发育性髋关节发育不良人类位石膏固定术中外展角度的测量

The optimal means for measuring the abduction angle before Spica cast in developmental dysplasia of the hip

目的比较发育性髋关节发育不良(developmental dysplasia of the hip,DDH)术中测量人类位石膏固定外展角度(abduction angle,AA)的不同年资医生目测和使用电子软件根据不同体表标识测量的四种方法的准确度和可信度。方法回顾性收集2019年1月至2021年11月共27例(32髋)因DDH行闭合复位或单纯切开复位的患儿资料,男6例,女21例;年龄为(13.2±6.86)个月(范围4~28个月)。5位医生分别通过目测和手机软件共四种方法,术中即刻测量髋关节AA并记录,并与术后MRI测量结果(AA-MRI)进行比较。术中测量的4种方法为:①低低年资目测腘窝中心和臀部(坐骨结节)石膏架接触中心连线与两坐骨结节连线垂线交角(junior visualization,AA-JV);②高年资目测腘窝中心和臀部(坐骨结节)石膏架接触中心连线与两坐骨结节连线垂线交角(senior visualization,AA-SV);③腘窝中心和肛门中心连线与坐骨结节连线垂线交角(anus-popliteal,AA-AP);④腘窝中心和腹股沟垂线与肛门中心水平线交点连线和两坐骨结节连线垂线交角(anus-groin crease-popliteal,AA-AGCP)。采用t检验、相关系数、线性回归和Bland-Altman检验评估测量结果的差异性、信度和一致性。结果对比术中4种以及术后AA-MRI测量方法,AA-JV(42.69°±4.13°)<AA-SV(44.80°±4.08°)<AA-AGCP(46.25°±5.15°)<AA-MRI(47.68°±4.21°)<AA-AP(51.77°±5.30°),其中AA-JV和AA-SV、AA-AP和AA-AGCP的差异有统计学意义(t=2.53,P=0.013;t=5.47,P=0.001),AA-AGCP和AA-MRI的差异无统计学意义(P>0.05)。五种方法ICC检验组间一致性范围为0.807~0.892,AA-MRI的组内平均一致性为0.948。所有ICC结果均>0.75,一致性好。线性回归结果显示术中4种测量方法与AA-MRI有良好或中等的线性关系,AA-AGCP(R^(2)=0.499)>AA-AP(R^(2)=0.318)>AA-SV(R^(2)=0.253)>AA-JV(R^(2)=0.217),AA-AGCP为最佳测量方法。AA-AGCP和AA-MRI的Bland-Altman散点图结果一致性良好,偏倚的均值和标准差为-0.796±3.247,一致性界限95%LoA(-7.160,-5.568)。结论DDH患儿在行人类位石膏固定前,常用目测方法所得AA偏小,推荐使用AA-AGCP法预估,该法操作简便、可信度高、一致性强、测量客观精确。

Objective Comparison of four methods in intraoperative abduction angles(AA)measurements of human cast immobilization in developmental dysplasia of the hip(DDH)by visual inspection and electronic software according to different body surface markers.Methods Data were retrospectively collected from January 2019 to November 2021 in a total of 27 patients(54 hips)who underwent closed or simple open reduction.There were 6 males and 21 females with an average age of 13.2 months.Five doctors used visual inspection and mobile phone software to measure the AA of the hip joint immediately during the operation,and compared with the postoperative MRI measurement results(AA-MRI).The four methods of intraoperative measurement were:Junior visualization(AA-JV),the intersection angle between the line connecting the center of the popliteal fossa and the contact center of the plaster frame and the line connecting the two ischial tuberosities;the same methods as method one by Senior visualization(AA-SV);the intersection angle between the line connecting the center of the popliteal fossa and the center of the anus and the line connecting the ischial tubercle(anus-popliteal,AA-AP);the intersection of the vertical line between the center of the popliteal fossa and the groin and the horizontal line of the center of the anus and the vertical line connecting the two ischial tuberosities intersect(anus-groin crease-popliteal,AA-AGCP).The t-test,correlation coefficient,linear regression and Bland-Altman test were used to evaluate the measurements.Results Comparing the four intraoperative and postoperative AA-MRI measurement methods,AA-JV(42.69°±4.13°)<AA-SV(44.80°±4.08°)<AA-AGCP(46.25°±5.15°)<AA-MRI(47.68°±4.21°)<AA-AP(51.77°±5.30°),and the difference between AA-JV and AA-SV,AA-AP and AA-AGCP was statistically significant(t=2.53,P=0.013;t=5.47,P=0.001),there was no significant difference between AA-AGCP and AA-MRI(t=1.57,P=0.118).The inter-group agreement of the five methods ICC test ranged from 0.807 to 0.892,and the intra-group average agreement of AA-MRI was 0.948.All ICC results were greater than 0.75 with good agreement.Linear regression results showed that the four intraoperative measurement methods had a good or moderate linear relationship with AA-MRI,AA-AGCP(R^(2)=0.499)>AA-AP(R^(2)=0.318)>AA-SV(R^(2)=0.253)>AA-JV(R^(2)=0.217),AA-AGCP was the best measurement method.The results of Bland-Altman scatterplot of AA-AGCP and AA-MRI were in good agreement,the mean and standard deviation of bias were-0.796±3.247,and the limit of agreement was 95%LoA(-7.16,-5.57).Conclusion The AA method of visualization before Spica casting was smaller than truth.The method AA-AGCP objectively by landmarks was the advocated means measuring abduction angle during operation with highly consistency,agreement and easily performed.