Pavlik吊带与牵引石膏早期治疗发育性髋脱位的疗效比较

Comparison of two methods of early treatment in developmental dislocation of the hips

目的比较Pavlik吊带与牵引后闭合复位石膏固定（牵引石膏）早期治疗发育性髋脱位（developmentaldislo．cationofthehip，DDH）的疗效。方法回顾性分析2009年1月至2013年12月经B超筛查确诊的GrafⅢ或Ⅳ型DDH患儿257例（298髋），男31例，女226例；初始治疗年龄为30～159d，平均（74．1±39．2）d，末次随访年龄超过2岁。采用Pavlik吊带治疗190例（219髋），牵引石膏治疗67例（79髋）。末次随访时拍摄早期治疗成功病例2-3岁时的骨盆正位X线片，测量髋臼指数（acetabularindex，AI）、干骺端中心边缘（Opointedge，OE）角及Smith不稳定（Smithinstability，SI）指数（包括水平位移SI—c、垂直位移SI—h），采用jSalter标准判断有无股骨头坏死。结果牵引石膏组复位成功率（97．5％）高于Pavlik吊带组（69．9％），差异有统计学意义（x2=0．353，P=0．000）；牵引石膏组股骨头坏死发生率（6．6％）与Pavlik吊带组（4．6％）的差异无统计学意义（X2=0．106，P=0．745）。Pavlik吊带组早期治疗GrafⅢ型DDH的复位成功率低于牵引石膏组（分别为80．7％和98．4％，x2=11．248，P=0．001）；且Pavlik吊带复位成功后2-3岁时AI、OE角及sI—c（分别为22．9°±3．7°、16．5。±6．3。及0．74±0．06）较牵引石膏组（分别为21．4°±3．4°、18．9°±3．6°及0．72±0．03）差（P均〈0．05）。Pavlik吊带组与牵引石膏组早期治疗GrafIv型DDH复位成功率的差异较大（分别为25．6％和94．4％，X2=24．231，P=0．001），且Pavlik吊带复位成功后2-3岁时OE角（16．0°±4．1°）较牵引石膏组（18．6°±4．5°）差（t=-2．141，P=0．038）。结论Pavlik吊带早期治疗GrafIU或Ⅳ型DDH具有局限性，尤其是GrafⅣ型复位失败牢高，不利于复位后髋关节发育；而牵引石膏固定能够显著提高早期治疗的复位成功率，有利于髋关节发育，且不增加股骨头坏死的风险。

Objective To compare the early treatment results of Pavlik harness and closed reduction plus spica casting in treating developmental dislocation of the hips （DDH）. Methods The patients with Graf m/IV type DDH diagnosed by ultrasound in our hospital were analyzed retrospectively from January 2009 to December 2013. The subjects with intact clinical and radiologic data a,ld more than 2 years follow-up were included. The present study included 257 patients （298 hips）, 31 male and 226 female, with the average age of 74.1±39.2 d （from 30 to 159 d）. Pavlik harness underwent in 190, while 67 cases were treated with closed reduction plus spica casting. Acetabular index （AI）, Wiberg OE angle （point O was the middle point of proximal metaphyseal border） and Smith instability index （SI, SI-c： the lateral displacement index, SI-h： the vertical displacement index） on the pelvic X-ray film at 2-3 years of age after successful early treatment were recorded. Femoral head avascular necrosis （AVN） was diagnosed according to the Salter criteria. Results The success rate of reduction of closed reduction was significantly higher than Pavlik harness （97.5% vs. 69.9%, X2=0.353, P=0.000）. There was no significant difference in the incidence of AVN between the closed reduction and Pavlik harness （6.6% vs. 4.6%, X2=0.106, P=0.745）. For Graf 111 type DDH, the success rate of reduction of Pavlik harness and closed reduction were 80.7% and 98.4% respectively （x2=1 1.248, P=0.001）, while the Pavlik harness group had significantly worse results of At, OE and SI-c at the age of 2-3 years （Pavlik harness： 22.90±3.7°, 16.5°± 6.3° and 0.74±0.06; closed reduction： 21.4°±3.4°, 18.9°_＋3.6° and 0.72±0.03; P 〈 0.05）. For Graf IV type DDH, the success rate of reduction of Pavlik harness was much less than closed reduction （25.6% vs. 94.4%, X2=24.231, P=0.001）, with significantly worse results of OE at the age of 2-3 years （16.0°±4.1° vs. 18.6°±4.5°, t=-2.141, P=0.038）. Conclusion Pavlik harness has limitations in treating Graf Ⅲ/Ⅳ type DDH, with lower success rate of reduction for Graf Ⅳ type DDH. Closed reduction plus spica casting has better clinical results than Pavlik harness in success rate of reduction and subsequent hip development with-out the additional risk of AVN.