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Лекция: Дисплазия тазобедренных суставов новорожденных |
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Лекция: Дисплазия тазобедренных суставов новорожденныхòà íåâïðàâèìèé çâèâèõ; · îö³íêà ñòóïåíÿ ðîçâèòêó ñóãëîáó - ãëèáèíà òà êîíô³ãóðàö³ÿ àöåòàáóëþìó, ðîçâèòîê òà êîíòóð ëàáðóìó 7,15,16,17. Õî÷à â îñíîâ³ ìîðôîìåòðè÷íîãî ìåòîäó Graf12 òà äèíàì³÷íîãî Harcke7 ëåæàòü ð³çí³ ô³ëîñîôñüê³ êîíöåïö³¿, ìåòîäè ìàþòü áàãàòî ñï³ëüíîãî.  ¿õ îñíîâ³ ëåæèòü âèçíà÷åííÿ âçàºìîðîçòàøóâàííÿ ñòðóêòóð êóëüøîâãî ñóãëîáó. Òàê ìåòîä Graf íå ìຠôóíêö³îíàëüíèõ òåñò³â, àëå ðîçâèíåí³ òà ïåðåâ³ðåí³ ÷àñîì ìîæëèâîñò³ îö³íêè ñï³ââ³äíîøåííÿ àíàòîì³÷íèõ ìàðêåð³â. Ìåòîä Harcke - êð³ì îö³íêè ðîçòàøóâàííÿ ãîë³âêè ñòåãíà òà àöåòàáóëþìó â ð³çíèõ àíàòîì³÷íèõ çð³çàõ, ôóíêö³îíàëüí³ òåñòè ñòàá³ëüíîñò³ ñóãëîáó, àëå ìåíøå ìîæëèâîñòåé äëÿ âèçíà÷åííÿ çð³ëîñò³/íåçð³ëîñò³ ñóãëîáó17. Ëîã³÷íî ïðèïóñòèòè çàêîíîì³ðí³ñòü ïîºäíàííÿ âèêîðèñòàííÿ îáîõ ìåòîä³â ïðè äîñë³äæåíí³ ÄÊØ, îñîáëèâî ïðè ïðîâåäåíí³ ñêðèí³íãîâèõ äîñë³äæåíü, ùî ³ áóëî ñï³ëüíî çàïðîïîíîâàíî Graf, Harcke òà Clarcke ó 1993 ðîö³ 19, òàêîæ âèçíà÷åíî ì³í³ìàëüíèé ñòàíäàðòíèé ïðîòîêîë ÓÑ êóëüøîâèõ ñóãëîá³â. Îñíîâí³ ïðèíöèïè ÿêîãî : · Êóëüøîâ³ ñóãëîáè ìóñÿòü äîñë³äæóâàòèñü â ñòàí³ ñïîêîþ òà ç ôóíêö³îíàëüíèìè òåñòàìè; · Äîñë³äæåííÿ âêëþ÷ຠð³çí³ àíàòîì³÷í³ çð³çè; · Äîñë³äæåííÿ âêëþ÷ຠâèçíà÷åííÿ ìîðôîëî㳿 òà ñòàá³ëüíîñò³ ñóãëîá³â. Äèñêóòóþòüñÿ ïèòàííÿ â³äíîñíî ïðîâåäåííÿ óëüòðàñîíîãðàô³÷íîãî ñêðèí³íãó ÄÊØ ó íîâîíàðîäæåíèõ òà éîãî îïòèìàëüíèõ òåðì³í³â. Óëüòðàçâóêîâèé ñêðèí³íã âñ³õ íîâîíàðîäæåíèõ â ïåðø³ 2 òèæí³ æèòòÿ ïðîâîäèòüñÿ â äåÿêèõ êðà¿íàõ ªâðîïè3,14,32,36. Íåçâàæàþ÷è, ùî äîñë³äæåííÿ 3,32 äîêàçóþòü ïåðåâàãè ñîíîãðàô³¿ â ä³àãíîñòèö³ òà êë³í³÷íîìó ìåíåäæåìåíò³ ÄÊØ â ðàííüìó â³ö³, òàêîæ çàóâàæåíî ùî òîòàëüíèé ñêðèí³íã íîâîíàðîäæåíèõ ïðèâîäèòü äî ã³ïåðä³àãíîñòèêè ³ ã³ïåðòåðàﳿ 18,31. Òîòàëüíèé ñêðèí³íã ìຠòðè ñóòòºâ³ íåäîë³êè18: 1) ó áàãàòüîõ ä³òåé ñîíîãðàô³ÿ ïîêàçóº íàÿâí³ñòü íåçíà÷íèõ â³äõèëåíü ÿê ñòàá³ëüíîñò³ òà ðîçâèòêó àöåòàáóëþì³â, ÿê³ çíèêàþòü ï³çí³øå áåç ë³êóâàííÿ; 2) îáñåðâàö³ÿ òà ë³êóâàííÿ öèõ ôàëüñ-ïîçèòèâíèõ âèïàäê³â ÿê ³ çàãàëüíèé ñêðèí³íã íîâîíàðîäæåíèõ ïîòðåáóþòü çíà÷íèõ êîøò³â òà ðåñóðñ³â; 3) äåÿê³ âèïàäêè äèñïëà糿, ÿê³ ðîçâèâàþòüñÿ ï³ñëÿ íåîíàòàëüíîãî ïåð³îäó ìîæóòü áóòè íå ä³àãíîñòîâàí³. ²íøèé ï³äõ³ä äî âèêîðèñòàííÿ ñîíîãðàô³¿ º ñôîêóñóâàííÿ ñåãìåíòó ïîïóëÿö³¿ ç äîñòîâ³ðíî ï³äâèùåíèì ðèçèêîì ÄÊØ 19 (òàáë 1), ùî º ÿâíîþ ïåðåâàãîþ, îñê³ëüêè çíà÷íî çìåíøóºòüñÿ êëüê³ñòü îáñòåæåíèõ ä³òåé, ñïðîùóºòüñÿ ïðîâåäåííÿ òà çíèæóºòüñÿ çàãàëüíà âàðò³ñòü ïðîãðàì. Boere òà Clarke (íåîïóáë³êîâàí³ äàí³) ïåðåâ³ðèëè öþ êîíöåïö³þ íà òåðèòî𳿠Âåëèêîáðèòàí³¿. Àâòîðè ïðîâåëè êë³í³÷íå îáñòåæåííÿ íîâîíàðîäæåíèõ ÿê ïî÷àòêîâèé åòàï ç ïîäàëüøîþ ñîíîãðàô³ºþ ä³òåé ç âèÿâëåíèìè â³äõèëåííÿìè. Íà äîäàòîê, êîæíà äèòèíà ç ôàêòîðàìè ðèçèêó áóëà ñîíîãðàô³÷íî îáñòåæåíà ó â³ö³ 6 òèæí³â. Ñåðåä ïîïóëÿö³¿ ç 23 535 îáñòåæåíèõ ä³òåé 2079 (9%) áóëè ñêåðîâàí³ íà ñîíîãðàô³þ âíàñë³äîê âèùåçãàäàíèõ ôàêòîð³â ðèçèêó. Ñîíîãðàô³ÿ äîêàçàëà ñâîþ åôåêòèâí³ñòü ïåðåä ðóòèííèì êë³í³÷íèì îáñòåæåííÿì, àëå â ïîäàëüøîìó ñïîñòåðåæåíí³ ó 5 ä³òåé (0.02%) ç íîðìàëüíèìè êë³í³÷íèìè äàíèìè òà â³äñóòí³ñòþ ôàêòîð³â ðèçèêó ðîçâèíóëàñü ÄÊØ. Õî÷à ó äåÿêèõ ä³òåé ç ö³º¿ ãðóïè ïðè òîòàëüíîìó ñîíîãðàô³÷íîìó ñêðèí³íãó ïàòîëîã³ÿ ìîãëà áóòè âèÿâëåíà ÷è íåä³àãíîñòîâàíà ç îäíàêîâîþ éìîâ³ðí³ñòþ, ùî ñâ³ä÷èòü ïðî íàÿâí³ñòü â³äñòðî÷åíèõ â ÷àñ³ êë³í³÷íèõ ïðîÿâ³â ÄÊØ 19,31. Íàñòóïíå ïèòàííÿ ïðî òåðì³íè ïðîâåäåííÿ ñêðèí³íãó. Êóëüøîâ³ ñóãëîáè ç ï³äçâèâèõàìè ÷è çâèâèõàìè ìîæóòü ñàìîñò³éíî ñêîðèãóâàòèñü ï³ä ÷àñ ïåðøîãî ì³ñÿöÿ æèòòÿ áåç ë³êóâàííÿ 2 . Ñêðèí³íã, ïðîâåäåíèé ï³ñëÿ íåîíàòàëüíîãî ïåð³îäó äຠçìîãó âèêëþ÷èòè ôàëüñ-ïîçèòèâí³ âèïàäêè àëå íå âèêëþ÷ຠïîìèëîê â ä³àãíîñòèö³ â³äñòðî÷åíî¿ ÄÊØ. Åôåêòèâí³ñòü êîíñåðâàòèâíèõ ìåòîäèê, òàêèõ ÿê øîðè Pavlik, çàëåæèòü â³ä â³êó äèòèíè íà ïî÷àòîê ë³êóâàííÿ 2,27 . Âðàõîâóþ÷è ö³ ì³ðêóâàííÿ íàéîïòèìàëüí³øèì ÷àñîì ïðîâåäåííÿ ñêðèí³íãó âèãëÿäຠâ³ê äèòèíè 4-6 òèæí³â19. Êîëè ïåðø³ êë³í³÷í³ îáñòåæåííÿ âêàçóþòü íà íåñòàá³ëüí³ñòü ñóãëîá³â (Barlow òà Ortolani òåñòè), ñîíîãðàô³ÿ ìóñèòü áóòè ïðîâåäåíà äî 2 òèæí³â â³êó äèòèíè. Ó äåÿêèõ ä³òåé ðåçóëüòàòè Barlow òà Ortolani òåñò³â º äîñòîâ³ðíèìè. Ö³ ä³òè òàêîæ ïîòðåáóþòü ñîíîãðàô³¿. Êîëè íåñòàá³ëüí³ñòü íå âèçíà÷àºòüñÿ, àëå ïðèñóòí³ ³íø³ îçíàêè, íàïð. ñ-ì ëóñêîòó, ïîêàçàíèé ñîíîãðàô³÷íèé êîíòðîëü, àëå íå ðàí³øå 4-6 òèæíÿ â³êó äèòèíè. Íàéá³ëüø òèïîâî, êîëè íåçíà÷íà íåñòàá³ëüí³ñòü âíàñë³äîê ô³ç³îëîã³÷íî¿ íåäîðîçâèíåíîñò³ çíèêຠíà ïðîòÿç³ ïåðøîãî ì³ñÿöÿ æèòòÿ ³ íå ïîòðåáóº ë³êóâàííÿ. Ó âèïàäêàõ, êîëè ñîíîãðàô³ÿ ä³òåé ó â³ö³ äî 4 òèæí³â âêàçóº íà íåçíà÷í³ â³äõèëåííÿ ÿê ñëàáê³ñòü, ï³äçâèâèõ òà ïîì³ðíî âèðàæåíó íåäîðîçâèíåí³ñòü àöåòàáóëþì³â ðåêîìåíäóºòüñÿ ñïîñòåðåæåííÿ áåç ë³êóâàííÿ. Äèíàì³÷íå ñïîñòåðåæåííÿ äîêàçóº çíèêíåííÿ öèõ ïðîÿâ³â ç ÷àñîì 19. ijòè, ÿê³ ìàþòü ôàêòîðè ðèçèêó, àëå êë³í³÷íå îáñòåæåííÿ áåç â³äõèëåíü ïîâèíí³ ïðîõîäèòè ñîíîãðàô³÷íå îáñòåæåííÿ ó â³ö³ 4-6 òèæí³â. Íàâ³òü ïðè íàÿâíîñò³ ïàòîëîã³÷íèõ çì³í ðîçïî÷àòå ó öüîìó â³ö³ ë³êóâàííÿ ãàðàíòóº óñï³õ 1. Âíàñë³äîê îáìåæåííÿ ðåñóðñ³â òà ³íøèõ ôàêòîð³â óëüòðàñîíîãðàô³÷íèé ñêðèí³íã âñ³õ íîâîíàðîäæåíèõ âèçíàºòüñÿ íåäîö³ëüíèì. Òàáëèöÿ 1 Ôàêòîðè ðèçèêó ÄÊØ
ijâ÷àòêà ìàþòü á³ëüøó ÷àñòîòó ÄÊØ, í³æ õëîï÷èêè, àëå âëàñíå ñòàòü íå âèçíà÷åíà ÿê ôàêòîð ðèçèêó. Òàáëèöÿ 2 Àëãîðèòì ñêðèí³íãó ÄÊØ.
˳òåðàòóðà 1. Aronsson DD, Goldberg MJ, Kling TF, Roy DR. Developmental dysplasia of the hip. Pediatrics 1994; 94:201-208 2. Barlow TG. Early diagnosis and treatment of congenital dislocation of the hip. J Bone Joint Surg (Br) 1962; 44:292-301 3. Berman L, Klenerman L. Ultrasound screening for hip abnormalities: reliminary findings in 1001 neonates. BMJ 1986; 293:719-722 4. Boal DKV, Schwenrker EP. The infant hip: assessment with real-time ultrasound. Radiology 1985; 157:667-672 5. Bick U, Muller-Leisse C, Troger J. Ultrasonography of the hip of preterm neonates. Pediatr Radiol 1990; 20:331-333 6. Burke SW, Macey TI, Roberts JM, et al. Congenital dislocation of the hip in the American black. Clin Orthop 1985; 192:120-123 7. Clarke NMR, Harcke HT, McHugh P, Lee MS, at al. Real-time ultrasound in the diagnosis of congenital dislocation and dysplasia of the hip. J Bone Surg (Br) 1985; 67-B: 406-412 8. Chung SMK. Diseases of of the developing hip joint. Pediatr Clin North Am 1986; 33: 1457-1473 9. Dahlstrom H, Oberg L, Friberg S. Sonography in congenital dislocation of the hip. Acta Orthop Scand 1986; 57:402-406 10. Donaldson JS. Pediatric muskuloskeletal US. Syllabus: Acategorical course in diagnostic radiology. Pediatr Radiol 1989; 77-88 11. Engesaeter LB, Wilson DJ, Nag D, et al. Ultrasound and congenital dislocation of the hip: The importance of dynamic assessment. J Bone Joint Surg (Br) 1990; 72: 197-201 12. Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic compound treatment. Arch Orthop Trauma Surg 1980; 97:117-133 13. Graf R. The ultrasonic image of acetabular rim in infants. Arch Orthop Trauma Surg 1981; 99:35-41 14. Graf R. Sonographie der Sauglingshufte: ein Kompendium. 3rd. Enke, Stuttgart, 1989 pp 20,90-91,98-99 15. Harcke HT, Grissom LE. Sonographic Evaluation of the Infant Hip. Seminars in Ultrasound, CT and MRI 1986; 7: 331-338 16. Harcke HT, Grissom LE, Finkelstein MS. Evaluation of the Musculosceletal System with Sonography. AJR 1988; 150:1253-1261 17. Harcke HT, Grissom LE. Performing Dynamic Sonography of the Infant Hip. AJR 1990; 155:837-844. 18. Harcke HT. Screening Newborns for Developmental Dysplasia of the Hip: The Roule of Sonography. AJR 1994; 162: 395-397 19. Harcke HT. The role ou ultrasound in diagnosis and management of developmental dysplasia of the hip. Pediatr Radiol 1995; 25: 225-227 20. Hayden CK, Swischuk LE. Pediatric Ultrasonography. Williams & Wilkins, Baltimore, 2nd Ed., 1992, pp. 426- 429 21. Hensinger RN. Congenital dislocation of the hip: treatment in infancy to walking age. Orthop Clin North Am 1987; 18:597-616 22. Millis MB, Share JC. Use of Ultrasonography in Dysplasia of the Immature Hip. Clinical Orthopaedics and Related Research. 1992; 274: 160-170 23. Novick GS, Ghelman B, Schneider M. Sonography of neonatal and infant hip. AJR 1983; 141:639-645 24. Novic GS. Sonography in pediatric hip disorders. Radiol Clin North Am 1988; 26:29-53 25. Ortolani M. The classic: Congenital hip dysplasia in the light of early and very early diagnosis. Clin Orthop 1976; 119:6-10 26. Pratt WB, Freiberger RN, Arnold WD. Untreated congenital hip dysplasia in Navajo. Clin Orthop 1982; 162:69-7727. Renshaw TS. Pediatric Orthopedics. Philadelphia: WB Saunders, 1986 27. Renshaw TS. Pediatric Orthopedics. Philadelphia: WB Saunders, 1986 28. Rosendahl K, Aslaksen A, Lie RT, Markestad T. Reliability of ultrasound in the early diagnosis of developmental dysplasia of the hip. Pediatr Radiol 1995; 25:219-224 29. Saies AD, Foster BK, Lequesne GW. The value of a new ultrasound stress test in assessment and treatment of clinically detected hip instability. J Pediatr Orthop 1988; 8:436-441 30. Szoke N, Kuhl L, Heinrichs J. Ultrasound examination in the diagnosis of congenital hip dysplasia in newborns. J Pediatr Orthop 1988; 8:12-16 31. Teele RL, Share JC. Ultrasonography of infants and children. Philadelphia: WB Saunders,1991, pp. 123-136 32. Tonnis D, Storch K, Ulbrich H. Results of newborn screening for CDH with and without sonography and correlation of risk factors. J Pediatr Orthop 1990; 10:145-152 33. Yamamuro T, Ishida K. Recent advances in prevention, early diagnosis, and treatment of congenital dislocation of the hip in Japan. Clin Orthop 1984; 184:34-40 34. Zieger M, Hilpert S, Schulz RD. Ultrasound of the infant hip. Part 1. Basic principles. Pediatr Radiol 1986; 16: 483-487 35. Zieger M. Ultrasound of the infant hip. Part 2. Validity of the method. Pediatr Radiol 1986; 16: 488-492 36. Zieger M, Schulz RD. Ultrasound of the infant hip. Part 3:Clinical application. Pediatr Radiol 1987; 17: 226-232 37. Zieger M, Hilpert S. Ultrasound of the infant hip. Part 4: Normal development in the newborn and preterm neonate. Pediatr Radiol 1987 ; 17: 470-473 Страницы: 1, 2 |
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