13849731 OR On dysplasia and on therapy of congenital hip dislocations Dotaz Zobrazit nápovědu
Úvod: Na základě časné diagnostiky pomocí ultrazvukové metody je možné zahájit terapii vývojové dysplazie kyčelního kloubu brzy po narození. Cílem práce je zhodnocení úspěšnosti konzervativní terapie subluxace a luxace kyčelního kloubu pomocí distrakčního režimu. Materiál a metodika: V letech 2013-2016 bylo na naší klinice sonograficky vyšetřeno okolo 8000 novorozenců a kojenců. Pavlíkovy třmeny jsme indikovali u sonografického nálezu IIc za toto čtyřleté období u 92 kojenců. U decentrovaných kyčlí typu III a IV jsme indikovali distrakční režim. Na naší klinice používáme modifikaci Lloyd-Robertsovy trakce. V letech 2013-2016 bylo přijato na distrakční režim celkem 59 kojenců - 50 dívek a 9 chlapců. V 17 případech bylo postižení oboustranné. Celkem bylo léčeno 76 kyčelních kloubů. Padesát dva kyčlí bylo označeno dle Grafa jako typ III, z toho 30 typ IIIa, 22 typ IIIb. Dvacet čtyři kyčelních kloubů bylo dle Grafa verifikováno jako typ IV. Po šesti týdnech distrakčního režimu je výsledek konzervativní terapie verifikován artrografií. Průměrný věk dětí přijatých na distrakční režim byl 2,4 měsíce. Výsledky: U kyčlí klasifikovaných dle Grafa jako typ III, z toho 30 typ IIIa, 22 typ IIIb, jsme zaznamenali úspěšnost repozice distrakčním režimem ve všech případech, tj. ve 100 %. Dvacet čtyři kyčelních kloubů bylo dle Grafa verifikováno jako typ IV. Z těchto 24 luxací se distrakčním režimem zdařila konzervativní repozice v 15 případech, 9krát byla konzervativní terapie neúspěšná, což si vyžádalo následnou operační repozici (36 %). Diskuse: Časná repozice umožňuje normální vývoj kyčelního kloubu. Distrakční režim minimalizuje riziko poškození hlavice kyčelního kloubu, postupně uvolňuje kontrahované svaly a nenásilnou cestou umožňuje repozici kyčelního kloubu. Závěr: Distrakční režim je indikován pro léčení subluxovaných a luxovaných kyčlí klasifikovaných dle Grafa IIIa, IIIb a IV. Jedná se o metodu, která významně snižuje riziko avaskulární nekrózy.
Introduction: On the basis of early diagnosis using ultrasonography, it is possible to commence therapy for developmental dysplasia of the hip soon after birth. The objective of this study was to analyse the results of conservative therapy using closed reduction by traction in subluxated and dislocated hips. Material and Methods: In the period from 2013 to 2016, roughly 8,000 thousand neonates and infants were tested using ultrasonography at our department. We diagnosed Pavlik harness during this period in 92 infants. In the period from 2013 to 2016, a total of 59 children (76 hips) were treated by traction. The indication criteria included classes IIIa (30 hips) III b (22 hips) or IV (24 hips) according to the Graf ultrasonographical classification. There were 50 girls and 9 boys. The average age at the beginning of treatment was 2.4 months. Arthrography was indicated after six weeks of distraction therapy in all children. Results: The efficiency of closed reduction was 100% in the class III group (52 hips), and in the class IV group (15 hips). 9 hips were indicated for open reduction (36%). Discussion: Early reduction is very important for normal development of the hip joint. Traction therapy is the preferred method for minimising risks, with releasing the muscles and reducing damage to the femoral head. Conclusions: Traction therapy is indicated for the treatment of the subluxation and dislocation hip and classified as Graf IIIa, IIIb and IV. It is a method that significantly reduces the risk of avascular necrosis.
PURPOSE OF THE STUDY Developmental dysplasia of the hip (DDH) is a disorder affecting the development of the acetabulum, proximal femur and joint capsule. The objective of this study was to analyse the results of closed reduction by overhead traction in subluxated and dislocated hips. MATERIAL AND METHODS In the period from 2002 to 2007, a total of 109 patients (124 hips) were treated by overhead traction. The indication criteria included adductor contracture and misalignment of the hip joint assessed as classes III A, III B or IV according to the Graf ultrasonographic classification. There were 96 (88 %) girls and 13 (12 %) boys. The left side was more frequently affected, at a ratio of 83 to 41, and bilateral DDH was found in 15 patients. Teratologic dislocations were not included in the study. The patients were divided into two groups according to age and the place of primary diagnosis. The children primarily diagnosed at our hospital Na Bulovce where placed in group 1, the patients diagnosed outside our hospital fell in group 2. The average age at the beginning of treatment was 2.2 months in the first group and 6 months in the second group. Our method of overhead traction consists of two phases. Horizontal traction is applied for two weeks in phase 1; the hips are then flexed beyond 90 degrees and gradually abducted for another 4 weeks in phase 2. The outcome of traction is examined by arthrography and a spica cast is applied in the safe zone. We observed the relation between the Graf classification and arthrograpy The outcome of closed reduction was compared between the groups and the development of avascular necrosis was observed. The hips treated by open reduction were assessed in a different study. RESULTS The efficiency of closed reduction was 84 % in group 1 and 60 % in group 2 in which also two cases of recurrent dislocation were found. No significant differences between the Graf classification and the final arthrographic findings were recorded in either group (p>0.05). Avascular necrosis as defined by the Salter criteria was not diagnosed. DISCUSSION Early reduction is essential to ensure normal development of the hip joint. Overhead traction therapy for misalignment of the hip joint is a safe method reducing damage to the femoral head. Its principle lies in gradual distraction of the contracted muscles and joint capsule with a concomitant change in traction direction in order to achieve a reduction manoeuvre without placing increased stress on the femoral head. CONCLUSIONS Overhead traction is the method of choice for management of Graf's class III A, III B and IV hips. For the efficiency of treatment, an early diagnosis and a correct indication are essential. To avoid complications such as avascular necrosis, it is necessary to observe the principle of a safe zone.
Developmental dysplasia of the hip (DDH) is a serious anatomical abnormality. The aims of the study were to compare the current views on general screening for DDH and, in a group of patients diagnosed for DDH both clinically and ultrasonographically, to analyse the results of their treatment with Wagner stockings. MATERIAL AND METHODS: In the years 2000 to 2001, a total of 3,221 children were examined at birth clinically and by ultrasonography using Graf's method. DDH was diagnosed in 137, and Wagner stockings were used for treatment in 127 patients. This Wagner abduction device consists of linen stockings buttoned to a linen baby shirt. It is based on the Pavlik harness treatment of DDH, and enables us to start therapy at neonatal age. The group was followed up, with checkups including clinical examination and AP radiography to evaluate position of the femoral head in relation to avascular necrosis (AVN) by the Salter method. The data obtained was statistically analysed by the SPSS software, version 14 (SPSS Inc., Chicago, USA). RESULTS: Out of the 127 children, 106 (95 girls and 11 boys) completed the treatment. In 87 (82%) children with Wagner stockings only, the treatment took place for an average of 82 days (range, 28 to 167), with abduction therapy starting on average at 13 days (range, 1 to 76 days). In 19 (18%) children it was necessary to continue abduction therapy and Wagner stockings were replaced by a Pavlik's harness. The total abduction treatment then lasted on average for 152 days (range, 81 to 289). After January 1, 2005, 75 children (follow-up rate, 70.7%) were examined, 33 at regular checkups and the rest at invitation. The average follow-up was 5.9 (3.8-7.5) years. On two early radiograms with left-side findings, proximal femoral lesions met the Salter criteria of AVN diagnosis. The AVN rate was 2.6% or 1.8% when related to either the patients or the affected hips. At the latest follow-up even in these cases the radiographic findings were resolved. DISCUSSION: At present there is no consensus concerning either screening of newborns for DDH or its early therapy. In the Czech Republic the general screening known as three-step examination of infant hips attained a legal frame by the Regulation issued by the Ministry of Health in 1977 and its amendment in 1996. In Austria the general clinical and ultrasonographic screening is regarded as the gold standard. On the other hand, some official bodies such as the U.S. Preventive Services Task Force, American Academy of Pediatrics or Canadian Task Force do not recommend any general screening.The results of this retrospective study were compared with those of treatment with the Pavlik harness or Frejka pillow, which are both based on a passive mechanical mode of therapy. The comparison has shown that the treatment with Wagner stockings is highly effective and has a low AVN rate. CONCLUSION: This retrospective study has shown that, in DDH, therapy with Wagner stockings is sufficient to provide for physiological development of the hip, while the AVN rate is very low. Early diagnosis and treatment related to general screening are both beneficial. Based on these results we recommend Wagner stockings as a useful aid in the treatment which is initiated early in infancy and is in agreement with the Pavlik method of functional DDH therapy.
Pro arthrogryposis multiplex congenita jsou typické kongenitální kontraktury končetin s chybným vývojem svalů, které chybí nebo jsou atrofické. Jedná se o vzácné systémové onemocnění s frekvencí výskytu podle typu postižení 1 : 3000 až 1 : 10 000 živě narozených. Vrozené kontraktury jsou zařazeny do 3 skupin podle přidružených systémových anomálií. Nejčastěji se vyskytuje amyoplazie – klasická artrogrypóza a distální artrogrypóza, které patří do 1. skupiny. Distální artrogrypóza je charakterizovaná především kontrakturami periferie – rukou a nohou, někdy kolenních kloubů a rozlišuje se 6 typů podle klinického nálezu. Autozomálně dominantní dědičnost byla prokázána především u distální artrogrypózy typu I. Amyoplazie se od spinálních degenerativních onemocnění odlišuje 3 znaky: 1. neprogreduje po narození, 2. čití není porušeno, 3. inteligence je normální. Závažnost neurogenního nebo myogenního postižení je verifikována elektromyografickým vyšetřením. V léčení pacientů s artrogrypózou sledujeme dva základní cíle – snahu o dosažení chůze a dosažení jisté sebeobsluhy v rámci denních aktivit. Operační léčení kontraktur dolních končetin je indikováno již v 1. roce života – repozice luxace kyčelního kloubu, řešení flekčních kontraktur kolenního kloubu, subluxace nebo luxace kolenního kloubu, rigidního pes equinovarus nebo eventuálně vertikálního talu. Operační léčení kontraktur horních končetin je indikováno okolo 4. roku věku, kdy je dítě již schopno jisté spolupráce. Prvním cílem je dosažení pasivní flexe loketního kloubu při extenčních kontrakturách. Aktivní flexi je možné u některých pacientů zlepšit pomocí svalových transpozic. Výsledek terapie závisí na závažnosti vrozených kontraktur, na včasnosti a komplexnosti terapie, na čemž spolupracuje ortoped, fyzioterapeut a při výskytu přidružených vrozených vad i další odborníci. Dobře spolupracující rodiče jsou jednou z hlavních podmínek úspěšnosti terapie.
Arthrogryposis multiplex congenita is a disease involving multiple joint contractures with deficient musculature. Arthrogryposis is a rare disorder that occurs in about 1 in 3000 to 1 in 10000 live births. Congenital contractures are divided into three groups according to associated system anomalies. The most common type of arthrogryposis (group 1) is termed amyoplasia or classic arthrogryposis. Distal arthrogryposis is characterized by restriction of motion of the distal joints of the hand, feet and sometimes the knees and has been classified into six types. Autosomal dominant transmission has been noted especially in type I distal arthrogryposis. Amyoplasia differs from spinal degenerative diseases by 3 symptoms: 1. it does not deteriorate after the birth, 2 sensation is not affected, 3 intelligence is normal. The severity of the neurogenic or myogenic disability is determined by electromyography examination. In most patients with arthrogryposis the two major goals of treatment are independent ambulation and independent function of the upper extremities for activities of daily living. The surgical treatment of contractures of the lower extremities is indicated in the first year of life – reduction of dislocated hips, flexion contractures of the knee, hyperextension and dislocation of the knee, rigid equinovarus deformity or talus verticalis. The surgical treatment of contractures of the upper extremities is indicated around four years of life – the first goal is to achieve passive elbow flexion. Procedures to achieve active elbow flexion – muscles transfer may be indicated. The result of the therapy depends on the severity congenital contractures, timeliness and comprehensiveness therapy, which involved an orthopaedic surgeon, a physical therapist. In the presence of other associated congenital defects also by other specialists. Adequate involvement of parents is a necessary condition for a successful treatment.
- MeSH
- artrogrypóza * diagnóza etiologie klasifikace patofyziologie terapie MeSH
- dítě MeSH
- kojenec MeSH
- kolenní kloub chirurgie patofyziologie MeSH
- kontraktura chirurgie terapie MeSH
- kyčelní kloub chirurgie patofyziologie MeSH
- lidé MeSH
- loketní kloub chirurgie MeSH
- luxace kolena chirurgie vrozené MeSH
- novorozenec MeSH
- ortopedické výkony * metody MeSH
- pes equinovarus chirurgie MeSH
- ramenní kloub chirurgie MeSH
- sádrové obvazy MeSH
- vývojová kyčelní dysplazie chirurgie MeSH
- zápěstí chirurgie MeSH
- Check Tag
- dítě MeSH
- kojenec MeSH
- lidé MeSH
- novorozenec MeSH
- Publikační typ
- přehledy MeSH
