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Дисплазия тазобедренных суставов новорожденных




Óëüòðàñîíîãðàô³ÿ â ä³àãíîñòèö³ äèñïëà糿 êóëüøîâèõ ñóãëîá³â íîâîíàðîäæåíèõ òà ä³òåé ðàííüîãî â³êó

Îãëÿä çàðóá³æíî¿ ë³òåðàòóðè

Â.². Æåëüîâ

Äèñïëàç³ÿ êóëüøîâèõ ñóãëîá³â (ÄÊÑ), çãàäêè ïðî ÿêó çíàéäåí³ ùå â ïðàöÿõ óïîêðàòó äî òåïåð³øåüîãî ÷àñó çàëèøàºòüñÿ ïðîáëåìîþ äëÿ êë³í³öèñò³â. Íåçâàæàþ÷è íà òå, ùî öÿ ïàòîëîã³ÿ ìຠâ³äíîñíî ñòàëó ÷àñòîòó, íåñâîº÷àñíà ä³àãíîñòèêà òà íåàäåêâàòíå ë³êóâàííÿ ìîæóòü ïðèâåñòè äî ñåðéîçíèõ ïðîáëåì êóëüøîâèõ ñóãëîá³â íà ïðîòÿç³ æèòòÿ 2,2,20,26,27,34.

Âðîäæåíà ÄÊÑ ïîºäíóº øèðîêèé ä³àïàçîí ïàòîëîã³÷íèõ ïðîÿâ³â â³ä íåçíà÷íî¿ äåôîðìàö³¿ âëàñíå àöåòàáóëþìó, íåñòàá³ëüíîñò³ ïðàâèëüíî ïîç³ö³îíîâàíèõ ñóãëîá³â äî âèðàæåíèõ ï³äçâèâèõ³â òà çâèâèõ³â. ²ñíóº äåÿêà ð³çíèöÿ ì³æ òåðì³íîëî㳺þ íàö³îíàëüíèìè êëàñèô³êàö³ÿìè ÄÊÑ, òàê ó ÑØÀ ç 1994 ðîêó çàì³ñòü âðîäæåíîãî çâèâèõó êóëüøîâèõ ñóãëîá³â âæèâàºòüñÿ òåðì³í äåâåëîïìåíòàëüíà äèñïëàç³ÿ 1 .

Ñåðåä îñíîâíèõ ôàêòîð³â ðèçèêó âèíèêíåííÿ ÄÊÑ â³äì³÷àþòü ñ³ìåéíó (ãåíåòè÷íî äåòåðì³íîâàíó) ñõèëüí³ñòü; íåäîñòàòí³é ðîçâèòîê (ñïëîùåííÿ) àöåòàáóëþì³â; ñëàáê³ñòü çâ’ÿçîê òà îòî÷óþ÷èõ ñóãëîá ì’ÿç³â; íåíîðìàëüíó ïîçèö³þ ïëîäó in utero; òåðàòîãåíí³ ôàêòîðè; ï³äâèùåííÿ êîíöåíòðàö³¿ ìàòåðèíñüêèõ åñòðîãåí³â 20,31.

Ïðè ñ³äíè÷íèìó ïðåäëåæàíí³ ïëîäó ÄÊÑ çóñòð³÷àºòüñÿ ó 17% âèïàäê³â, ñï³ââ³äíîøåííÿ ê³ëüêîñò³ ä³â÷àòîê äî õëîï÷èê³â ñÿãຠ6 : 1. 7% ä³â÷àòîê, íàðîäæåíèõ ñ³äíè÷êàìè ìàþòü âèðàæåíó íåñòàá³ëüí³ñòü ÊÑ, ïåðåâàæíî á³ëàòåðàëüíó.  ö³ëîìó â³äì³÷àºòüñÿ ïåðåâàãà á³ëàòåðàëüíèõ ÄÊÑ íàä óí³ëàòåðàëüíèìè. Á³ëüøèé ðèçèê ìàþòü ä³òè â³ä ïåðøèõ ïîëîã³â³. Ñåðåä ä³òåé, íàðîäæåíèõ âçèìêó ÄÊÑ òðàïëÿºòüñÿ ó 5 ðàç³â ÷àñò³øå, í³æ âë³òêó 27.

Ïîì³òí³ ðàñîâî-åòí³÷í³ ôàêòîðè, òàê ÷àñòîòà ÄÊÑ á³ëüøà ñåðåä íàðîä³â Ñêàíäèíà⳿ (äî 4%) 9, ó Ãåðìàí³¿ - äî 2% 34. Ó ÑØÀ ñåðåä á³ëîãî íàñåëåííÿ âèùà í³æ ñåðåä ä³òåé àôðèêàíñüêîãî ïîõîäæåííÿ ³ ñÿãຠ1-2% 6.

²ñíóº çâ’ÿçîê ÷àñòîòè ÄÊÑ ç ñïîñîáîì ïåëåíàííÿ íîâîíàðîäæåíèõ. Ó ³íä³àíö³â ïëåìåí³ Íàâàõî, ÿê³ òðàäèö³éíî âèêîðèñòîâóþòü òóãå ïåëåíàííÿ òà äåðåâ’ÿí³ ò³ñí³ êîëèñêè ÷àñòîòà ÄÊÑ äîõîäèòü äî 6% 26.  ßïîí³¿ â³äìîâà â³ä òðàäèö³éíîãî ñïîñîáó ïåëåíàííÿ çàâäÿêè ïðîïàãàíä³ ²íñòèòóòó Íàö³îíàëüíîãî Çäîðîâ’ÿ çà îñòàíí³ ðîêè çíèçèëà ÷àñòîòó ÄÊÑ ç 3.5% äî 0.2% 33.

Âíàñë³äîê ðîçâèòêó êë³í³÷íî¿ ä³àãíîñòèêè ÄÊÑ ñôîðìóâàëèñü ÷³òê³ êðèòå𳿠ô³ç³êàëüíîãî ñêðèí³íãó ïðîÿâ³â ÄÊÑ, ÿê àñèìåòðè÷íå âêîðî÷åííÿ íèæíüî¿ ê³íö³âêè, îáìåæåííÿ ðîçâåäåííÿ ñòåãîí ïðè ôëåêñ³¿ ó êîë³ííîìó ñóãëîá³, òåñò Barlow 2 (çì³ùåííÿ ãîë³âêè ñòåãíîâî¿ ê³ñòêè äîçàäó ïðè íàòèñíåíí³ âçäîâæ îñ³ ñòåãíà ïðè ôëåêñ³¿ 90o ó êîë³ííîìó ñóãëîá³ òà ïðèâåäåíí³ ñòåãíà ), òåñò Ortolani 25 - çì³ùåííÿ çâèõíóòî¿ ãîë³âêè ñòåãíà äîïåðåäó ïðè òðàêö³¿ ôëåêñîâàíî¿ í³æêè), âòðàòà ô³ç³îëîã³÷íî¿ ïîì³ðíî âèðàæåíî¿ (â³ä 20 äî 40o) àääóêö³éíî¿ êîíòðàêòóðè 27. ²íø³ îçíàêè, ÿê àñèìåòð³ÿ ñêëàäîê ñòåãíà òà ñ-ì ëóñêîòó ïðè ðîçâåäåíí³ ñòåãîí ââàæàþòüñÿ íåäîñòàòíüî ñïåöèô³÷íèìè 21. Àñèìåòð³ÿ øê³ðíèõ ñêëàäîê çóñòð³÷àºòüñÿ â íîðì³ äî 30% íîâîíàðîäæåíèõ 21,27. Ñ-ì ëóñêîòó â á³ëüøîñò³ âèïàäê³â âèíèêຠâíàñë³äîê ïåðåêèäàííÿ øèðîêî¿ ôàñö³¿ ñòåãíà ÷åðåç âåëèêèé òðîõàíòåð àáî ïîïåðåêîâî¿ ôàñö³¿ ÷åðåç êàïñóëó êóëüøîâîãî ñóãëîáó ³ òàêîæ íå º ñïåöèô³÷íèì äëÿ ÄÊÑ 8.

Îñíîâí³ êë³í³êî-åò³îëîã³÷í³ êëàñèô³êàö³¿ ÄÊÑ âèä³ëÿþòü òðè òèïè 1,2,7,8.21,25,31 :

1- òåðàòîãåíí³ çâèâèõè, ÿê ïðàâèëî, ñôîðìîâàí³ in utero;

2- íåñòàá³ëüí³ñòü êóëüøîâèõ ñóãëîá³â - ïðè íîðìàëüíî ðîçâèíóòèõ àöåòàáóëþìàõ â³äì³÷àºòüñÿ ëåãêå çì³ùóâàííÿ ãîë³âîê (ïîçèòèâíèé êë³í³÷íèé òåñò Áàðëîëó) âíàñë³äîê ñëàáêîñò³ (íåäîðîçâèíåíîñò³) çâÿçîê ñóãëîáó;

3- çì³ùåííÿ ãîë³âîê , ìîðôîëîã³÷íî - ñïëîùåííÿ àöåòàáóëþì³â, êë³í³÷íî- íåñòàá³ëüí³ñòü ñóãëîá³â â³ä íåçíà÷íèõ ï³äâèâèõ³â äî âèðàæåíèõ çâèâèõ³â.

Äî ê³íöÿ 70-õ ðîê³â îñíîâíèì ðàä³îëîã³÷íèì ìåòîäîì ä³àãíîñòèêè ÄÊÑ ÿâëÿëàñü ðåíòãåíîãðàô³ÿ òàçó ó ïåðåäíüî-çàäí³é ïðîåêö³¿. Àëå êð³ì åêñïîçèö³¿ ³îí³çóþ÷îãî âèïðîì³íþâàííÿ, ðåíòãåíîãðàô³ÿ ó ä³òåé äî 3 ì³ñÿö³â ìàëîôåêòèâíà, âíàñë³äîê íåäîñòàòíüî¿ â³çóàë³çàö³¿ õðÿùåâèõ ñòðóêòóð, íåìîæëèâîñò³ ïðîâåäåííÿ äèíàì³÷íîãî äîñë³äæåííÿ 2,22,24,36. ³äì³÷åíà íèçüêà åôåêòèâí³ñòü ðåíòãåíîãðàô³¿ ÊÑ â ä³àãíîñòèö³ äèñïëàç³é áåç çì³ùåííÿ òà íåñòàá³ëüíîñò³ ÊÑ 10.

Óëüòðàñîíîãðàô³ÿ, ÿêà íå ìຠòàêî¿ äîâãî¿ ³ñòî𳿠âèêîðèñòàííÿ â îðòîïå䳿, ÿê íàïðèêëàä â ãàñòðîåíòåðîëî㳿 ÷è íåôðîëî㳿 ³ç-çà ñïåöèô³êè ñëàáêî¿ ïåíåòðàö³¿ óëüòðàçâóêîì ê³ñòêîâî¿ òêàíèíè, äຠçìîãó äåòàëüíî âåðèô³êóâàòè ã³äðîô³ëüí³ ñòðóêòóðè, íàïðèêëàä ì’ÿçè, çâ’ÿçêè, õðÿù³ òà ³í. Îñòàíí³é àñïåêò äóæå âàæëèâèé ïðè äîñë³äæåíí³ íîâîíàðîäæåíèõ ä³òåé, ó ÿêèõ ó êóëüøîâèõ ñóãëîáàõ ïåðåâàæຠõðÿùîâà òêàíèíà. Çà 15 ðîê³â ç ìîìåíòó ïåðøèõ ñïðîá âèêîðèñòàííÿ óëüòðàñîíîãðàô³¿ â ä³àãíîñòèö³ ÊÑ öåé ìåòîä íå ìຠñîá³ ð³âíèõ ó ÷óòëèâîñò³ òà ñïåöèô³÷íîñò³ ðàííüî¿ ä³àãíîñòèêè ÄÊÑ 3,7,9,19,28,30.

ϳîíåðîì ÓÑ â ä³àãíîñòèö³ ÄÊÑ ïî ïðàâó ââàæàºòüñÿ àâñòð³éñüêèé îðòîïåä Graf, ÿêèé âïåðøå çàïðîïîíóâàâ ó 1980 ð. âëàñíó îðèã³íàëüíó ìåòîäó ä³àãíîñòèêè ÄÊÑ ç âèêîðèñòàíÿì Â-ñòàòè÷íîãî ñêàíåðó 12, îñíîâó ÿêî¿ ñêëàäàþòü äîñë³äæåííÿ ñóãëîá³â ó êîðîíàðí³é ïðîåêö³¿, âåðèô³êàö³þ îñíîâíèõ àíòîì³÷íèõ ñòðóêòóð 13, òà ìîðôîìåòð³þ çà äîïîìîãîþ ñòàíäàðòíèõ ë³í³é, ïðîâåäåíèõ ÷åðåç îñíîâí³ îð³ºíòèðè, òà âèì³ð³â êóò³â ì³æ íèìè. Ïðîåêö³ÿ çð³ç³â ôàêòè÷íî àíàëîã³÷íà ïðîåêö³¿ ïåðåäíüî-çàäíüî¿ ðåíòãåíîãðàìè. Äàò÷èê ðîçòàøîâàíèé âåðòèêàëüíî, ïàðàëåëüíî îñ³ ò³ëà, íîãè ïðèâåäåí³, â³ëüí³, ÷è íåçíà÷íî ç³ãíóò³ â êîë³ííèõ ñóãëîáàõ. Äèòèíà ëåæèòü íà êîíòðëàòåðàëüíîìó áîö³. Òàê ÿê ³ ðåíòðåíîãðàô³ÿ, öÿ ìåòîäà º ìîðôîìåòðè÷íîþ, äîçâîëÿº îö³íèòè ðîçòàøóâàííÿ ãîë³âêè òà àöåòàáóëþìó ëèøå â îäí³é ïðîåêö³¿. Çàïðîïîíîâàíà Graf êëàñèô³êàö³ÿ ÄÊÑ áàçóºòüñÿ íà âåëè÷èíàõ êóò³â ì³æ áàçîâèìè ë³í³ÿìè (ò. çâ. êóòè a òà b ) ³ âêëþ÷ຠ4 îñíîâí³ òèïè 14:

Òèï I - íîðìàëüíî ðîçâèíåí³ ñóãëîáè

Òèï II - äèñïëàç³ÿ áåç çì³ùåííÿ

Òèï III - âèðàæåíà äèñïëàç³ÿ, ï³äçâèâèõ

Òèï IV - ïîâíèé çâèâèõ.

Íåäîë³êàìè ìåòîäè º äîñèòü âèðàæåíà ñóá’ºêòèâí³ñòü ó âèáîð³ ñòàíäàðòíîãî çð³çó, ïðîâåäåííÿ áàçîâèõ ë³í³é ÷åðåç àíàòîì³÷í³ îð³ºíòèðè òà âèì³ðè êóò³â ì³æ íèìè. Òàêîæ â³äñóòíÿ ìîæëèâ³ñòü ïðîâåäåííÿ ôóíêö³îíàëüíèõ ïðîá. Õî÷à ï³çí³øå Graf 14, Rosendahl et al. 28 çàïðîïîíîâàíî ïðîâîêàö³éíèé òåñò - ïîì³ðíó òðàêö³ÿ ê³íö³âêè äîíèçó, àëå àâòîðè íå ïîäàþòü äàíèõ ïðî éîãî ³íôîðìàòèâí³ñòü. Äîñë³äæåííÿ äîñòîâ³ðíîñò³ ö³º¿ ìåòîäè ïîêàçàëè â³äíîñíî âåëèêèé, àëå äàëåêî íå àáñîëþòíèé ïðîöåíò ñï³âïàä³íü - 69% ïðè àíàë³ç³ ñîíîãðàì äâîìà íåçàëåæíèìè ðàä³îëîãàìè 4,28.

Ç ïîÿâîþ ñêàíåíð³â ðåàëüíîãî ÷àñó ìîðôîìåòðè÷íèé ìåòîä Graf íàáóâ øèðîêîãî ðîçïîâñþäæåííÿ, îñîáëèâî ó êðà¿íàõ ªâðîïè ïðè ïðîâåäåíí³ ñêðèí³íãó ÄÊÑ, áóâ äîïîâíåíèé òà ìîäèô³êîâàíèé 34,35. Ïåðåâàæíî âèêîðèñòîâóâàëèñü ë³í³éí³ äàò÷èêè ç ÷àñòîòíèì ä³àïàçîíîì 3.5 - 7 Ìãö â çàëåæíîñò³ â³ä â³êó äèòèíè.

²íø³ àâòîðè íàìàãàëèñü ðîçøèðèòè ìîæëèâîñò³ äîñë³äæåííü çà ðàõóíîê âèêîðèñòàííÿ ïîë³ïîçèö³éíèõ çð³ç³â 4,9,23. Harcke ç ñîàâò.7 çàïðîïîíóâàëè äèíàì³÷íó óëüòðîñîíîãðàô³ÿ êóëüøîâèõ ñóãëîá³â - ïîºäíàííÿ ïîë³ïîçèö³éíî¿ ñîíîãðàô³¿ ç ïðîâåäåííÿì ôóíêö³îíàëüíèõ òåñò³â ñòàá³ëüíîñò³ ñóãëîá³â, ïîä³áíî äî êë³í³÷íèõ òåñò³â Ortolani òà Barlow, ÿê³ âèçíà÷àëè áàçèñ êë³í³÷íèõ êëàñèô³êàö³é ÄÊÑ 17,29. Êëþ÷îâ³ ìîìåíòè ìåòîäó - îö³íêà ðîçòàøóâàòòÿ òà ñòàá³ëüíîñò³ ãîë³âêè ñòåãíîâî¿ ê³ñòêè 15.

Îñíîâè äèíàì³÷íî¿ óëüòðàñîíîãðàô³¿ ÊÑ:

  • îö³íêà ðîçòàøóâàííÿ ãîë³âêè ñòåãíà â àöåòàáóëþì³ â ïîë³ïîçèö³éíèõ çð³çàõ - íà íåéòðàëüíîìó êîðîíàðíîìó, íåéòðàëüíîìó ïîïåðå÷íîìó, ôëåêñ³éíîìó ïîïåðå÷íîìó òà êîðîíàðíîìó çð³çàõ - ÿê íîðìàëüíå ïîç³ö³îíóâàííÿ, ï³äçâèâèõ ÷è çâèâèõ;

  • îö³íêà ñòàá³ëüíîñò³ ñóãëîáó ïðè ïðîâåäåí³ òåñò³â Ortolani òà Barlow ïðè ôëåêñ³éíèõ ïîïåðå÷íèõ òà êîðîíàðíèõ çð³çàõ - ÿê íîðìàëüíå, íåñòàá³ëüíå, ï³äçâèâèõ, âïðàâèìèé òà 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 ðîö³19, 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 ã³ïåðòåðàﳿ18,31. 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

Çì³íè, âèÿâëåí³ ïðè êë³í³÷íîìó îáñòåæåíí³

Íåñòàá³ëüí³ñòü

Ñ-ì ëóñêîòó

Îáìåæåííÿ ðîçâåäåííÿ

ѳìåéí³ âèïàäêè ÄÊØ

ѳäíè÷íå ïðåäëåæàííÿ ïðè íàðîäæåíí³

Âàã³íàëüí³ ïîëîãè

Êåñàð³â ðîçòèí

Äåôîðìàö³¿ ïîëîæåííÿ ( ñêëàäêè)

Êðèâîøèÿ

Äåôîðìàö³¿ ñòîï

²íø³

Äåôîðìàö³¿ êóïðèêà

Ãåíåòè÷í³ çàõâîðþâàííÿ òà ñ-ìè

ijâ÷àòêà ìàþòü á³ëüøó ÷àñòîòó ÄÊØ, í³æ õëîï÷èêè, àëå âëàñíå ñòàòü íå âèçíà÷åíà ÿê ôàêòîð ðèçèêó.

Òàáëèöÿ 2 Àëãîðèòì ñêðèí³íãó ÄÊØ.

Êë³í³÷íå îáñòåæåííÿ íîâîíàðîäæåíîãî


Áåç â³äõèëåíü

Âèÿâëåí³ â³äõèëåííÿ


Ôàêòîðè ðèçèêó â³äñóòí³

ª ôàêòîðè ðèçèêó

Ñòàá³ëüíèé ñ-ì ëóñêîòó

Íåñòàá³ëüíèé ñóãëîá


Ñîíîãðàô³ÿ íå ïîêàçàíà

Ñîíîãðàô³ÿ ó 4-6 òèæí³â

Ñîíîãðàô³ÿ ó 4-6 òèæí³â

Ñîíîãðàô³ÿ ó 2 òèæí³

˳òåðàòóðà

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