联合应用Graf和Harcke超声技术评价DDH早期诊治的临床效果

Combining Graf and Harcke ultrasounds for evaluating the clinical outcome of DDH in early diagnosis and treatment

目的联合应用Graf和Harcke超声评价发育性髋关节发育不良(developmental dysplasia of the hip,DDH)的早期诊治效果,探讨关节稳定性与发育状况的关系。方法收集2017年6月至2018年5月小儿骨科首诊的存在DDH风险因素的婴儿资料共113例226髋,平均年龄为10周,范围为4~19周。应用Harcke技术评价髋关节外展程度和稳定性,应用Graf技术对髋关节进行分型。其中GrafⅠ型髋关节不予治疗,首诊后4~6周复查,若仍为GrafⅠ型则终止随访。GrafⅡa^+型且"外展正常"的髋关节暂不治疗,于婴儿12周龄后复查,若连续2次复查均为GrafⅠ型则终止随访;若转为GrafⅡb型则予以治疗。"外展受限"的GrafⅡa^+型和其他分型均予Ottobock支具治疗。经过治疗的患儿均于1岁时复查X线片,测量髋臼指数,应用IHDI分型评价髋关节发育情况,比较首诊时各Graf分型髋关节的稳定性。结果GrafⅡa^+型且"稳定"、"外展受限"2髋,Ⅱa^+型且"松弛"、"外展正常"转为Ⅱb型2髋,予以治疗;其余分型53髋均予治疗。共治疗57髋,平均治疗时间为13周,范围为7~22周。"松弛"11髋、"加压可脱位"3髋、"脱位可复位"14髋中的12髋及"脱位不可复位"1髋经治均转为"稳定",其余"脱位可复位"2髋均转为"松弛"。1岁复诊时57髋均为IHDI-Ⅰ型,髋臼指数为(24±2)°,范围为21°~28°。以Fisher确切概率法比较首诊时各Graf分型的髋关节稳定性。GrafⅠa型稳定性与Ⅱ型及以上分型比较,差异有统计学意义(P<0.05)。GrafⅠb型稳定性与Ⅰa型和Ⅱa^+型比较,差异均无统计学意义(P>0.05);但与Ⅱa-及以上分型比较,差异有统计学意义(P<0.05)。GrafⅡa^+型、Ⅱa-型和Ⅱb型三者稳定性相互比较,差异均无统计学意义(P>0.05)。结论Graf联合Harcke超声技术能够满足临床筛查DDH的基本需求,可以从髋臼发育和关节稳定性两个角度出发,共同判断髋关节的发育状况,指导临床干预和监测随访,值得在临床推广。

Objective To combine Graf and Harcke ultrasounds for evaluating the clinical outcomes of developmental dysplasia of the hip(DDH)and discuss the relationship between hip development and stability.Methods From June 2017 to May 2018,a total of 226 hips in 113 infants with risk factors of DDH were collected.The average age was 10(4-19)weeks.Harcke method was employed for evaluating the abductions and stabilities of the hips and Graf method for classifying the hips.Hips of Graf I were not treated and follow-ups stopped if reviewed ultrasound was still Graf I 4-6 weeks later.Hips of GrafⅡa^+with normal abductions would not be treated immediately and reviewed ultrasounds were given to infants aged above 12 weeks.Follow-ups ceased if 2 consecutive outcomes were both Graf I and treatment would be given if the outcome turned to GrafⅡb.Hips of GrafⅡa^+with restricted abductions and other classifications were treated with Ottobock harness.Radiograph was given to infants aged above 1 year and acetabular indices were measured.Hip developments were evaluated with the classification scheme of International Hip Dysplasia Institute(IHDI).Stabilities of hips in each type of Graf classification during an earlier examination were compared mutually.Results Two hips of GrafⅡa^+with stabilities but restricted abductions were treated.Another 2 hips of GrafⅡa^+with relaxations but normal abductions were treated as their types turned to GrafⅡb.All other 53 hips were treated.Fifty-seven hips were treated for an average period of 13(7-22)weeks.Eleven hips of relaxations,3 hips of pressure dislocations,12 of 14 hips of reducible dislocations and 1 hip of irreducible dislocation stablized.The other 2 hips of reducible dislocations became relaxed.All hips turned IHDI-I at age of 1 year and acetabular index was(24°±2°)(21°-28°).The stabilities in hips of GrafⅠa were better than inⅡabove(P<0.05).No statistical significance existed in differential stability in hips of Graf Ib compared with Ia/Ⅱa^+(P>0.05).However,it was present as compared withⅡa-above(P<0.05).No statistical significance existed in GrafⅡa^+、Ⅱa-andⅡb(P>0.05).Conclusions A combination of Graf and Harcke ultrasounds fulfills basic requirements of clinical screening of DDH.And the developments of hips may be evaluated from both perspectives of acetabular developments and joint stabilities for guiding treatments and monitoring follow-ups.Wider clinical popularization is worthwhile.