婴儿GrafⅡa型髋关节自然转归及治疗指征的前瞻性研究

A prospective study of the natural outcome and treatment indications of infant Graf Ha hip dysplasia

目的观察6周至3月龄婴儿GrafⅡa型髋关节的自然转归，探讨其治疗指征。方法采用前瞻性研究方法，收集2012年7月至2014年7月进入“天津市发育性髋关节异常早期筛查”项目的婴幼儿，年龄6～12周，B超检查确定为GrafⅡa型髋关节（50°≤仅角〈60°），临床检查稳定（Ortolani征、Barlow征均阴性），既往无治疗史且不合并神经肌肉疾患。首诊时不予以任何治疗，每2周复查B超一次，并于3、4.5、6个月摄X线片。6个月前当B超提示分型加重为GrafⅡc型及以上，或体格检查出现不稳定时立即给予Pavlik吊带或外展支具治疗；如X线检查示发育不良持续不改善，则在6个月时开始Pavlik吊带或外展支具治疗。未治疗病例在12、24个月复查X线片，排除晚期出现发育不良进展的风险。对治疗组及未治疗组的初始OL角、髋关节外展受限情况、3个月时骨盆正位X线片髋臼顶形态（锐利、圆顿或缺损）及髋臼指数进行比较。结果共纳入238例285髋，男25例28髋，女213例257髋；年龄6-12周，平均9周。左侧193髋，右侧92髋。未出现B超分型加重为Ⅱc型或更差的病例，100例（120髋）在6个月时仍存在发育不良接受治疗。治疗组与未治疗组首诊年龄、性别、侧别的差异均无统计学意义。治疗组初始d角为54．5°±3．3°，未治疗组为55．6°±2．9°，差异有统计学意义（P〈0．05）；治疗组47髋（39．2％，47／120）存在髋关节外展受限，52髋（43．3％，52／120）3个月X线片上有髋臼顶外上缘圆顿或缺损，与未治疗组比较差异均有统计学意义（P〈0．05）。GrafⅡa＋型（α角≥55°）38例（47髋）接受治疗，其中21髋（44．7％，21／47）存在外展受限、31髋（66．0％，31／47）有髋臼外上缘形态不良，与未治疗病例比较[分别为17．9％（19／106）和17．0％（18／106）]发生率的差异均有统计学意义（P〈0．05）。Logistic多因素回归分析结果显示，GrafⅡa型髋关节需要治疗与GrafⅡa-型（OR=2．908）及髋臼形态不良（OR=2．822）相关，GrafⅡa＋型髋关节需要治疗与外展受限（OR=4．145）及髋臼形态不良（OR=10．117）相关。结论对临床检查稳定的GrafⅡa型髋关节，出生后6周时若B超α角〈55°（Ⅱa-型），以及α角≥55°（Ⅱa＋型）伴有髋关节外展受限或3个月X线出现髋臼外上缘圆顿或缺损应予以Pavlik吊带或外展支具治疗。

Objective To observe the natural outcomes of Graf type Ⅱ a hip dysplasia aged 6 weeks to 3 months, and to explore the indications of treatment. Methods A prospective study was conducted to collect children aged from 6 to 12 weeks with Graf type Ⅱ a dysplasia （50°≤α angle〈60°） but clinically stable hips according to the ＂Early Screening of Developmental Dysplasia of the Hip in Tianjin＂ project from July 2012 to July 2014. Those hips with history of treatment or neuromuscular disorders were excluded. All infants had no treatment initially following with ultrasound surveillance each 2 weeks and radiograph evaluation each at 3, 4.5 and 6 months of age. Patients received Pavlik harness or abduction brace treatment if hip dysplasia turned to be type Graf Ⅱ c or worse, or clinical unstable before 6 months; also if hip dysplasia was persistent in radiograph at 6 months. All infants were routinely followed up at 12 and 24 months of age to detect the late cases. The difference of initial c～ angle, hip abduction, acetabulum index and acetabulum margin morphology （sharp, round or defect） in the pelvic radiograph at 3 month were compared between the treated and untreated groups. Results A total of 238 children （285 hips） were enrolled in the present study, of which there were 25 males and 213 females, 193 left and 92 right hips. The average age was 9 weeks （range 6 to 12 weeks）. No hip turned to be type Ⅱ c or worse, or clinically unstable. One hundred patients （120 hips） received treatment for persistent dysplasia at 6 months. There had statistically significant difference in initial α angle between the treated and untreated groups （respectively 54.5°±3.3° and 55.6°±2.9°, t=-2.749, P=0.004）. In the treated group, there were 47 hips （39.2%, 47/120） with limited abduction initially, and 52 hips （43.3%, 52/120） with poor acetabular morphology at 3 months. The differences were statistically significant comparing with the untreated group （χ^2=4.010, P=0.045; χ^2=14.143, P=0.000）. Logistic multivariate regression analysis showed that patients with Graf Ⅱ α- hips （0R=2.908） and poor acetabular morphology hips （0R=2.822） were more likely to receive treatment. Thirty-eight patients （47 hips） received treatment among Graf Ⅱ α＋ hips （α angle ≥55°）, of which 21 hips （44.7%, 21/47） had limited abduction and 31 hips （66.0%, 31/47） poor acetabular morphology. The differences were statistically significant comparing with untreated cases （χ^2=12.073, P=0.001; χ^2=35.879, P=0.000）. Logistic multivariate regression analysis showed that Graf Ⅱ a＋ hips with limited hip abduction （OR=4.145） and poor acetabular morphology （OR=10.117） were more likely to receive treatment. Conclusion Graf Ⅱ a dysplasia with clinically stable hips should be treated if α angle 〈55° at 6 weeks or if α angle ≥55° with limited hip abduction or poor acetabular morphology （round or defect ） at 3 months.