【作者】 王亮；

【导师】 沈钧康；

【作者基本信息】 苏州大学 ， 影像医学与核医学， 2013， 硕士

【摘要】 第一部分DR对6个月以内婴幼儿发育性髋关节脱位三线比例与脱位类型关系的探讨目的：探讨数字化摄片（DR）婴幼儿发育性髋关节脱位（DDH）三线比例与脱位类型关系的诊断价值。材料和方法：选取我院放射科2009年6月至2012年5月间临床疑诊DDH婴幼儿146例，其中男26例，女120例，男女之比为1:4.6；月龄为0-6个月，平均月龄为3.9个月，其中0-2月33例，3-4月53例，5-6月60例；根据Campbell分类，将DDH分为髋关节发育不良、髋关节半脱位、髋关节全脱位三型，本组病例中正常髋关节36例，DDH110例，其中髋关节发育不良40例，髋关节半脱位43例，髋关节全脱位27例；146例中共有正常髋关节134个，脱位髋关节158个，其中发育不良髋57个，半脱位髋59个，全脱位髋42个。以股骨近端干骺端中点（o点）为起点，分别至髋臼外上缘点、Y型软骨中心点、髋臼下缘点作连线（a、b、c线），对此三线长度进行测量，并作统计学处理，探讨三线长度比例与髋关节脱位类型的相关性。结果：146例患儿的292个髋关节中，36例正常髋关节三线长度的两两比（a/b、a/c、b/c）为1，40例发育不良髋关节其比值大于1，43例半脱位髋关节及27例全脱位髋关节其比值均小于1。b/c值对诊断正常髋关节、髋关节发育不良、髋关节半脱位的敏感性（Se）、特异性（Sp）、尤登指数（YI）较低，而对诊断髋关节全脱位的Se、Sp、YI较高；a/b、a/c值对诊断DDH各脱位类型的Se、Sp、YI均较高。诊断髋关节发育不良，a/b≥1.08的Se、Sp、YI分别为0.917、0.921、0.838(x2=42.89, P=0.000），a/c≥1.05的Se、Sp、YI分别为0.875、0.789、0.644(x2=26.09, P=0.000)，二者间差异无显著统计学意义（x2=0.22, P=0.650），初步认为a/b≥1.08或a/c≥1.05可作为诊断髋关节发育不良的参考指标。诊断正常髋关节，0.98≤a/b≤1.07的Se、Sp、YI分别为0.826、0.923、0.749(x2=35.47, P=0.000)，0.96≤a/c≤1.04的Se、Sp、YI分别为0.869、0.974、0.843(x2=46.00, P=0.000)，二者间差异无显著统计学意义（x2=0.17, P=0.681），初步认为0.98≤a/b≤1.07或0.96≤a/c≤1.04是正常髋关节三线的比值范围。诊断髋关节半脱位，0.87≤a/b≤0.97的Se、Sp、YI分别为0.867、0.957、0.824(x2=42.11, P=0.000)，0.83≤a/c≤0.95的Se、Sp、YI分别为0.867、0.936、0.803(x2=38.28, P=0.000),二者间差异无显著统计学意义（x2=0.00, P=0.999），初步认为0.87≤a/b≤0.97或0.83≤a/c≤0.95可作为诊断髋关节半脱位的参考指标。诊断髋关节全脱位，0.57≤a/b≤0.86的Se、Sp、YI分别为0.889、0.968、0.857(x2=58.70, P=0.000)，0.50≤a/c≤0.82的Se、Sp、YI分别为0.833、0.968、0.801(x2=53.50, P=0.000),0.73≤b/c≤0.90的Se、Sp、YI分别为0.944、0.903、0.847(x2=48.93, P=0.000)，三者间差异无显著统计学意义（x2值分别为0.23、0.36、1.13，P值均大于校正后的检验水准0.017），初步认为此三个区间值均可作为诊断髋关节全脱位的参考指标。结论：应用DR对婴幼儿发育性髋关节脱位三线比例与脱位类型关系探讨为6个月以内患儿DDH早期诊断提供了客观参考依据。第二部分低场MRI在婴幼儿发育性髋关节脱位诊断中的应用目的：探讨低场MRI在婴幼儿发育性髋关节脱位（DDH）诊断中的应用价值。材料和方法：搜集我院2011年01月至2012年10月间经手术证实的DDH45例（病例组），选择同期无相关临床症状和体征的正常髋关节40例（对照组），共85例。所有85例患儿均作MRI检查，所获图像符合测量及观察标准。45例DDH患儿中，男7例，女38例，年龄5-36个月，平均月龄为16个月；其中双侧髋脱位28例，单侧髋脱位17例，左侧脱位髋41个，右侧脱位髋32个。40例正常髋关节中，男9例，女31例，年龄为5-36个月，平均月龄为14个月。根据Dunn标准将DDH分为三型（Ⅰ型、Ⅱ型、Ⅲ型）。在MRI冠状位T1WI图像上测量病例组与对照组髋关节的骨性髋臼指数（BAI）、软骨性髋臼指数（CAI），对测量结果进行统计学分析，比较两组间BAI和CAI的差异，并对病例组、对照组及病例组内各型（Ⅰ型、Ⅱ型、Ⅲ型）髋脱位BAI、CAI二者间进行线性相关分析；同时观察影响DDH复位的髋关节内及其周围组织的异常改变（关节软骨、盂唇、圆韧带、脂肪增生、关节积液、髂腰肌）。结果：对照组40例正常髋关节80个，病例组45例脱位髋关节73个，BAI分别为（26.13±2.19）°、（35.87±4.42）°，CAI分别为（13.84±1.07）°、（21.92±4.70）°；Ⅰ型脱位髋30个、Ⅱ型脱位髋20个、Ⅲ型脱位髋23个，BAI分别为（31.80±1.74）°、（37.80±3.40）°和（39.17±4.11）°；CAI分别为（17.20±2.68）°、（20.91±2.02）°和（27.50±2.78）°。BAI和CAI在对照组与病例组间的差异均具有显著统计学意义（t值分别为-11.048和-9.188，P值均为0.000）。BAI和CAI在病例组内各型（Ⅰ型、Ⅱ型和Ⅲ型）髋脱位间的差异均具有显著统计学意义（F值分别为22.159和47.241，P值均为0.000）。病例组、对照组及病例组内各型（Ⅰ型、Ⅱ型、Ⅲ型）髋脱位BAI与CAI二者间呈线性正相关（r值分别为0.964、0.844、0.953、0.931和0.870，P值均为0.000）。Ⅱ型和Ⅲ型脱位髋关节中观察到盂唇内翻，圆韧带粗大，髂腰肌挛缩，关节软骨增生，关节积液、脂肪增生等病理变化。结论：MRI可用于术前测量DDH BAI和CAI值，比较二者在对照组、病例组及病例组内各型（Ⅰ型、Ⅱ型、Ⅲ型）间的线性相关关系，清晰地显示关节内影响复位的因素，为诊断与治疗提供重要的参考依据。更多还原

【Abstract】 PartⅠThe value of digital radiography in relationshipbetween the proportion of three lines and the dislocationtypes of developmental dislocation of the hip in infantsObjective: To evaluate the value of digital radiography in relationship between theratio of three lines and the dislocation types of developmental dislocation of the hip (DDH)in infants.Materials and Methods: One hundred and forty six infants less than six months oldwith suspected diagnosis were retrospectively reviewed between June2009and May2012.There were26male and120female patients. Male to female ratio was1:4.6. The mean agewas3.9months, ranging from10days to6months, including33cases less than2months,53cases between3-4months,60cases between5-6months. DDH was classed into threetypes: dysplasia, subluxation, dislocation according to Campbell′s criteria. In our group,there were36normal cases and110abnormal cases, including dysplasia (40cases),subluxation (43cases), dislocation (27cases). Pelvic plain films were analyzed and threelines were measured from the midpoint of the femoral metaphysis to upper margin, lowermargin and Y-shaped cartilage center of the acetabulum respectively.Then the relationshipbetween the ratio of the three lines and dislocation types was investigated by Chi-squaretest.Results: One hundred and forty six infants (n=292hips）include normal hips (n=36cases)、dysplasia (n=40cases)、subluxation (n=43cases)、dislocation (n=27cases). Thevalue of a/b and a/c is1for normal hips, more than1for dysplasia, less than1for subluxation and dislocation. The sensitivity, specificity and Youden index of a/c value anda/b value were much higher than b/c value. The Se, Sp and YI of dysplasia were0.917,0.921and0.838(x2=42.89, P=0.000) when a/b≥1.08and0.875,0.789and0.644(x2=26.09,P=0.000) when a/c≥1.05, respectively. Both are found to be statistically insignificant(x2=0.22, P=0.650). We can consider them as the diagnosis indicators of dysplasia hipspreliminarily. The Se, Sp and YI of normal hips were0.826,0.923and0.749(x2=35.47,P=0.000) when0.98≤a/b≤1.07and0.869,0.974,0.843(x2=46.00, P=0.000) when0.96≤a/c≤1.04, respectively. Both are found to be statistically insignificant (x2=0.17,P=0.681). We can also consider them as the diagnosis indicators of nomal hipspreliminarily. The Se, Sp, YI of subluxation were0.867,0.957and0.824(x2=42.11,P=0.000) when0.87≤a/b≤0.97and0.867,0.936and0.803(x2=38.28, P=0.000) when0.83≤a/c≤0.95. Both are also found to be statistically insignificant (x2=0.00, P=0.999). Wecan consider them as the diagnosis indicators of subluxation hips preliminarily. The Se, Sp,YI of dislocation were0.889,0.968and0.857(x2=58.70, P=0.000) when0.57≤a/b≤0.86and0.833,0.968and0.801(x2=53.50, P=0.000) when0.50≤a/c≤0.82and0.944,0.903and0.847(x2=48.93, P=0.000) when0.73≤b/c≤0.90. Differences among the three are alsofound to be statistically insignificant (x2values were0.23,0.36and1.13respectively, P＞0.017). We can consider them as the diagnosis indicators of dislocation hips preliminarily.Conclusion: The research on digital radiography in relationship between theproportion of three lines and the dislocation types provides a new method for infants‘DDH,especially less than six months old. PartⅡ The preoperative study of MRI in the infantiledevelopmental dislocation of the hipObjective: To investigate the diagnostic value of the preoperative MRI in theinfantile developmental dislocation of the hip.Materials and Methods: Forty-five cases of preoperative hip MRI data of DDH(patient group) and40cases of normal hip (control group) MRI data were retrospectivelyanalyzed between January2011and October2012. There were7male and38femalepatients in45cases of DDH. The mean age was16months, ranging from5to36months.The left hip of DDH is41hips and the right is32hips. There were9male and31femalepatients in40cases of normal hips. The mean age was14months, ranging from5to36months. Three types were classified according to the standard of Dunn, then the bony andcartilaginous hip parameters of all hips, including the bony acetabular index (BAI),cartilaginous acetabular index (CAI), were measured in coronal MRI and all the intra-articular structures (articular cartilage, labrum, teres ligament and iliopsoas) in theacetabulum that impede the reduction of the femoral head can be observed.Results: For the normal hips (80hips), dislocated hips (73hips), the typeⅠhips (30hips), the typeⅡhips (20hips), the type Ⅲ hips (23hips), BAI was (26.13±2.19)°,(35.87±4.42)°,(31.80±1.74)°,(37.80±3.40)°and (39.17±4.11)°, respectively, CAI was(13.84±1.07)°,(21.92±4.70)°,(17.20±2.68)°,(20.91±2.02)°and (27.50±2.78)°, respectively.Differences of BAI and CAI among the normal hips, dislocated hips (t=-11.048and-9.188,P=0.000), the typeⅠhips, the typeⅡhips, the type Ⅲ hips (F=22.159and47.241,P=0.000) were found to be statistically significant. There was a linear correlation betweenBAI and CAI in the normal hips, dislocated hips, the typeⅠhips, the typeⅡhips, the typeⅢ hips (r=0.964,0.844,0.953,0.931and0.870, P=0.000). Some pathological changessuch as varus labrum, thick teres ligament, iliopsoas spasm, articular cartilage hyperplasia,fat hyperplasia, joint effusion can be observed between the typeⅡhips and Ⅲ hips. Conclution: The preoperative MRI is not only a very scientific imaging modality forassessment of the bony and cartilaginous structures, but also some factors hindering thereduction of the femoral head can be found clearly. It can provide an important referencebasis for the diagnosis and treatment of DDH.更多还原