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Лекция: 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
ìàº
â³äíîñíî
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
êðèòåð³¿
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
âèíèêàº
âíàñë³äîê
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 ìàº
òàêî¿
äîâãî¿
³ñòîð³¿
âèêîðèñòàííÿ
â îðòîïå䳿,
ÿê íàïðèêëàä
â
ãàñòðîåíòåðîëî㳿
֏
íåôðîëî㳿
³ç-çà
ñïåöèô³êè
ñëàáêî¿
ïåíåòðàö³¿
óëüòðàçâóêîì
ê³ñòêîâî¿
òêàíèíè, äàº
çìîãó
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
ïåðåâàæàº
õðÿùîâà
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. Â
¿õ îñíîâ³
ëåæèòü
âèçíà÷åííÿ
âçàºìîðîçòàøóâàííÿ
ñòðóêòóð
êóëüøîâãî
ñóãëîáó. Òàê
ìåòîä Graf íå
ìàº
ôóíêö³îíàëüíèõ
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
òåðèòîð³¿
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
֏
çâèâèõàìè
ìîæóòü
ñàìîñò³éíî
ñêîðèãóâàòèñü
ï³ä ÷àñ
ïåðøîãî
ì³ñÿöÿ æèòòÿ
áåç
ë³êóâàííÿ 2
. Ñêðèí³íã,
ïðîâåäåíèé
ï³ñëÿ
íåîíàòàëüíîãî
ïåð³îäó äàº
çìîãó
âèêëþ÷èòè
ôàëüñ-ïîçèòèâí³
âèïàäêè àëå
íå âèêëþ÷àº
ïîìèëîê 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 â³äõèëåíüÂèÿâëåí³ â³äõèëåííÿ

Ôàêòîðè ðèçèêó â³äñóòí³ª ôàêòîðè ðèçèêóÑòàá³ëüíèé ñ-ì ëóñêîòóÍåñòàá³ëüíèé ñóãëîá
Ñîíîãðàô³ÿ íå ïîêàçàíàÑîíîãðàô³ÿ ó 4-6 òèæí³âÑîíîãðàô³ÿ ó 4-6 òèæí³âÑîíîãðàô³ÿ ó 2 òèæí³
˳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