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陶可主治醫(yī)師 北京大學(xué)人民醫(yī)院 骨關(guān)節(jié)科 患有雙髖Perthes病兒童的臨床結(jié)果和預(yù)后因素：對(duì)40名兒童進(jìn)行5年的前瞻性研究北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科陶可譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要：目的：本研究目的是闡述非手術(shù)治療、雙髖Perthes病的病程，并確定放射學(xué)和臨床結(jié)果的具體預(yù)后因素?；颊吆头椒ǎ何覀兇_定了40名平均年齡為5.9歲（1.8至13.5歲）的兒童，這些兒童均納入我們這項(xiàng)對(duì)雙髖Perthes病進(jìn)行非手術(shù)性治療的多中心、前瞻性研究中，這包括了挪威所有在1996年至2000年5年內(nèi)被診斷出患有Perthes病的兒童。所有兒童都進(jìn)行了五年的隨訪。髖關(guān)節(jié)病變嚴(yán)重程度按照Catterall分類法進(jìn)行分類。一種改良的Stulberg三組分類被用作臨床結(jié)果的評(píng)價(jià)，其中，球形股骨頭被定義為優(yōu)良，橢圓形頭被定義為尚可，扁平狀股骨頭被定義為差。結(jié)果：23名兒童可見(jiàn)雙髖Perthes病，同時(shí)17名兒童在隨訪中出現(xiàn)雙髖Perthes病。后一組第二側(cè)髖關(guān)節(jié)發(fā)病平均延遲1.9年（0.3至5.5年）。五年放射學(xué)結(jié)果中，30髖優(yōu)良（39%），25髖尚可（33%）和21髖差（28%）。預(yù)后不良的最強(qiáng)預(yù)測(cè)因素是范圍大于50%的股骨頭壞死，比值比（OR）為19.6和確診時(shí)年齡=6歲（OR 3.3）。結(jié)果差的其他危險(xiǎn)因素是疾病發(fā)病的時(shí)間，即前后連續(xù)發(fā)生雙髖Perthes病的兒童比同時(shí)發(fā)生雙髖Perthes病的兒童風(fēng)險(xiǎn)更高（p = 0.021，卡方檢驗(yàn)）。一側(cè)髖關(guān)節(jié)確診Perthes病后，有5%的機(jī)會(huì)對(duì)側(cè)髖關(guān)節(jié)會(huì)出現(xiàn)Perthes病。結(jié)論：上述結(jié)果表明，我們需要區(qū)分同時(shí)發(fā)病的兒童和前后連續(xù)發(fā)生雙髖Perthes病的兒童，因?yàn)轭A(yù)后結(jié)果可能不同。之前尚無(wú)研究對(duì)此進(jìn)行闡述。雙髖同時(shí)出現(xiàn)Perthes病兒童的臨床結(jié)果與之前我們研究的一系列單髖患有Perthes病的兒童相似，而前后連續(xù)發(fā)生雙髖Perthes病的兒童預(yù)后較差。對(duì)孩子和父母需要注意的是，一側(cè)髖關(guān)節(jié)出現(xiàn)Perthes病，對(duì)側(cè)髖患病風(fēng)險(xiǎn)增加。文獻(xiàn)出處：O Wiig, S Huhnstock, T Terjesen, A H Pripp, S Svenningsen. The Outcome and Prognostic Factors in Children With Bilateral Perthes' Disease: A Prospective Study of 40 Children With Follow-Up Over Five Years. Bone Joint J, 2016 Apr;98-B(4):569-75.The Outcome and Prognostic Factors in Children With Bilateral Perthes' Disease: A Prospective Study of 40 Children With Follow-Up Over Five YearsAbstractAims: The aims of this study were to describe the course of non-operatively managed, bilateral Perthes' disease, and to determine specific prognostic factors for the radiographic and clinical outcome. Patients and methods: We identified 40 children with a mean age of 5.9 years (1.8 to 13.5), who were managed non-operatively for bilateral Perthes' disease from our prospective, multicentre study of this condition, which included all children in Norway who were diagnosed with Perthes' disease in the five-year period between 1996 and 2000. All children were followed up for five years. The hips were classified according to the Catterall classification. A modified three-group Stulberg classification was used as an outcome measure, with a spherical femoral head being defined as a good outcome, an oval head as fair, and a flat femoral head as a poor outcome. Results: Concurrent, simultaneous bilateral Perthes' disease was seen in 23 children and 17 had the sequential onset of bilateral disease. The mean delay in onset for the second hip in the latter group was 1.9 years (0.3 to 5.5). The five-year radiographic outcome was good in 30 (39%), fair in 25 (33%) and poor in 21 (28%) of the hips. The strongest predictors of poor outcome were > 50% necrosis of the femoral head, with odds ratio (OR) 19.6, and age at diagnosis > 6 years (OR 3.3). Other risk factors for poor outcome were the timing of the onset of disease, where children with the sequential onset of bilateral disease had a higher risk than those with the concurrent onset of bilateral disease (p = 0.021, chi-squared test). Following a diagnosis of Perthes' disease in one hip, there was a 5% chance of developing it in the contralateral hip.Conclusion: These results imply that we need to distinguish between children with concurrent onset and those with sequential onset of bilateral Perthes' disease, as the outcomes may be different. This has not been previously described. Children with concurrent onset of bilateral disease had a similar outcome to our previous series of those with unilateral disease, whereas children with sequential onset of bilateral disease had a worse prognosis. The increased risk of developing Perthes' disease in the contralateral hip in those with unilateral disease is important information for the child and parents. Anteroposterior and Lauenstein radiograph projections of the hips of a 3.5 year old boy with the concurrent onset of bilateral Perthes disease, at the time of diagnosis (a). The right hip was classified as Catterall I, the left as Catterall IV. And (b); five years after diagnosis. The right hip was classified as spherical (Stulberg 1) and the left hip as oval (Stulberg 3)圖1. 在確診時(shí)，一個(gè)3.5歲男孩的髖關(guān)節(jié)前后位和Lauenstein位X線片，發(fā)現(xiàn)雙髖Perthes?。╝）右髖被歸類為Catterall I型，左髖為Catterall IV型；（b）確診5年后右髖被歸類為球形（Stulberg 1型），左髖被歸類為橢圓形（Stulberg 3型）Anteroposterior and Lauenstein radiograph projections of the hips of a 4.5 years old boy with the sequential onset of bilateral Perthes disease, at the time of diagnosis (a) The left hip was classified as Catterall group III. And (b); six months later. The right hip is now also affected, in the initial phase of the disease and classified as Catterall IV when in the fragmentation phase. And (c); When aged ten years with both hips classified as oval (Stulberg 3).。圖2. 在確診時(shí)，一個(gè)4.5歲男孩的髖關(guān)節(jié)前后位和Lauenstein位X線片，提示前后連續(xù)發(fā)生雙髖Perthes?。╝）左髖被歸類為Catterall III型；（b）6個(gè)月后，右髖也受到影響，在疾病的早期并分類為Catterall IV型，碎片階段；和（c）10歲，雙側(cè)髖關(guān)節(jié)分類為橢圓形（Stulberg 3型）。2020年08月25日
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張中禮主任醫(yī)師 天津醫(yī)院 小兒骨科 周五上午出門(mén)診，安徽的小S回來(lái)復(fù)查，從兩年前孩子剛被診斷為“兒童股骨頭壞死”時(shí)全家的緊張不安到現(xiàn)在的談笑風(fēng)生，很高興我們不僅僅為孩子提供了及時(shí)、恰當(dāng)?shù)闹委?，還盡量降低這樣病程長(zhǎng)的疾病對(duì)家庭、孩子的心理方面不良影響。兒童股骨頭壞死，也叫Perthes病，和成年人的股骨頭壞死是完全兩種病。早期發(fā)現(xiàn)、及時(shí)恰當(dāng)治療，利用好孩子神奇、強(qiáng)大的自我修復(fù)能力，治療效果會(huì)非常理想。6歲3個(gè)月男孩，走路跛行后拍片診斷“右側(cè)股骨頭壞死”，蛙式位片顯示股骨頭壞死范圍大、塌陷嚴(yán)重經(jīng)過(guò)早期及時(shí)保守治療，恢復(fù)滿意，預(yù)計(jì)可達(dá)到S-2級(jí)結(jié)果，蛙式位片顯示股骨頭修復(fù)非常滿意2020年08月16日3333
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