股骨远端截骨和髌腱止点远端移位联合手术治疗儿童脑瘫屈膝步态的近期效果评价  

Distal femoral extension osteotomy plus patellar tendon advancement for crouch gait in children： a preliminary report

作　　者：朱光辉[1] 梅海波[1] 赫荣国[1] 刘昆[1] 唐进[1] 伍江雁[1] 叶卫华[1] 胡欣[1] 谭谦[1] 张妮[1] 

机构地区：[1]湖南省儿童医院骨科,南华大学儿科学院,长沙410007

出　　处：《中华小儿外科杂志》2016年第10期785-789,共5页Chinese Journal of Pediatric Surgery

基　　金：湖南省高层次卫生人才“225”工程培养项目

摘　　要：目的评价股骨远端截骨和髌腱止点远端移位联合手术治疗儿童痉挛性脑瘫屈膝步态的近期效果。方法2009年4月至2012年7月对存在屈膝步态、膝关节固定屈曲畸形10°～30°的痉挛性脑瘫儿童行股骨远端截骨和髌腱止点远端移位联合手术。16例（26侧下肢）纳入研究，其中男11例，女5例，年龄7．5～11．6岁，平均8．9岁。术后高分子绷带固定6周，拆除石膏后功能锻炼，夜间长腿管型支具固定维持矫形。记录手术前后的膝关节固定屈曲畸形角度、胭角、膝关节活动范围、屈膝步态改善情况、膝关节疼痛视觉模拟评分（VAS）评分、股四头肌肌力、胭绳肌肌力、小腿三头肌肌力、侧位膝关节X线片Insall-salvati指数和Wren改良的屈膝步态的医师视觉评分，并进行统计学分析。结果GMFCS分级为Ⅱ级9例，Ⅲ级7例，无GMFCS分级Ⅰ、Ⅳ、Ⅴ级病例。均行股骨远端截骨和髌腱止点远端移位联合手术。6侧下肢同时行髂腰肌松解术。10侧下肢同时行跟腱延长术。病例随访48～65个月，平均54个月。治疗后所有病例屈膝步态均明显改善或消失。患儿膝关节疼痛VAS评分较术前降低（P〈0.05）。膝关节屈曲畸形角度及胭角明显减小（P〈0．01），膝关节屈伸活动范围明显增大（P〈0．01）。股四头肌肌力显著增加（P〈0．05）。胭绳肌肌力、小腿三头肌肌力无显著变化。侧位膝关节X线片Insall-salvati指数明显减小，髌骨高位得到纠正。2例（2侧下肢，7．7％）出现一过性坐骨神经损伤症状，经更换高分子绷带，增大膝关节屈曲至20°左右，并予营养神经等对症处理后症状消失。2例（3侧下肢，11．5％）出现切口感染，经换药处理后愈合。3例（3侧下肢，11．5％）出现股骨截骨远端轻度移位，未做特殊处理，截骨端塑型良好。无一例出现过度矫正、膝反屈、压疮等其他并发症。结论�Objective To evaluate the preliminary outcomes of distal femoral extension osteotomy plus patellar tendon advancement for crouch gait in children. Methods From April 2009 to June 2012, distal femoral extension osteotomy plus patellar tendon advancement were performed for crouch gait in cerebral children with 10-30 degree fixed knee flexion contracture. A total of 16 cases （26 lower extremities） were enrolled with a mean follow-up period of 54 （48-65） months. There were 11 males and 5 females with an average age of 8. 9 years （7. 5-11.6）. Cast immobilization was applied for 6 weeks post-operation. After cast removal, functional exercise was enforced and long leg night splint used for maintaining correction. Degree of fixed knee flexion deformity, popliteal angle, range of motion in knee joint, improvement of crouch gait, visual analogue score （VAS） of knee pain, strength of quadriceps, hamstring and musculus triceps surae, Insall-salvati index on lateral radiographic view and Wren modified crouch gait visual score by physicians were recorded and analyzed for outcome evaluation. Results The GMFCS levels were Ⅰ （n = 0）, Ⅱ （n = 9）, Ⅲ （n = 7）, Ⅳ （n = 0） and Ⅴ （n = 0）. Iliopsoas release was implemented contemporarily in 6 lower limbs and achilles tendon lengthening in 10 lower limbs simultaneously. Crouch gait improved or disappeared in all cases. Compared with preoperative VAS scores of knee pain, the postoperative scores decreased significantly （P 〈 0. 05）. Degree of fixed knee flexion deformity and poplital angle diminished significantly （P〈0.01）. Range of motion expanded in knee joints （P〈0.01）. Strength of quadriceps improved significantly （P 〈 0. 05 ）. Strength of hamstring and musculus triceps surae showed insignificant changes. Insall-salvati index on lateral radiographic view diminished with patella alta disappeared in all cases. Two cases of transient sciatic nerve injury remitted through changing cast immobilization in a 20 knee flexion po

关 键 词：股骨 大脑性瘫痪 步态 

分 类 号：R726.8[医药卫生—儿科]