Pavlik吊带治疗发育性髋脱位失败病例的临床特点及后续治疗

Pavlik harness failure in the treatment of developmental dislocation of the hip: clinical feature and treatment

目的总结Pavlik吊带治疗发育性髋脱位(development dislocation of the hips,DDH)失败病例的临床特点,比较分析闭合复位(closed reduction,CR)石膏裤和外展支具的治疗结果,探讨Pavlik吊带治疗失败后的治疗选择。方法回顾2010年1月至2017年12月在我院应用Pavlik吊带治疗的GrafⅢ和Ⅳ型DDH病例,纳入吊带治疗失败后行CR或外展支具治疗、资料完整、随访> 2年的病例,共74例(92髋)。根据临床Ortolani检查和动态B超将失败病例分为两型:可复性脱位(维持复位失败)及难复性脱位(复位失败)。在2岁阶段骨盆正位X线片测量髋臼指数(acetabulr index,AI)。末次X线片根据Satler标准判断是否发生股骨头缺血性坏死(avascular necrosis,AVN)。单因素及多因素Logistic分析CR治疗是否成功的相关因素。比较CR和外展支具治疗成功率、AVN发生率及2岁阶段AI。结果 Pavlik吊带治疗失败后92髋中21髋(22.8%)为难复性脱位,71髋(77.2%)为可复性脱位。72髋行CR石膏治疗,62髋(86.1%)复位成功,16.1%(10/62)发生AVN。单因素和Logisitic多因素分析均显示男孩及难复性脱位是CR治疗失败的风险因素。20髋行外展支具治疗,均为可复性脱位,13髋(65.0%)复位成功,15.4%(2/13)发生AVN。GrafⅢ型15髋中12髋(80.0%)、GrafⅣ型5髋中1髋(20%)复位成功。CR和外展支具治疗GrafⅢ型可复性脱位的复位成功率、AVN发生率及2岁阶段AI差异均无统计学意义。结论 Pavlik吊带治疗失败具有难复性(复位失败)和可复性(维持复位失败)两种临床类型,而近80%均为维持复位失败。CR是Pavlik吊带治疗失败后安全、可靠的后续治疗选择,男孩、难复性脱位治疗失败率较高。外展支具可作为GrafⅢ型可复性脱位的治疗选择,具有不需要麻醉和住院的优势。

Objective To summarize the clinical characteristics of Pavlik failure in the treatment of development dislocation of the hip (DDH),to compare the treatment results of closed reduction and spica casting (CR) or abduction brace,and to explore the subsequent treatment after Pavlik failure.Methods Graf Ⅲ / Ⅳ DDH cases treated with Pavlik harness from January 2010 to December 2017 in our hospital were reviewed.Patients treated by CR or abduction with complete clinical data and more than 2 years’ follow-up were included in our study.There were 74 cases with (92 hips).According to the clinical Ortolani test and dynamic ultrasound examination,all failure cases were divided into reducible dislocation (failure of reduction maintance) and irreducible dislocation (failure of reduction).Acetabular index (AI) was measured on the X-ray at the age of 2 years.Femoral head avascular necrosis(AVN) was determined on the latest X-ray according to Satler’s criteria.Univarite and multivariate analyses were used to analyze the related factors to the success or failure of CR treatment.Success rate,AVN incidence and AI at 2 years old were compared between CR and abduction brace treatment groups.Results There were 21 (22.8%)irreducible dislocated hips and 71 (77.2%) reducible dislocated hips.Among 72 hips treated with CR,62 hips(86.1%) were reduced successfully and AVN occurred in 10 hips (16.1%).Both univariate and Logisitic multivariate analyses showed that boy and irreducible dislocated hip were risk factors of CR failure.Among 20 reducible dislocated hips treated with abduction brace,13 hips (65.0%) were reduced successfully and AVN occurred in 2 hips (15.4%).Success rates of reduction in Graf Ⅲ and Graf Ⅳ were 80% and 20%,respectively.There were no statistical differences in success rate of reduction,AVN incidence,and AI at 2 years old between CR and abduction brace for the treatment of reducible Graf Ⅲ hips.Conclusions There are two clinical types of Pavlik harness failure including failure of reduction and failure of reduction maintance,and nearly 80% of patients are of the latter.CR is safe and reliable after Pavlik harness failure.The risk of CR failure is much higher in male and irreducible dislocated hips.Abduction brace could be used for the treatment of reducible Graf Ⅲ hips without anesthesia and hospitalization.