Pavlik吊带早期治疗发育性髋关节脱位

Pavlik harness in early treatment of developmental dislocation of the hips： preliminary results and reasons for failure of reduction

目的 探讨Pavlik吊带治疗不同类型发育性髋脱位的临床效果,并分析复位失败的原因.方法 回顾性分析2009年1月至2013年3月,初始采用Pavlik吊带治疗髋关节脱位的163例（195髋）资料完整且随访超过1年的患儿资料,男18例（21髋）,女145例（174髋）;年龄18～129 d,平均（65.9±20.2）d;左侧85例,右侧46例,双侧32例;超声Graf分型：Ⅲ型165髋,Ⅳ型30髋.根据屈髋、外展时动态超声检查示能否复位及Ortolani试验,将髋关节脱位分为可复性及难复性两类.吊带佩戴3周后临床查体及超声检查仍示未复位或复位但不稳定者,视为吊带治疗失败.末次随访时摄骨盆正位X线片,并在其上测量髋臼指数,根据T（o）nnis标准判断残余髋臼发育不良,根据Salter标准判断股骨头缺血性坏死.分析年龄、性别、单双侧、脱位分类（可复性/难复性）及超声Graf分型与吊带复位效果的关系.结果 195髋中,144髋（73.8％,144/195）经吊带治疗复位成功;51髋（26.2％,51/195）复位失败,其中47髋再次行皮牵引后复位石膏固定治疗,4例4髋拒绝再治疗.163例患儿均获得随访,随访时间12～49个月,平均19个月.末次随访时,10髋（6.9％,10/144）残余髋臼发育不良,4髋（2.8％,4/144）发生股骨头坏死.单因素分析结果显示,复位成功率与年龄、性别及侧别无明显相关性,与超声分型（GrafⅢ：Ⅳ型,79.4％：43.3％）及脱位分类（可复性：难复性,79.1％：34.8％）有关.多因素分析结果显示,脱位分类（OR=6.071,P=0.000）及超声Graf分型（OR=4.629,P＜ 0.001）是影响复位成功的独立相关因素.GrafⅣ型且不可复性脱位仅12.5％（1/8髋）复位成功.结论 Pavlik吊带是早期治疗发育性髋关节脱位有效安全的方法之一,Pavlik吊带适用于GrafⅢ型可复性脱位,对Graf Ⅲ型难复性及Ⅳ型可复性脱位吊带复位失败率高,可尝试作为初始治疗的手段;GrafⅣ型难复性脱位不宜作为首选治疗方法.

Objective To evaluate the result of early treatment for developmental dislocation of the hips by Pavlik harness,and to seek the reasons of failure.Methods We retrospectively reviewed the patients of developmental dislocation of the hips who initially received Pavlik harness treatment between 2009 January and 2013 march by ultrasound examination.163 cases （195 hips） were collected complete data and followed up for more than 1 year.We combined the Ortolani test and ultrasound examination to determine whether the dislocated hip was reducible or irreducible.The ultrasound examinations were conducted every week after Pavlik harness treatment.If the reduction was not achieved in three weeks after Pavlik harness treatment confirmed by ultrasound examination,we determined the treatment was failure.A plain anteroposterior radiograph was taken for measuring the acetabular index at the last follow up and T（o）nnis Criterion was accorded to evaluate the residual dysplasia.The Salter Criterion was used to evaluate the avascular necrosis of femoral head.The relationships between age,gender,single-sided,reducibility,the ultrasonic type and reduction were analyzed.Results In 195 dislocated hips,144 hips （73.8％） were treated successfully by Pavlik harness,51 hips were failed with 49 hips were changed to the cast and 4 hips refused.The average time of follow-up was 19 months （12-49 months）.At the last follow-up,10 hips （6.9％,10/144） were residual dysplasia,4 hips （2.8％,4/144） occurred avascular necrosis of the femoral head.Univariate analysis showed that there was no significant correlation between age,gender,singlesided and reduction （P ＞ 0.05）,but the ultrasonic type （Graf Type Ⅲ/Ⅳ,79.4％ vs.43.3％） and the reducibility （reducible/irreducible,79.1％/34.8％） were relevant factors （P ＜ 0.001）.Multivariate analysis showed that the reducibility （OR=6.071,P=0.000）and ultrasonic type （OR=4.629,P ＜ 0.001） were independent factors.Further analysis revealed that only 12.5％ （1/8） of Graf Type Ⅳ with irreducible hips received reduction by harness.Conclusion Pavlik harness is an effective and safe method in early treatment of dislocated hips.Pavlik harness treatment applies for Graf Type Ⅲ reducible dislocated hips,and can be used as initial treatment for Graf Type Ⅲ with irreducible or Graf TypeⅣ and reducible dislocated hips which may have a higher failure rate.Pavlik harness should not be considered as the best choice for Graf Type Ⅳ irreducible dislocated hips.