步态分析在儿童发育性髋关节脱位治疗中的应用研究

发布时间：2018-05-11 02:31

本文选题：步态分析 + 足底压力　；参考：《郑州大学》2017年硕士论文

【摘要】：背景发育性髋关节脱位(developmental dislocation of hip,DDH)是一种儿童常见的髋部畸形,据国外最新报道新生儿DDH发病率约为4~11‰,未经治疗其髋部畸形会逐渐加重,导致疼痛、活动受限、步态异常,严重影响患儿下肢活动及功能,并早期出现退行性关节疾病。DDH一经确诊应尽早干预治疗,早期保守治疗可以取得良好的临床效果,但仍有一部分患儿因地域、家庭经济原因、家长的疏忽未能早期确诊及治疗,或经保守治疗失败的DDH仍需手术治疗。18个月后DDH患儿首选手术治疗,经过手术治疗,大部分获得了满意的临床效果,但有报道称长期随访过程中,仍发现一部分患者出现了再脱位、发育不良、股骨头坏死(AVN)、早期关节退行性变、骨性关节炎等。有学者对DDH手术前后进行了三维步态分析,发现手术后所有患儿都出现骨盆降低并前倾不足,患侧髋关节降低并屈曲活动减少,可能与术后髋关节周围软组织挛缩,导致健侧过度代偿,股骨短缩旋转截骨有关。也有学者通过步态分析中足底压力测试发现切开复位Pemberton截骨手术(PPO)后的髋关节的负荷在行走过程中比正常儿童要大,可能是发生髋关节骨性关节炎的危险因素,且发现足底不同分区的触地面积、压强也有异常,进而研制出保护异常足底区域的矫正鞋,有效减轻了足痛和局部损伤。目前,髋关节切开复位salter骨盆截骨股骨去旋转截骨术(SIO)是治疗DDH主要的术式,但对其手术后步态分析,特别是足底压力分布情况研究较少,本研究主要是评估DDH患儿手术后步态及足底压力分布是否异常,以及异常的特点及程度,并与同年龄段正常儿童对比,从而分析原因,为评估手术效果和术后康复治疗提供客观依据。目的探讨单侧DDH患儿在SIO手术后的步态及足底压力分布特点,以及与同年龄段正常儿童的差异,为传统方法评估手术效果提供有效补充,为下一步康复治疗提供客观的生物力学依据。方法1.实验组:选择我院骨科病区2014年9月至2016年1月收治的经SIO治疗的单侧DDH患儿25名;对照组:选取25名同年龄段的健康儿童作为对照。手术前后常规进行体格检查及影像学检查,应用Severin评分行影像学评估以及应用Mckay评分行髋关节功能评估。2.通过footscan7足底压力测试系统的测力平台,对实验组患儿进行术后1年时的步态分析检查,对实验组健康儿童进行相同的检查,记录相关数据。在患肢与健肢,患肢与对照组,健肢与对照组之间的数据进行统计学分析,描述手术后患者步态及足底压力的分布情况。结果1.病变组手术取得了良好的临床效果。按照McKay功能评定标准,术后优良率96%;按Severin评分标准术后优良率96%;髋臼指数(AI):术前(34.87±3.15)°,术后(22.32±1.89)°,差异有统计学意义(p0.05);中心边缘角(CEA):术前(14.87±1.15)°,术后(30.02±3.89)°,差异有统计学意义(p0.05);股骨颈前倾角(FNA):术前(49.38±9.67)°,术后(21.32±3.11)°,差异有统计学意义(p0.05)。2.SIO术后1年时,步态分析检查发现患儿平均步长为(30.15±4.97)cm,与对照组的平均步长相比有统计学差异(p0.05),小于对照组;在步宽、步速方面,与对照组相比无显著统计学意义(p0.05)。3.SIO术后1年时,患肢足底各分区荷载率与健肢相比,无显著统计学差异(p值均0.05);患肢与对照组相比较,T1区存在显著差异(p0.05),且由95%置信区间为[-0.082,-0.026],患肢T1区的负载率小于对照组;T2-5区也存在统计学差异(p0.05),且95%置信区间为[-0.067,-0.011],患肢T2-5区负载率也小于对照组。健肢T2-5、M2、LH区域的负载率与对照组相比有统计学差异(p0.05),且小于对照组。4.SIO术后1年时,患肢足底各分区CA%与健肢相比,M2有统计学差异(p0.05),患肢M2的CA%小于健肢;患肢MH的CA%与健肢相比有统计学差异(p0.05),患肢MH的CA%大于健肢;余组相比较,无显著统计学差异(p值均0.05)。患肢与对照组相比较,M1、M2、M5、LH、MH区均存在显著差异(p值均0.05),M1、M2、LH、MH的CA%小于对照组,而M5的CA%大于于对照组;余区域相比较,无显著统计学差异(p值均0.05)。健肢与对照组相比较,MH区均存在显著差异(p0.05),MH的CA%小于对照组;余区域相比较,无显著统计学差异(p值均0.05)。5.SIO术后1年时,患肢足底各分区冲量与健肢相比,T2-5有统计学差异(p0.05),患肢T2-5的冲量小于健肢;患肢MF的冲量与健肢相比有统计学差异(p0.05),患肢MF的冲量小于健肢;余组相比较,无显著统计学差异(p值均0.05)。患肢与对照组相比较,M2、M3均存在显著差异(p值均0.05),M2、M3的冲量小于对照组;余区域相比较,无显著统计学差异(p值均0.05)。健肢与对照组相比较,M2、LH均存在显著统计学差异(p0.05),M2、LH的冲量小于对照组;余区域相比较,无显著统计学差异(p值均0.05)。结论1.SIO术后在Severin影像学及McKay功能评分优良率均有显著提高,髋臼指数、前倾角均较术前显著减小,中心边缘角较术前显著增大,归于正常范围,手术疗效确切。2.SIO术后1年时,步长仍小于正常,步宽、步速基本正常。3.SIO术后1年时,患儿足底某些分区在荷载率、触地面积、冲量等方面仍存在异常,可能与残余畸形有关。
[Abstract]:Developmental dislocation of hip (DDH) is a common deformity of the hip in children. According to the latest reports, the incidence of DDH in newborn infants is approximately 4~11 per thousand, and the hip malformation will gradually aggravate without treatment, which leads to pain, limited activity and abnormal gait, which seriously affects the activity and function of the lower extremities, and early appears. The treatment of degenerative joint disease.DDH should be treated as early as possible. Early conservative treatment can achieve good clinical effect, but there are still some children because of the region, family economic reasons, parents' negligence failed early diagnosis and treatment, or the failure of conservative treatment of DDH still needs surgical treatment.18 months after the first choice of surgical treatment for children with DDH. Most of the patients received satisfactory clinical results, but some patients were reported to have redislocation, dysplasia, osteonecrosis of the femoral head (AVN), early degeneration of the joint, osteoarthritis, and so on. Some scholars conducted a three-dimensional gait analysis before and after the DDH operation and found all the children after the operation. The reduction of the pelvis and forward tilt, the reduction of the affected hip joint and the decrease of flexion, may be associated with the soft tissue contracture around the hip joint, resulting in excessive compensatory side of the healthy side, and the femoral shortening rotation osteotomy. Some scholars also found the load of the hip joint after the resection of the Pemberton osteotomy (PPO) through the foot stress test in the gait analysis. In the course of walking, larger than normal children may be a risk factor for the occurrence of osteoarthritis of the hip, and the area of the ground in different subareas of the foot is found and the pressure is abnormal, and the corrective shoes are developed to protect the abnormal foot area, which effectively alleviates the foot pain and local injury. At present, the hip joint is cut and repositioned by the Salter pelvis osteotomy femur. Rotational osteotomy (SIO) is the main operation for the treatment of DDH, but the analysis of the gait, especially the distribution of the foot pressure after operation, is less. This study is mainly to evaluate the abnormal distribution of the gait and the foot pressure in the children of DDH, and the abnormal characteristics and degree, and compare it with the normal children of the same age, and analyze the reasons. Objective to provide an objective basis for evaluating the effect of operation and postoperative rehabilitation. Objective to explore the distribution of the gait and the foot pressure of the unilateral DDH children after SIO operation, and the difference between the normal children of the same age group, and to provide an effective supplement to the traditional methods to evaluate the effect of the operation, and to provide an objective biomechanical basis for the next step of rehabilitation. 1. experimental group: selected 25 children of unilateral DDH treated by SIO from September 2014 to January 2016 in our hospital; control group: 25 healthy children of the same age group were selected as control. The routine examination and imaging examination before and after operation, the application of Severin score for image evaluation and the application of Mckay score for hip joint work .2. can be evaluated through the force platform of the footscan7 foot pressure test system to examine the gait analysis of the children in the experimental group 1 years after the operation. The same examination was carried out on the healthy children in the experimental group, and the related data were recorded. The data between the affected limbs and the limbs, the affected limbs and the control group, the health limb and the control group were statistically analyzed, and the operation after the operation was described. Results of the patients' gait and the distribution of foot pressure. Results the 1. lesion group had good clinical effect. According to the McKay function evaluation standard, the excellent rate was 96%, the excellent rate was 96% after the Severin score; the acetabular index (AI): before operation (34.87 + 3.15) and (22.32 + 1.89) degrees, the difference was statistically significant (P0.05); the center edge angle (CEA Preoperative (14.87 + 1.15) degrees, postoperative (30.02 + 3.89) degrees, the difference was statistically significant (P0.05), femoral neck obliquity (FNA): preoperative (49.38 + 9.67) degrees, postoperative (21.32 + 3.11) degrees, the difference was statistically significant (P0.05).2.SIO after 1 years, gait analysis found that the average step of children was (30.15 + 4.97) cm, compared with the average step of the control group. The study difference (P0.05) was less than that of the control group; there was no significant statistical significance in step width and step speed compared with the control group (P0.05) 1 years after.3.SIO, there was no significant statistical difference (P value, 0.05) compared with the healthy limbs at 1 years after the operation, and there was a significant difference between the affected limbs and the control group (P0.05), and the 95% confidence interval was [-0.. 082, -0.026], the load rate of T1 area in the affected limb was less than that of the control group, and there was also a statistical difference in the T2-5 area (P0.05), and the 95% confidence interval was [-0.067, -0.011], and the load rate of T2-5 zone in the affected limb was also smaller than that of the control group. The load rate of the limb T2-5, M2, LH area was statistically different from the control group (P0.05), and was less than that of the control group at 1 years after the.4.SIO operation. Compared with the healthy limb, M2 had statistical difference (P0.05), and the CA% of M2 in the affected limb was less than that of the healthy limb, and the CA% of the affected limb MH was significantly different from the healthy limb (P0.05), and the CA% of the limb MH was larger than the healthy limb; there was no significant difference between the remaining groups (P, all 0.05). The CA% of M2, LH and MH was less than that of the control group, and the CA% of M5 was greater than that of the control group. There was no significant difference in the residual region (P value was 0.05). Compared with the control group, there were significant differences in MH area (P0.05), MH CA% was smaller than the control group, and there was no significant difference between the remaining regions (P values were 0.05) at 1 years after the operation. Compared with the healthy limb, T2-5 had statistical difference (P0.05), and the impulse of T2-5 in the affected limb was less than that of the healthy limb; the impulse of MF in the affected limb was significantly different from that of the healthy limb (P0.05), and the impulse of the affected limb was less than that of the healthy limb; there was no significant difference (P value 0.05) in the remaining group (P value). There were significant differences in M2 and M3 (P value 0.05), M2 in the affected limbs compared with the control group. The impulse of M3 was less than that of the control group; there was no significant difference in the residual region (P value was 0.05). Compared with the control group, there were significant differences in M2 and LH (P0.05), M2, LH were less than the control group, and there was no significant difference in the residual region (P value, 0.05). Conclusion: Severin imaging and McKay function score after the operation of 1.SIO. The rate of good and good is significantly improved. The acetabular index and the pretilt angle are significantly lower than those before the operation, and the center edge angle is significantly increased in the normal range. The step length is still less than the normal and step width at 1 years after the operation, and the step speed is basically normal after the operation of.3.SIO. At the time of 1 years after the operation, the children's plantar areas are in the load rate, the area of touch ground, the impulse and so on. There is still abnormality in the surface, which may be related to the residual deformity.

【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R726.8

【参考文献】