| Backgrand:Two types of avacular necrosis of femoral head occur in children. The first type is the well known Perthes disease which is an idiopathic avascular necrosis of the proximal femoral epiphysis in children. The second is the traumatic type, which is one of the common complications of hip trauma. And the most common reason of posttraumatic avascular necrosis of femoral head is old fractures of femoral neck in children. But in clinic, the well known avacular necrosis of the femoral head usually refers to Perthes disease.The male to female ratio of Perthes disease is about 4~6:1. The unilateral lesion is more common. It is probably 0.2 to 29.4 cases per 100,000 of the population between 0 and 14 about the incidences. The clinical symptoms are pain, limp and limitation of range of motion in hip. Because the epiphyseal line is still remain, the femoral head can be cured by the proper remodelling of the femoral epiphysis, which is based on the principle of containment. So Perthes disease is a self-limited process. The etiology and pathogenesis are unknown. There is still doubt over which is the best method about the treatment. There is also no general agreement regarding whether operative or nonoperative method isbeneficial. Conservative wa-y lasts for a long period of time, and not all of them will form a spherical, covered, and congruent hip after the natural history. And it may lead to osteoarthritis of hip, which is the serious complication and must be cured by total hip replacement. At present, most surgical ways of the treatment are femoral or innominate osteotomy. A combination of femoral and innominate osteotomy is also suggested. But the surgical way is suitable for the patients whose curative effect may be poor by conservative treatment. And the injury of the surgical way is huge.Posttraumatic avascular necrosis of femoral head in children is often occurred after hip trauma which can deprive the blood supply of the femoral head epiphysis. It is most common in old fractures of femoral neck. Pediatric femoral neck fractures account for less than 1% of all children’s fractures. As to the fresh fractures of pediatric femoral neck, which way to choose, operative or nonoperation methods, may depend on the displacement and difficulty degree of reset. As to the hard reset and poor blood supply of old fractures of femoral neck, nonoperation methods are difficult to obtain satisfactory results. Because of their low incidence, there are much less researches about old fractures of femoral neck and posttraumatic avascular necrosis of femoral head in children. There are still many challenges about the treatments. The present treatments include cannulated screw fixation only or internal fixation combined with osteotomy. Total hip arthroplasty can be used if the femoral head collapse obviously.At present, the treatments about the two types of avascular necrosis of femoral head in children are very difficult. The reported methods are many. At the end of last century, the domestic scholars put forward to the method of the internal fixation combined with bone flap implantation. The bone grafts include vascular pedicle bone graft and muscle pedicle bone graft. As to the source of vascular pedicle, there are deep iliac circumflex blood vessel and a deep branch of medial femoral circumflex artery. As to the source of muscle pedicle, there are sartorius and rectus femoris. But the bone grafts above have the disadvantage of poor blood supply of the bone-flaps, much cartilage attached to the bone and flap’s difficult interception. So we invented a new operation: periosteal bone-flapstransfer with partial tensor fasciae lata.Objective:To observe the clinical effect about the treatment of Perthes disease and old fracture of femoral neck in children by periosteal bone-flaps transfer with partial tensor fasciae lata, and to evaluate its effectiveness and safety.Methods:(1) From March 2011 to April 2014, there were eleven cases of Perthes disease collected from department of orthopedics, Daping Hospital of Third Military Medical University. There were nine males and two females; six cases of left hip and five cases of right hip. The mean age was 10 ± 3.7 years with the range from 6 to 16 years old. Four cases were in stage Catterall II and seven were in stage Catterall III. The Harris scores ranged from 66 to 87 points with the average scores of 74.0 ± 6.5 points. Visual analog scales(VAS) pain scores ranged from 0 to 5 points with the average sorces of 3.4 ± 1.7 points. The femoral head ratio was 1.09 ± 0.05. The femoral head subluxation ratio was 1.38 ± 0.31. The CE angle was 20.5 ± 5.5 degrees. T he acetabular coverage was 0.84 ± 0.10. During the follow-up, the Harris hip scores were used to evaluate the function of the hip and the VAS pain scores were used to evaluate the degree of pain. The radiographic measurements about femoral head ratio, femoral head subluxation ratio, acetabular coverage and CE angle were measured on the X-rays. Stulberg classification was also used to evaluation.(2) From June 2011 to February 2014, there were seven cases of old fractures of femoral neck, of which three cases were accompanied with avascular necrosis of femoral head. There were four males and three females. The mean age was 12.6 ± 3.0 years with the range from 9 to 18 years old. There were one case of Delbet type I and six cases of type II. The Harris scores ranged from 62.2 to 74 points with the average scores of 68.3 ± 4.6 points. VAS pain scores ranged from 0 to 4 points with the average sorces of 2.7 ± 1.3 points. The residual leg shortening ranged from 0.5 to 6 cm, with an average of 2.8 ± 1.7 cm. During the follow-up, the Harris scores and VAS scores were used. The measurement of residual leg shortening and Ratiliff system were also used to evaluate the curative effects.Results:(1) Eleven cases of Perthes disease were followed up successfully. The incisions were healed well. The follow up time ranged from 9 to 38 months with the average time of 24.6 ± 9.5 months. All the patients became better about the pain and range of motion of the hip. There were no infections and deep venous thrombosis in lower limb. The Harris scores ranged from 79 to 97 points with the average scores of 90.1 ± 5.7 points.The postoperative Harris scores were significantly different from the preoperative scores(P <0.01); among which were seven cases of excellent(63.6%), three cases of good(27.3%), one case of fair(9.1%), the excellent and good rate was 90.9%. VAS pain score ranged from 0 to 1 point with the average sorce of 0.2 ± 0.4 point. The postoperative VAS score was significantly different from the preoperative score(P <0.01). As to the radiographic measurements, the differences between preoperative and postoperative in femoral head subluxation ratio(1.15 ± 0.14) and CE angle(25 ± 6.6 degrees) were statistically significant(P<0.05). But there were no significant differences in the femoral head ratio(1.09 ± 0.08) and acetabular coverage(0.86 ± 0.15)(P>0.05). The Stulberg classification were three cases of stage I, six cases of II, one case of III and one case of IV.(2) Seven cases of old fractures of femoral neck in children were followed, all incisions healed. The follow up time ranged from 7 to 32 months, with an average time of 16.1 ± 8.7 months. All the fractures achieved clinical healing standards. The range of motion of hip increased significantly, with the femoral head repaired. There was no screw breakage or loosening happened. The Harris scores ranged from 81 to 91 points with the average of 86.3 ± 3.7 points. The postoperative Harris scores were significantly different from thepreoperative scores(P <0.01); The VAS pain score ranged from 0 to 1 point with an average score of 0.1 ± 0.4 point. The postoperative VAS score was significantly different from the preoperative score(P <0.01). The residual leg shortening ranged from 0 to 2 cm, with an average of 0.9 ± 0.7 cm. According to Ratiliff system, excellent standard was in three cases and good in four cases.Conclusion:It can successfully repair the femoral head of Perthes disease with the treatment by periosteal bone-flaps transfer with partial tensor fasciae lata. It can obtain pain relief and joint activity improving. Combined with hollow screw, it can effectively promote the healing process of old fracture of femoral neck in children and reduce residual leg shortening. It is especially suitable for children with the advantage of small injury and bone-flap obtained easily. It is a safty and effiective surgical method. |
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