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Trang chủ Tom tat luan an tieng anh nghiên cứu chẩn đoán và ứng dụng phẫu thuật tạo hình ...

Tài liệu Tom tat luan an tieng anh nghiên cứu chẩn đoán và ứng dụng phẫu thuật tạo hình ổ cối có ghép xương đồng loại trong điều trị trật khớp háng bẩm sinh ở trẻ nhỏ tại bệnh viện nhi trung ươn

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1 INTRODUCTION Treatment for congenital dislocation of the hip (CDH) is quite complex, comprising many stages. If detected early before 6 month old baby wearing a splint corrected Parlik, children 6-18 months of age can be treated with closed reduction or open reduction combined cast. The patient is detected, treatment late has serious risks and complications such as dislocated joints, avascular femoral necrosis, dysplasia and femoral head dislocation causing lower limb discrepancy. Globally, acetabuloplasty using bone allografts of the same type with different techniques has produced superior results in shortening operation time, minimizing encroachment to surrounding tissue, and achieving aesthetic value. The treatment has been applied by authors such as Trevor (1975), Kessler (2001), Grudziak 2001, Wade (2010), and Nguyen Ngoc Hung in Vietnam (2013). Salter innominate surgical is often surgeons used treatment of congenital dislocation of the hip, the results are quite good. Nguyen Ngoc Hung (2004) treatment of congenital dislocation of the hip, according to the Salter technique for 79 hip joint results are as follows: good is 17.5%, quite is 73%, poor is 9.5%. However, the surgery must take autologous iliac, so long incision, causing iliac wing bone defects, also need surgery to remove foreign body. For the purpose of limiting the disadvantages we have improved the Ziggaz bone cutting method, combined with the use of Bone Allograft to create grafts instead of self-pelvic bone. In order to evaluate the effectiveness of the above techniques, we conducted the research: “Diagnosis and application of acetabuloplasty using bone allografts treating congenital dislocation of the hip in young children at Vietnam National Hospital of Pediatrics”. The objectives of our study are: 1. Clinical and diagnostic subclinical of congenital dislocation of the hip in young children undergoing Salter's improved technique at the National Hospital of Paediatrics, 2011-2015. 2 2. Assessing the results of Salter's improved technique of acetabuloplasty using bone allografts of the same type in the treatment of congenital dislocation of the hip in young children. CHAPTER 1 - OVERVIEW 1.1. Anatomy and development of the hip, acetabulum, femur 1.2. Causes and diagnosis of CDH 1.3. Treatment status of CDH 1.3.1. In the world 1.3.1.1. Methods of osteotomy for dysplasia In reality, an acetabula angle greater than 30 0 is considered abnormal and suffers a risk of dislocation. Kleinberg and Lieberman conducted research and came to a similar conclusion. The treatment options for acetabular dysplasia are divided into the following categories: - The first group consists of osteotomies of the pelvis that redirect the entire acetabulum, increasing the coverage of the femoral head. Salter innominate osteotomy, done in the mid-1950s. Advantages: does not affect the volume of the acetabulum, the technique is simple. Disadvantages: Relatively unstable, the bone is immobilized with Kirshner wires inside, so a second surgery is needed to remove these wires. - The second group: acetabuloplasties that involve incomplete cuts on different aspects of the "Y" cartilage, including the acetabular procedures described by Pemberton and Dega. - The third group: acetabuloplasty involving placing bone over the hip joint capsule on the uncovered portion of the femoral head. This includes the various shelf procedures and the medial displacement osteotomy described by Chiari 1.3.1.2. Methods of bone grafting Autograft bone: autograft bone is effective in providing not only the threedimensional bone structure, but also a network of bone-forming cells, which help to regenerate the bones better. 3 The drawback of self-grafting is that it causes pain, risk of complications such as high blood loss, hematoma or fracture and limited supply. * Characteristics and mechanics of bone allograft freeze Bone morphogenetic protein (BMP), collagen-containing organic substrates and bone-forming proteins retain the most important components. * Risks of bone allografts - Infectious disease. - The graft is rejected. 1.3.1.3. Surgery methods to form joints * Colonna’ capsular arthroplasty * Salter’ capsular arthroplasty 1.3.1.4. Classification and treatment of CDH according to age * Infants and children under 6 months In 1945, Pavlik successfully treated CDH for children under 6 months with Pavlik harness. * Children from 6 months to 18 months - Closed reduction: fixed and fixed castings are indicated for children diagnosed with CDH over 6 months and those who have failed treatment with Pavlik harness. - Open reduction: indicated for patients aged 6 to 18 months, when seizure control treatment has failed, subluxation of the hip, soft tissue insertion in the middle and instable hip structure. * Children over 18 months to 36 months In this age group, the placenta is often deficient in the frontal area. The operation usually applied is Salter’s or Pemberton’s osteotomy * Children older than 3 years of age, open reduction with femoral shortening is required. Surgery can be executed immediately or delayed for about 6 weeks, depending on hip joint stability at the time of surgery. 1.3.2. In Vietnam In 2001, Phan Van Tiep reported the second dissertation on the epidemiological factor of congenital hip replacement. In 2004, Nguyen Ngoc Hung reported treating for 76 patients CDH. 4 In 2012, Hoang Hai Duc, Nguyen Ngoc Hung reported treating 292 children with CDH using Salter’s method. In 2013, Nguyen Ngoc Hung described the Zigzag pelvic osteotomy combined with Fibular Allograft treating for 73 patients with CDH. Report published in the Open Journal of Orthopedics. 1.4. SEQUELAE AND COMPLICATIONS * Redislocation * Deformation of proximal femoral * Avascular necrosis of the capital femoral. Avascular necrosis of the capital femoral may be due to causes such as damage to blood vessel, cartilage growth, or pressure stress that affects the cartilage. Kalamchi and MacEwen developed a classification of avascular necrosis combined with growth disorders at four different levels. 1.5. The role of postoperative rehabilitation Chapter 2 SUBJECTS AND STUDY METHODS 2.1. Object, location, time of study 2.1.1. Research subjects 61 patients with 73 dislocated hips treated at Orthopedic Department of National Hospital of Paediatrics. 2.1.1.1. Patient selection criteria * Patients selected in this study meet the following criteria: Patients diagnosed with congenital hip dislocation and indicatied for surgery. Patients are aged ≥ 18 months - <36 months. * Indication surgery: Grade III, IV dislocation according to Tonnis. Acetabular angle > 350. Pelvic osteotomy is indicated when Zadeh test result is positive. 2.1.1.2. Exclusion criteria 5 - Cases in which surgery is denied include bodily diseases, patients with congenital malformation, patients treated at other facilities, patients outside of the target age group, patients who did not consent to participate in the study. * Contraindications surgery: dislocated hip with cerebral palsy causing cramps in the lower limbs, children with dysplasia, patients with multiple stiffness. 2.1.2. Research location The study was conducted at Orthopedic Department - National Hospital of Paediatrics. 2.1.3. Research period The study was conducted from July 2011 to July 2015, consisting of patients diagnosed with CDH and indicatied for surgery. 2.2. Research methods 2.2.1. Research design This research is designed by two methods: - Analytical and descriptive research. - Clinical intervention combined with longitudinal monitoring study. 2.2.2. Sample size and sampling methods 2.2.2.1. Study sample size As the study proceeded by prospective descriptive method, all patients who met the criteria for selection, were diagnosed and prescribed for CDH at the Orthopedic Department of National Hospital of Pediatrics during the research period. 2.2.2.2. Sampling method 2.2.3. Research content, data collection and evaluation 2.2.3.1. Exploring medical history 2.2.3.2. Collection of clinical indicators, clinical examination before and after surgery 2.2.3.3. Information about surgery 2.2.3.4. Collection of laboratory parameters before and after surgery * X-ray 6 - Patients were assessed for the Tonnis degree of CDH. - Measure the acetabular angle. - Assess femoral cap necrosis, classified according to Kalamchi and Mac Ewen, with four levels. - Measure the angle of the femur - Measure the Wiberg angle * CT scan of the hip and knee joint to determine the angle of the front of the femur neck. Resonance from the hip to determine the angle of the acetabulum. * Blood test: evaluation of HBsAg infection, HIV. 2.2.4. Treatment procedure, surgery CDH 2.2.4.1. Preparing patients before surgery 2.2.4.2. Prepare instruments for pelvic osteotomy. 2.2.4.3. Preparation of bone graft: freeze-dried fibula of the same type, originated from laboratory preservation tissue, Department of Molecular Medicine, Hanoi Medical University. 2.2.4.4. Hip-shaping surgery technique * Step 1: Incision - Patients lie on their back, the hip joint being operated on is padded up. - Adductor tenotomy - The skin incision begins at 1- 2cm below anterior superior iliac spine, 4 6cm long along the inguinal crease. - Tenotomy Psoat tendon. - Cut the rectus femoris muscle origin. - Expose the front of the hip. * Step 2: Surgery on the acetabulum + T-shape capsulotomy according to Salter. + Cut the teres ligaments. + Cut the transverse ligament. + Remove the fat at the bottom of the acetabulum + Cut the Limpus hypertrophy cartilage * Step 3: Cut the pelvis 7 Osteotomy site: on the graft of the straight muscle of the thigh (between the superior frontal spine and the inferior frontal spine). Use a drill to mark the osteotomy site. After sketching the cut lines, use small saw and chisel to connect the cut lines (Figure 2.12). + Line 1: transversal line at just above anterior iliac spine, about 5 - 8mm. + Line 2: Followed by road 1, go down and internal oblique to create angle 900 or 1350, about 5 - 7mm long. Between lines 1 and 2, a bone bridge will be created. + Line 3: to go internal obliquely to create angle 90 - 135 0 with line 2, about 8 - 10mm long. The graft site. + Line 4: connective line 3 and go down, about 10mm long. + Line 5: perpendicular to the line 4, to go internal transversal line, 6 - 8mm long. Between lines 4 and 5, a bone bridge will be created. Figure 2.12. line osteotomy of Pelvic - Perform bone grafts: Prepare bone grafts: Length about 11 - 15mm, height 12 - 14mm, width 8 - 10mm The bone is grafted to the middle of Line 3. * Step 4: Closing the incision 2.2.4.5. Postoperative care 2.2.4.6. Casting and rehabilitative physiotherapy - The spica cast was applied immediately post-surgery with the hip in 30 0 of flexion, 40-450 of abduction, and 100 - 200 of internal rotation. - Combine with rehabilitative physiotherapy. 8 2.2.4.7. Revise and evaluate the results after surgery Periodic examination at 6 months, 12 months, 24 months. Evaluation of the results was based on Trevor et al. (Classification adapted from McKay and Severin). Evaluation of femoral necrosis based on grading according to Kalamchi and Mac Ewen. 9 * Standardization of Trevor et al Pain Movement Limping Function-as described and by the patient assessed in the follow up clinic Radiological features the C/E angle of Wiberg The appearance of the femoral head Shenton’s line Evidence of degenerative changes - None - Occasional - Persistent - Full - Slight limitation but no fixed deformity - More than half the normal range - Less than half the normal or some fixed deformity range - Little or none - Absent - Present - Full - Slightly limited - Severely limited - 25 degrees or more - 0-24 degrees - Less than 20 degrees - Normal - Partial coxa plana or coxa magna - Complete coxa plana or other severe deformity - Intact - Present - Absent - Present Point s 3 2 1 5 4 3 2 1 1 0 3 2 1 3 2 1 3 2 1 1 0 1 0 10 Excellent 18 - 20 points Good 15 - 17 points Fair 12 - 14 points Poor < 12 points 2.3. Method of data processing research The data is digitised, entered and processed by medical statistical method with software SPSS 20.0. 2.4. The ethics of research The study was approved by Hanoi Medical University and approved by the National Hospital of Paediatrics under Decision No. 220B/BVNTWVNCSKTE dated April 11, 2013. CHAPTER 3 RESULTS OF STUDY 3.1. Clinical and subclinical characteristics of CDH 3.1.1. Characteristics of research subjects - Age of research object (month) Table 3.1. Detection age and surgery age (n = 61 patients) Detection and CDH status Age n Rate (%) surgery age < 12 months 16 26,2 12 - < 24 months 42 68,9 Detection age ≥ 24 - < 36 months 3 4,9 (CDH) Total 61 100 (Ẍ±SD) 14,69 ± 4.05 18 - < 24 months 42 68,9 ≥ 24 months - < 36 19 31,1 Surgery age months Total 61 100 (Ẍ±SD) 23,06 ± 4,9 Remarks: Detection age in group 12 - < 24 months accounted for the highest rate at 68,9% (42/61). 11 Patients receiving surgery interventions at the age of 18 - 24 months accounted for the highest rate of at 68,9%. 3.1.3. Clinical features - Status of CDH by sex (n = 61 patients) 11% Tỷ lệ mắc ở nam Tỷ lệ mắc ở nữ 54; 89% Figure 3.2. Hip dislocation by sex Remarks: Of the 61 patients, the group of female patients was highest at 88,5%; the rate of male patients was 11,5%. Female/male ratio = 7,7/1. - The extent of the difference in the length of the limb (only for the children with the difference in the length of the lower limb) Table 3.6. Degree of difference in limb length (n = 49) Difference in limb length n Rate (%) before surgery 1 - ≤ 1,5cm 6 12,2 > 1,5 - ≤ 2cm 31 63,4 > 2cm 12 24,4 Total 49 100,0 p < 0,01 Remarks: Patients with length difference of > 1,5 - ≤ 2cm account for the highest rate at 63,4%. 3.1.4. Subclinical characteristics - Left hip dislocation, right, bilateral on X-ray (n = 61 patients) 12 60% 52.400% 50% 40% 27.870% 30% 19.670% 20% 10% 0% Bên trái Bên phải Hai bên Figure 3.4. Dislocate the groin on the left, right, and both sides (p <0,05) Remarks: Left hip dislocation composes the highest rate at 52,4%. There were a 52,4% difference in left hip dislocation rate compared with right hip dislocation rate 27,9% and 19,7% in both sides; difference was statistically significant with p <0,05). - Assessment of CDH according to Tonnis levels (n = 73 joints) Patients with CDH level IV in accordance with Tonnis account for 71,2%; Level III is 28,8% 3.2. Surgical results 3.2.1. Results related to surgery - Dimensions of shin bone (n = 73 pieces of bone): + Average length (Ẍ ± SD) = 12,3 ± 0,7mm, the longest is 15mm, the shortest is 11mm. + Average height (Ẍ ± SD) = 13,5 ± 0,9mm, highest 15mm, lowest 13mm. + Average width (Ẍ ± SD) = 9,2 ± 0,5mm, width is 10mm, narrowest is 8mm. - Complications caused by surgery Table 3.12. A combination of complications and complications caused by surgery Complications during surgery n Rate (%) Damage to femoral artery 0/73 0 13 Damage to femoral nerves 0/73 0 Damage to lateral cutaneous nerve of the 4/73 5,5 thigh Comment: - Surgery related injury: In surgery, there is no case of artery and nerve damage. Only 4 in 73 cases damage lateral cutaneous nerve of the thigh. 3.2.2. Short-term results 3.2.3. Long-term results All patients were followed up until 12 months after surgery. Then, from 24 months onwards, we examined and evaluated 48 patients with 59 joints who underwent surgery, all patients were over 5 years old. 3.2.3.1. Redislocation (n = 73 joints) 5,48%(4/73) Tái trật khớp Không tái trật khớp Figure 3.7. Rate of dislocation Remarks: There were 4 out of 73 (5,48%) cases of redislocation during 6 months post-surgery. 3.2.3.2. Results related to bone grafts (n = 73 pieces of bone): There are no cases of slipping fragments. All of fibular allografts were completely in corporated post-surgery (from 12 to 18 weeks) 3.2.3.3. Effectiveness of pain relief intervention after surgery 3.2.3.4. Effectiveness of intervention that improves movement Table 3.15. Trevor’s Effectiveness of Intervention in Movement Improvement 14 Movement After After After Before surgery surgery surgery surgery 6 12 ≥ 24 months months months (1) (2) (3) (4) Rate Rate Rate Rate n n n n (%) (%) (%) (%) p 31 42,5 40 54,8 37 62,7 a (1: 2; 3; 4) < 0,01 Slight limitation but no fixed deformity 66 90,4 20 27,4 22 30,1 14 23,7 (b) b (1: 2; 3; 4) < 0,01 Full (a) More than half the normal range (c) 0 7 0 9,6 15 20,5 9 12,3 8 13,6 Less than half the normal 0 0 7 9,6 2 2,8 0 0 or some fixed deformity range (d) Little or none 0 0 0 0 0 0 0 0 (e) Total 73 100 73 100 73 100 59 100 p < 0,01 < 0,01 < 0,01 < 0,01 c (1: 3; 4) > 0,05 c (2: 1; 3; 4) < 0,05 d (2: 1; 3; 4) < 0,05 e (1: 2; 3; 4) > 0,05 Remarks: Post-surgery hip joints that have a "full movement" range has increased from 0% in to 42,5% after 6 months; 54,8% after 12 months and 62,7% after surgery ≥ 24 months; Significant change in motor range with p <0,01. There were no significant cases before surgery and after 6 months, 12 months and ≥ 24 months. 3.2.3.5. Effectiveness in reducing limping after surgery 3.2.3.6. Effectiveness in reducing function restriction 3.2.3.7. Evaluating the effectiveness of post-surgery intervention of the Wiberg angle This standard applies to patients under 14 years of age. Table 3.18. Wiberg angle before and after surgery by Trevor Wiberg angle value After surgery ≥ 24 p months 15 n >25° 20°- 24° < 20° < 00 Total 20 18 17 4 59 Percentag e (%) 33,9 30,5 28,8 6,8 100 < 0,01 < 0,01 < 0,01 < 0,01 Remarks: After the surgery, cases of good coverage of the acetabulum with Wiberg angle >200 account for 64,4%. The incidence of Wiberg angle <20° accounted for 28.8% after ≥ 24 months of surgery. There are 4 cases of Wiber's angle <0 0 due to the femoral head located outside the acetabular. These are cases of redislocation. 3.2.3.8. Assessing avascular necrosis of the capital femoral Table 3.19. Avascular necrosis of the capital femoral before and after surgery according to Trevor Avascular necrosis of the capital femoral Before surgery (1) 6 9 4 Rat e (%) 94, 5 5,5 0 0 0 0 0 0 7 3 100 n No necrosis (a) Level 1 necrosis (b) Level 2 necrosis (c) Level 3 necrosis (d) Level 4 necrosis (e) Total After surgery 6 months (2) Rat n e (%) 6 94,5 9 4 5,5 0 0 0 0 0 0 7 3 100 After surgery 12 months (3) Rat n e (%) 6 91,8 7 6 8,2 After surgery ≥ 24 months(4 ) n Rate (%) 54 91,5 1 1,7 0 0 1 1,7 0 0 2 3,4 0 0 1 1,7 7 3 100 59 100 p a (1: 2; 3; 4)>0,05 b (3: 4) < 0,05 c (1: 2; 3; 4)>0,05 d (1: 2; 3; 4)>0,05 e (1: 2; 3; 4)>0,05 b4: c4, d4, e4 >0,05 Remarks: The rate of Level 1 necrosis before surgery is 5,5%, that after 6 months is 5,5% and that after 12 months is 8,2%; remains unchanged at p > 0,05. This 16 change was statistically significant at p < 0,05 for 12 months versus ≥ 24 months (from 8,2% to 1,7%). After > 24 months of surgery, the necrosis rates of Levels 2, 3, 4 increase because of Level 1 necrosis has transitioned but the change is not statistically significant at p > 0,05. 3.2.3.9. Evaluating femoral neck before and after surgery Table 3.20. Change in the femoral neck before and after surgery according to Trevor After After After Before surgery surgery ≥ surgery 6 The appearance surgery 12 24 months p months of the femoral (1) months (4) (2) head (3) Rat Rat Rat Rate n e n e n e n (%) (%) (%) (%) Normal (a) 68 93,2 68 91,2 66 90,4 51 86,4 > 0,05 Partial deformity (b) 5 6,8 Severe deformity (c) 0 0 73 100 Total 5 6,8 0 0 73 100 7 9,6 8 13,6 > 0,05 0 0 0 0 > 0,05 73 100 59 100 Remarks: Cases of "partial deformity" of the femoral neck before and after surgery did not significantly change, the change was not statistically significant; 6,8% before surgery versus 6,8% after surgery 6 months; 9,6% after 12 months and 13,6% after surgery ≥ 24 months, with p> 0,05. There are no cases of severe deformity of femoral head before and after surgery. 3.2.3.10. Evaluating the effectiveness of Shenton line intervention 3.2.3.11. Assessing the acetabular angle, before and after surgery Table 3.22. Acetabula before and after surgery Evaluation time Acetabular angle 17 Before surgery (1) Immediately after surgery (2) 6 months after surgery (3) 12 months after surgery (4) ≥ 24 months after surgery (5) p n 73 73 73 73 59 Average 40,70 24,30 22,40 20,90 18,60 SD 3,65 1,75 1,53 1,54 1,69 (1: 2; 3; 4; 5) < 0,05; 0,05 Range 350-500 190-280 190-260 170-250 150-24,50 (2: 3; 4; 5) > Remarks: The acetabular angle before surgery was significantly reduced compared to 6 months, 12 months and ≥ 24 months with values of 40,7 0 versus 24,30; 22,40; 20,90 and 18,60; The change is statistically significant with p <0,05. 3.2.3.12. Trendelenburg's sign (n = 73 joints) 3.2.3.13. Evaluation of HBsAg and HIV test results before and after surgery 3.2.3.14. Summary of the evaluation results of the effectiveness of intervention - Evaluate the results of the last check, classified by Trevor Table 3.25. Synthesized results after surgery classified by Trevor Evaluation after surgery ≥ 24 months Excellent (18 - 20 points) n % 39 66,1 Good (15 - 17 points ) n % 10 16,9 Average (12 14 points ) n 6 % 10,2 Poor (< 11 points ) n % 4 6,8 Total 59 Remarks: Evaluation of follow-up results when patients over 5 years old; “Excellent” accounted for the highest percentage at 66,1% (39/59 hip joints); “Good” at 16,9% (10/59 hip joints); “Average” at 10,2% (6/59 of the hip). “Poor” results only account for 6,8% (4/59 of the hip) involve hip replacement, gait, avascular necrosis of the capital femoral. 3.3. Analysis of related factors in hip dislocation 18 Chapter 4 DISCUSSION 4.1. Clinical features and imaging diagnostics in pediatric patients at the National Hospital of Paediatrics 4.1.1 Characteristics of research subjects 4.1.1.1. Detection age The results showed that the detection age group of 12 - <24 months accounted for the highest share at 68,9%. At this age, children begin to learn to walk. Thus, difficulty in movement is easily detected by the parents by observing the length of the foot, the gait of the child with signs of limping and deflection. This finding is consistent with studies by Kocer et al. (2016), with 96% of cases detected early in the 24 month period. Samarah OQ et al. (2016) found that the prevalence of CKD below 12 months was 41,9%. 4.1.1.2. Age of surgery The results showed that the mean age of intervention was 23,06 ± 4,9 months (Table 3.1). This finding is consistent with some reports from other authors such as Ahmed E et al. (2013) for CDH in 20 patients with an average age of 14,7 months. Bhatti A et al. (2014) performed one CDH treatment for 38 children under 3 years of age with 50 patients with an average age of 24,26 ± 7,6 months. The results of the authors' study showed that the higher the age limit, the more open reduction in combination with pelvic osteotomy, and the higher the risk of femoral cap necrosis. 4.1.2. Factors related to CDH 4.1.3. Clinical characteristics CDH 4.1.3.1. Hip dislocation classified by sex RESULTS: Of the 61 patients with CDH, the proportion of female patients was 88,5% (54/61), the proportion of male patients was only 11,5% (7/61), female/male ratio = 7,7/1 (Figure 3.2). The results of our study are similar to those of local and international studies: Ulici A et al. (2016). Male/female ratio is 7/1. Woodacre T (2016) shows that the prevalence of female CDH cases is higher in men than in men, with 7,2/1 in female. In the study conducted by Nguyen Ngoc Hung 19 (2013), the percentage of female is 86,3% (63/73); 13,7% (10/73) are male; the female/male ratio is 6,3. 4.1.3.2. Dislocation of the hip on the left, right, and both sides Results showed that the rate of left hip replacement was highest at 52,4% (Figure 3.4). This result is similar to many other authors’ studies: In a study by Bhatti A et al. (2014), 31.57% of cases was on both sides; 28,94% right hip; 39,47% was on left hip. Phan Van Tiep (2001) showed that the rate of left hip dislocation was 50,0%, right hip dislocation 16,7%; and both 33,3%. 4.1.3.3. Hip pain 4.1.3.4. Difference of lower limb According to our result, the difference in length of the legs from more than 1,5cm - ≤ 2cm is 63,4% and the difference in length of over 2cm is 24,4% (Table 3.6). This result is perfectly consistent with the clinical manifestations of CDH. 4.1.3.5. Galeazzi sign The authors claimed that when Galeazzi test returns a positive, it is certain that the hip is dislocated. 4.2. Zigzag's modified pelvic bone transplantation technique improves combined with fibular allograft in treating CDH in young children. 4.2.1. Effectiveness in improving movement after surgery Research results show that the proportion of patients with full movement before surgery is 0% (0/0); after surgery this increased to 62,7% (37/59) (table 3.15). Thus, movement is significantly increased by surgery. This finding is in high accordance with the clinical situation of patients and studies of authors at home as well as abroad: Aksoy C et al (2013) studied 35 patients with an average age of 35 months (18 to 65 months), with 43 hips dislocated. Statistics show that before surgery, 100% of patients experienced pain with varying degrees and their movement was restricted. After surgery, at the last follow-up, 100% of the patients were no longer restricted in movement. 4.2.2. Changes in the Wiberg angle and the acetabular angle Results showed that the rate of post-surgery patients with Wiberg angle > 25° is 33,9% (Table 3.18). 20 The results showed that the change in the acetabular angle prior to surgery decreased from 40,70 to 24,30 immediately after surgery (Table 3.22). After 24 months, the average acetabular angle was 18,60. The results of our study are congruent to that of other authors such as Aksoy C et al (2013), on treatment of dysplasia. The results show that the average acetabular angle before surgery is 35°, and that after surgery is 20°. At the end of the follow-up, the average angle was 13°. In Vietnam, Nguyen Ngoc Hung (2013) concluded in his research that the acetabular angle was significantly improved: before surgery was 42,95°, last examination, after surgery was 19,15°. 4.2.3 Complications after intervention 4.2.3.1. Avascular necrosis of the capital femoral (AVN) Our results show that the rate of Level 1 necrosis prior to surgery is 5,5% and after 6 months, 5,5% and after 12 months, 8,2% with p> 0,05. After 24 months, Levels 2, 3, and 4 necrosis rate increased, having transitioned from Level 1 necrosis. However, the change was not statistically significant with p> 0,05 (Table 3.19). Prior to 1960, according to Esteve Rafael, the incidence of femoral necrosis was 70% after open reduction, with the lowest rate being 5% after open reduction and 0% after closed reduction. Aydin A et al. (2012) performed Pemberton pelvic osteotomy technique for 86 patients with dysplasia from 12 to 36 months of age. As a result, Level 1 necrosis was 9,9%; Level II is 7,7% and Level III is 1,1%. Postoperative surgery results showed that the femoral head necrosis complication rate in our group was lower than those of the authors. This result is due to the fact that we do not cut the femur combined acetabuloplasty using bone allografts, thus minimizing the damage to the arteries, and the soft tissues around the hip. 4.2.3.2. Femoral neck deformity The results show that partial femoral neck deformity rate before surgery is 6,8% compared to 6,8% after 6 months post-surgery; 9,6% after 12 months and 13,6% after surgery ≥ 24 months, the change was not statistically significant with p> 0,05 (Table 3.20). No cases of severe deformity of the capital femoral, and neck before and after surgery were detected. Trevor D, Johns DL, Fixsen JA (1975) showed that in 15 excellent joints, 7 experienced coxa magna; in 44 good joints, 20 joints experienced coxa
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