羅有師 魏達(dá)友 黃友清等
[摘要] 目的 探討超聲篩查新生兒發(fā)育性髖關(guān)節(jié)異常(DDH)的臨床價(jià)值。 方法 對(duì)926例新生兒進(jìn)行DDH超聲篩查,比較健康新生兒雙髖關(guān)節(jié)α、β角和股骨頭覆蓋率(MR),并比較正常髖關(guān)節(jié)與異常髖關(guān)節(jié)α、β角和MR。結(jié)果 926例新生兒中,738例(79.7%)髖關(guān)節(jié)正常,188例(20.3%)存在髖關(guān)節(jié)異常,其中41例(4.4%)為DDH患兒,男15例,女26例,男女之比為1∶1.73,健康新生兒兩側(cè)髖關(guān)節(jié)α、β角度及MR比較差異無統(tǒng)計(jì)學(xué)意義(P >0.05),正常髖關(guān)節(jié)α角和MR大于異常髖關(guān)節(jié),β角小于異常髖關(guān)節(jié),差異均有統(tǒng)計(jì)學(xué)意義(P <0. 05)。臀位、剖宮產(chǎn)和女性均為新生兒髖關(guān)節(jié)異常的危險(xiǎn)因素。 結(jié)論 超聲檢查操作簡(jiǎn)單,無輻射,具有可重復(fù)性,對(duì)新生兒DDH的診斷和治療過程的檢測(cè)具有重要意義,可作為新生兒DDH首選的篩查方法。
[關(guān)鍵詞] 新生兒;發(fā)育性髖關(guān)節(jié)異常;超聲
[中圖分類號(hào)] R587.2 [文獻(xiàn)標(biāo)識(shí)碼] B [文章編號(hào)] 1673-9701(2014)11-0061-03
[Abstract] Objective To investigate the clinical value of ultrasound screening of developmental dysplasia of hip (DDH) in neonates. Methods A total of 926 neonates underwent ultrasound screening of DDH, compared double hip α angle, β angle and femoral head coverage(MR) of healthy newborns, and compared α angle, β angle and MR of normal hip with those of abnormal hip. Results Among 926 newborns , 738 cases(79.7%) of normal hip joint, 188 cases(20.3%) of the hip abnormalities, including 41 cases(4.4%) of DDH were found, 15 cases were male, 26 cases were female, and male-female ratio of 1∶1.73, double hip α angle, β angle and MR of healthy newborns were compared, the differences had no statistical significance(P >0.05), α angle and MR of normal hip joint were greater than those of the abnormal hip, while β angle was less than that of the abnormal hip, the differences were statistically significant(P <0.05). Breech, cesarean section and women were risk factors for neonatal hip joint abnormality. Conclusion The ultrasonic measurement has the advantages of simple operation, no radiation and repeatability, it has an important significance in the diagnosis and treatment of detection of neonatal DDH, it can be used as the preferred method for DDH.
[Key words] Neonate; Developmental dysplasia of the hip; Ultrasound
發(fā)育性髖關(guān)節(jié)異常(developmental dysplasia of the hip,DDH)是嬰幼兒常見的肢體發(fā)育缺陷性疾病之一,我國(guó)1%~10%的新生兒中有DDH傾向,而發(fā)病率約0.07‰~1.75‰,尤以北方地區(qū)發(fā)病率較高[1]。DDH是由于新生兒出生時(shí)髖關(guān)節(jié)結(jié)構(gòu)存在異常,并且在發(fā)育過程中這種結(jié)構(gòu)異常情況不斷進(jìn)展所致[2],而并非先天性疾病。因此,對(duì)于DDH在新生兒明確診斷,并采取有效治療,可避免發(fā)生髖關(guān)節(jié)脫位和發(fā)育不良。超聲波可較好地穿透尚未完全骨化的髖關(guān)節(jié),高頻超聲檢查可提供髖關(guān)節(jié)清晰、可靠的圖像,且具有無創(chuàng)和可重復(fù)性的優(yōu)點(diǎn),成為新生兒DDH早期篩查的主要手段,本研究通過分析926例新生兒髖關(guān)節(jié)超聲篩查結(jié)果,探討超聲檢查對(duì)DDH篩查的臨床價(jià)值。
1資料與方法
1.1一般資料
所選對(duì)象926例均為2012年8月~2013年8月 本院產(chǎn)科出生的足月新生兒,男466例,女460例,胎齡37~42周,平均(39. 2±2.3)周,出生時(shí)體重2448~4016 g,平均(3547.4±367.6)g,篩查時(shí)間為出生后3~8 d,平均(5.1±2.2)d。
1.2儀器與方法
采用飛利浦IU22型超聲診斷儀進(jìn)行檢查,線陣探頭,頻率6~15 MHz,檢測(cè)新生兒呈側(cè)臥位,下肢稍屈曲、內(nèi)旋,將高頻線陣探頭置于股骨大轉(zhuǎn)子外側(cè)皮膚,并前后平行移動(dòng),直至獲得髖關(guān)節(jié)標(biāo)準(zhǔn)的冠狀切面,可清晰顯示髖臼窩內(nèi)髂骨的下緣、平直的髂骨及盂唇。同時(shí),還能夠?qū)σ韵陆馄式Y(jié)構(gòu)清晰顯示:股骨頭、骨-軟骨交界面、關(guān)節(jié)囊、滑膜皺褶、骨性髖臼頂、透明軟骨頂。以平直的髂骨為基線,髂骨下緣與骨性髖臼頂?shù)那芯€為骨頂線,骨緣轉(zhuǎn)折點(diǎn)與關(guān)節(jié)盂唇中點(diǎn)的連線為軟骨頂線,基線與骨頂線夾角稱為α角,基線與軟骨頂線夾角稱為β角,見圖1。同時(shí),股骨頭覆蓋率(MR)即股骨頭被髖臼覆蓋的程度也在標(biāo)準(zhǔn)切面進(jìn)行計(jì)算,參考線選擇平直的髂骨線,股骨頭被髖臼覆蓋部分的直徑與其最大直徑之比表示MR,以%表示。endprint
1.3評(píng)價(jià)標(biāo)準(zhǔn)
依照簡(jiǎn)化的Graf分類標(biāo)準(zhǔn)[3]對(duì)926例新生兒超聲篩查結(jié)果進(jìn)行分類,見表1。DDH包括髖關(guān)節(jié)脫位、半脫位及發(fā)育不良,髖關(guān)節(jié)異常包括DDH和髖關(guān)節(jié)不穩(wěn)定,對(duì)髖關(guān)節(jié)不穩(wěn)定和發(fā)育不良患兒進(jìn)行超聲隨訪觀察,對(duì)髖關(guān)節(jié)脫位、半脫位患兒轉(zhuǎn)骨科進(jìn)行治療,并進(jìn)行超聲隨訪。
1.4統(tǒng)計(jì)學(xué)方法
采用SPSS19.0版本軟件分析統(tǒng)計(jì)資料,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,組間比較采用配對(duì)資料t檢驗(yàn),計(jì)數(shù)資料比較采用χ2檢驗(yàn),P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2結(jié)果
2.1髖關(guān)節(jié)異常篩查情況
在所有926例新生兒中,738例(79.7%)髖關(guān)節(jié)正常,188例(20.3%)存在髖關(guān)節(jié)異常,其中雙髖關(guān)節(jié)異常86例,單髖關(guān)節(jié)異常102例,合計(jì)異常髖關(guān)節(jié)294個(gè),正常髖關(guān)節(jié)1 604例,單髖關(guān)節(jié)異常中左髖60例,右髖42例,左右之比為1.43∶1。所有新生兒中147例(15.9%)髖關(guān)節(jié)不穩(wěn)定,41例(4.4%)為DDH患兒,男15例,女26例,男女之比為1∶1.73,其中髖關(guān)節(jié)發(fā)育不良38例,髖關(guān)節(jié)半脫位3例,全脫位1例,分別占DDH患兒的97.3%、2.0%和0.7%。髖關(guān)節(jié)不穩(wěn)定和發(fā)育不良患兒6個(gè)月后復(fù)查超聲均正常,半脫位和全脫位共4例患兒在骨科治療,6個(gè)月后超聲檢查也恢復(fù)正常。
2.2健康新生兒雙髖關(guān)節(jié)超聲測(cè)量指標(biāo)
2.4 髖關(guān)節(jié)異常的發(fā)生因素分析
臀位、剖宮產(chǎn)及女性新生兒髖關(guān)節(jié)異常的發(fā)生率分別高于頭位、順產(chǎn)和男性新生兒,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05),臀位、剖宮產(chǎn)及女性均為髖關(guān)節(jié)異常發(fā)生的危險(xiǎn)因素。見表4。
3討論
DDH主要特點(diǎn)是患兒股骨頭與髖臼對(duì)位關(guān)系異常,股骨頭部分或全部脫出髖臼,病變累及股骨頭、髖臼、關(guān)節(jié)囊及周圍韌帶和肌肉等。新生兒髖關(guān)節(jié)尚未骨化,主要結(jié)構(gòu)股骨頭和髖臼頂均由透明軟骨組成,傳統(tǒng)X線攝片檢查無法對(duì)髖關(guān)節(jié)的發(fā)育情況做出明確診斷,而超聲波對(duì)透明軟骨具有良好的透聲性[4],超聲檢查對(duì)以軟骨為主要成分的新生兒髖關(guān)節(jié)具有高度敏感性,彌補(bǔ)了傳統(tǒng)X線檢查的不足,對(duì)股骨頭圓形無回聲區(qū)髖臼軟骨、關(guān)節(jié)囊和關(guān)節(jié)盂唇等髖關(guān)節(jié)解剖結(jié)構(gòu)均可清晰顯示[5],并且同時(shí)超聲探頭可以從多個(gè)角度對(duì)髖臼和股骨頭進(jìn)行動(dòng)態(tài)和靜態(tài)掃查,同時(shí)也避免了X檢查的輻射損傷,具有操作簡(jiǎn)單、可重復(fù)性的優(yōu)點(diǎn),超聲診斷設(shè)備提供的檢測(cè)軟件可準(zhǔn)確測(cè)定α和β角度、計(jì)算MR,提高了篩查髖關(guān)節(jié)異常的準(zhǔn)確性[6,7]。本研究結(jié)果顯示,健康新生兒雙側(cè)髖關(guān)節(jié)α、β角度及MR差異無統(tǒng)計(jì)學(xué)意義(P>0.05),異常髖關(guān)節(jié)α角度和MR低于正常髖關(guān)節(jié),而β角度高于正常髖關(guān)節(jié),差異均有統(tǒng)計(jì)學(xué)意義(P<0.05),與徐志強(qiáng)等[8]的報(bào)道一致。表明α、β角度及MR可作為新生兒髖關(guān)節(jié)異常超聲篩查的確切指標(biāo)。目前,超聲檢查已成為國(guó)內(nèi)外早期篩查嬰幼兒DDH的重要手段。
本研究對(duì)926例出生后3~8 d的新生兒進(jìn)行髖關(guān)節(jié)異常的超聲篩查,發(fā)現(xiàn)188例(20.3%)存在髖關(guān)節(jié)異常,其中41例為DDH患兒,男女比例為1∶1.73,女性新生兒明顯多于男性,髖關(guān)節(jié)半脫位和脫位患兒共4例(0.43%),與文獻(xiàn)報(bào)道結(jié)果相近[9]。女嬰發(fā)病率高主要是胎兒期對(duì)母體的松弛素肽較男性胎兒更為敏感有關(guān)[10]。國(guó)外有學(xué)者認(rèn)為,新生兒髖關(guān)節(jié)具有不斷生長(zhǎng)的能力,主張對(duì)超聲篩查發(fā)現(xiàn)存在髖關(guān)節(jié)脫位和半脫位的新生兒采用必要的治療措施,而對(duì)于髖關(guān)節(jié)不穩(wěn)定或發(fā)育不良的新生兒可暫時(shí)不予治療,而定期應(yīng)用超聲檢查,動(dòng)態(tài)觀察髖關(guān)節(jié)的發(fā)育情況[11]。目前對(duì)于哪些DDH新生兒進(jìn)行治療尚無明確標(biāo)準(zhǔn),部分學(xué)者支持早期治療可改善預(yù)后,然而在臨床工作中發(fā)現(xiàn),多數(shù)髖關(guān)節(jié)發(fā)育不良的新生兒未采取任何治療措施的情況下隨訪變?yōu)檎?。本研究?duì)髖關(guān)節(jié)發(fā)育不良的新生兒采取定期超聲復(fù)查,6個(gè)月后均恢復(fù)正常。對(duì)于半脫位和脫位患兒轉(zhuǎn)骨科積極治療后也恢復(fù)正常。本研究還對(duì)單髖關(guān)節(jié)異常新生兒發(fā)病的側(cè)別進(jìn)行了觀察,發(fā)現(xiàn)左髖發(fā)病率明顯高于右髖,表明左髖關(guān)節(jié)更容易發(fā)生DDH,可能與胎兒期多為左枕前位、限制了左髖關(guān)節(jié)外展有關(guān)[12]。
DDH的發(fā)病原因復(fù)雜,至今尚未完全闡明,國(guó)外有學(xué)者調(diào)查顯示,女性嬰兒DDH發(fā)病率為男性的4.1倍,而臀位生產(chǎn)的是其他生產(chǎn)方式的5.5倍,有家族史的發(fā)病率為無家族史的1.7倍[13]。本研究結(jié)果顯示,臀位、剖宮產(chǎn)、女嬰髖關(guān)節(jié)異常的發(fā)病率顯著高于頭位、陰道順產(chǎn)和男嬰,差異有統(tǒng)計(jì)學(xué)意義,表明臀位、剖宮產(chǎn)和女性是髖關(guān)節(jié)異常發(fā)病的高危因素,與黃冬平等[9]的研究結(jié)果一致。有學(xué)者建議將DDH篩查僅限于高危人群中進(jìn)行,這樣有利于提高工作效率,防止過度治療,但本研究結(jié)果顯示,盡管非高危人群中髖關(guān)節(jié)異常也有一定的發(fā)病率,忽視這部分人群的篩查,勢(shì)必導(dǎo)致部分患兒不能得到早期的診斷和治療,增加DDH的患病率。
綜上所述,超聲檢查操作簡(jiǎn)單,無輻射,具有可重復(fù)性,對(duì)新生兒DDH的診斷和治療過程的檢測(cè)具有重要意義,可作為新生兒DDH首選的篩查方法。
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(收稿日期:2014-01-08)endprint
[6] Heeres RH,Witbreuk MM,van JA. Diagnosis and treatment of developmental dysplasia of the hip in the Netherlands:National questionnaire of paediatric orthopaedic surgeons on current practice in children less than 1 year old[J]. J Child Orthop,2011,5(4):267-271.
[7] Delaney LR,Karmazyn B. Developmental dysplasia of the hip:Background and the utility of ultrasound[J]. Semin Ultrasound CT MR,2011,32(2):151-156.
[8] 徐志強(qiáng),齊秀玉,王維潔,等. 超聲波篩查發(fā)育性髖關(guān)節(jié)異常的臨床意義[J]. 臨床兒科雜志,2013,31(5):437-439.
[9] 黃冬平,黃苑銘,高薇薇,等. 新生兒發(fā)育性髖關(guān)節(jié)異常篩查結(jié)果分析[J]. 實(shí)用兒科臨床雜志,2011,26(5):382-384.
[10] Treiber M,Tomazic T,Tckatic Golob A,et al. Ultrasound screening for developmental dysplasia of the hip in the new-born:a population based study in the Maribor rigorn,1977-2005[J]. Wien Klin Wochenschr,2008,120(1-2):31-36.
[11] Kosar P, Ergun E,Unlübay D,et al. Comparison of morphologic and dynamic US methods in examination of the newborn hip[J]. Diagn Interv Radiol,2009,15(4):284-289.
[12] 沈潔,廖鴻飛,唐靜,等. 嬰幼兒發(fā)育性髖關(guān)節(jié)異常825例超聲篩查分析[J]. 重慶醫(yī)學(xué),2011,40(32):3300-3302. [13] Lehmann HP,Hinton R,Morello P,et al. Developmental dysplasia of the hip practice guideline: Technical report[J]. Pediatrics,2000,105(4):57-84.
(收稿日期:2014-01-08)endprint
[6] Heeres RH,Witbreuk MM,van JA. Diagnosis and treatment of developmental dysplasia of the hip in the Netherlands:National questionnaire of paediatric orthopaedic surgeons on current practice in children less than 1 year old[J]. J Child Orthop,2011,5(4):267-271.
[7] Delaney LR,Karmazyn B. Developmental dysplasia of the hip:Background and the utility of ultrasound[J]. Semin Ultrasound CT MR,2011,32(2):151-156.
[8] 徐志強(qiáng),齊秀玉,王維潔,等. 超聲波篩查發(fā)育性髖關(guān)節(jié)異常的臨床意義[J]. 臨床兒科雜志,2013,31(5):437-439.
[9] 黃冬平,黃苑銘,高薇薇,等. 新生兒發(fā)育性髖關(guān)節(jié)異常篩查結(jié)果分析[J]. 實(shí)用兒科臨床雜志,2011,26(5):382-384.
[10] Treiber M,Tomazic T,Tckatic Golob A,et al. Ultrasound screening for developmental dysplasia of the hip in the new-born:a population based study in the Maribor rigorn,1977-2005[J]. Wien Klin Wochenschr,2008,120(1-2):31-36.
[11] Kosar P, Ergun E,Unlübay D,et al. Comparison of morphologic and dynamic US methods in examination of the newborn hip[J]. Diagn Interv Radiol,2009,15(4):284-289.
[12] 沈潔,廖鴻飛,唐靜,等. 嬰幼兒發(fā)育性髖關(guān)節(jié)異常825例超聲篩查分析[J]. 重慶醫(yī)學(xué),2011,40(32):3300-3302. [13] Lehmann HP,Hinton R,Morello P,et al. Developmental dysplasia of the hip practice guideline: Technical report[J]. Pediatrics,2000,105(4):57-84.
(收稿日期:2014-01-08)endprint