn手术前后患有严重青少年股骨头骨骼溶解症的儿童椎-骨盆矢状面比值关系进行放射学对比评估。

材料和方法。本研究包括30名年龄在14至18岁之间、患有严重青少年股骨头骨骺溶解症的患者（30个髋关节），其特点是其中一个关节的骨骺向后方移位超过60°，向下方移位不超过10°，而另一个关节则无移位（前滑阶段）。所有患儿均接受了一侧的改良Dunn手术和另一侧的股骨头骨骺插管螺钉固定术。在术前和术后，患者接受了临床和放射学检查。立位X光片用于评估腰椎前凸和胸椎后凸、骨盆角、骨盆偏离角、骶骨倾斜角和矢状纵轴值。对获得的数据进行了统计处理。

结果。在采取上述干预措施3-3.5年后进行的检查中，骨盆角（PI）的平均值明显增加，符合P. Roussouly提出的III 型垂直姿势（和谐型）。位置指数的平均值也发生了变化：骨盆偏离角（PT）减小，骶骨倾斜角（SS）增大，骨盆后倾消失。腰椎前凸和平均整体腰椎前凸（GLL）增加，导致胸椎后凸和平均胸椎后凸（TK）减少。此外，所有临床观察结果均显示，总体矢状体平衡指数--矢状体垂直轴（SVA）的平均值显著降低，且无躯干失衡现象。

结论。一方面实施改良Dunn手术，另一方面用螺钉固定股骨头骨骺，在对患有严重青少年股骨头骨骺溶解症的儿童进行研究后，矢状脊柱-骨盆关系的所有研究指标均有所改善。因此，根据P. Roussouly的观点，垂直姿势的类型会从I型（脊柱发育不良）变为III型（和谐型），腰骶椎出现退行性萎缩过程的概率也会降低。

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作者简介

Dmitrii B. Barsukov

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

编辑信件的主要联系方式.
Email: dbbarsukov@gmail.com
ORCID iD: 0000-0002-9084-5634
SPIN 代码: 2454-6548

MD, PhD, Cand. Sci. (Med.)

俄罗斯联邦, Saint Petersburg

Pavel I. Bortulev

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: pavel.bortulev@yandex.ru
ORCID iD: 0000-0003-4931-2817
SPIN 代码: 9903-6861

MD, PhD, Cand. Sci. (Med.)

俄罗斯联邦, Saint Petersburg

Ivan Yu. Pozdnikin

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: pozdnikin@gmail.com
ORCID iD: 0000-0002-7026-1586
SPIN 代码: 3744-8613

MD, PhD, Cand. Sci. (Med.)

俄罗斯联邦, Saint Petersburg

Tamila V. Baskaeva

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: tamila-baskaeva@mail.ru
ORCID iD: 0000-0001-9865-2434
SPIN 代码: 5487-4230

MD, orthopedic and trauma surgeon

俄罗斯联邦, Saint Petersburg

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2. Fig. 2. Lateral panoramic radiograph of the spine with femoral heads captured in patient M (14 years 10 months old) as an example of calculating spine–pelvis ratios (see explanations in the text)

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3. Fig. 1. Anteroposterior (a) and Lauenstein (b) radiographs of the hip joints of patient Z. (14 years 6 months old) who had slipped capital femoral epiphysis with a posterior epiphyseal displacement of 71° and downward displacement of 7° on the right and absence of displacement (pre-slip stage) on the left. They were performed 3 years after surgery, i.e., modified Dunn surgery on the right side and fixation of the femoral head epiphysis with a screw on the left side

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4. Fig. 3. Radiographs of the hip joints (anteroposterior and Lauenstein projections) and lateral panoramic radiographs of the spine with femoral heads captured in patient A (16 years 5 months) before surgery (a–c), 6 months after surgery (d, e), and 3 years 3 months after surgery (f) (see explanations in the text)

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5. Fig. 4. Correlations between the main indices of sagittal vertebral–pelvic relationships and posterior epiphyseal displacement: a, immediately before surgery [17]; b, 3–3.5 years after surgery. GLL, global lumbar lordosis; PI, pelvic incidence; PT, pelvic tilt; SS, sacral slope; SSA, spinosacral angle (see explanations in the text)

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6. Fig. 5. Regression analysis results showing the relationship between the main indices of sagittal vertebropelvic relationships and residual posterior epiphyseal displacement: a, between PI and residual posterior epiphyseal displacement; b, between SS and residual posterior epiphyseal displacement; c, between SS and GLL; d, between PI and SS. GLL, global lumbar lordosis; PI, pelvic incidence; SS, sacral slope

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