Li Yiqiang,Liu Hang,Guo Yueming,et al.Prediction model of final outcomes in children with developmental dysplasia of the hip treated by closed reduction[J].Journal of Clinical Pediatric Surgery,2024,(06):509-520.[doi:10.3760/cma.j.cn101785-202404061-003]
儿童发育性髋关节发育不良闭合复位术后结局预测模型的构建
- Title:
- Prediction model of final outcomes in children with developmental dysplasia of the hip treated by closed reduction
- Keywords:
- Developmental Dysplasia of the Hip; Closed Reduction; Treatment Outcome; Residual Acetabulalr Dysplasia; Osteotomy; Pelvis; Prediction Model
- 摘要:
- 目的 建立儿童发育性髋关节发育不良(developmental dysplasia of the hip,DDH)闭合复位术后结局预测模型,并利用该模型指导DDH闭合复位术后残余髋臼发育不良(residual acetabulalr dysplasia,RAD)手术时机的选择。 方法 回顾性分析国内多个医疗中心2004-2015年采用闭合复位术治疗的449例(522髋)DDH患儿临床资料,患儿年龄(16.3±5.1)个月。术前在骨盆正位X线片上评估脱位程度的国际髋关节发育不良协会(International Hip Dysplasia Institute,IHDI)分型、股骨头骨化核以及髋臼指数(acetabular index,AI)。术后测量第1、2、3、4年及末次随访时的AI、中心边缘角(centre-edge angle of Wiberg,CEA)和Reimer指数(Reimer’s index,RI),评估股骨头缺血性坏死(avascular necrosis of the femoral head,AVN)情况。根据末次随访时Severin影像学评级以及是否接受二期骨盆截骨术,将患儿分成两组:Severin Ⅰ、Ⅱ级为痊愈组,Severin Ⅲ、Ⅳ级或接受了骨盆截骨术者为RAD组。利用Cox回归构建DDH闭合复位术后痊愈预测模型,并用受试者操作特征(receiver operating characteristic,ROC)曲线进行内部验证。 结果 522髋中,IHDI分型为Ⅱ型70髋(13.4%),Ⅲ型223髋(44.6%),Ⅳ型219髋(42%)。复位前410髋(78.5%)已出现股骨头骨化核。总体AVN(Ⅱ型以上)发生率为12.8%。痊愈组329髋(63%),痊愈时间(33.3±14.7)个月(8.4~111.4个月),93.6%(308/329)的痊愈患儿痊愈时间在术后5年以内。Cox回归分析显示,IHDI分型、股骨头骨化核、复位年龄、当前AI、CEA、RI、AVN是DDH闭合复位术后累积痊愈概率的影响因素,利用上述影响因素,本研究成功构建了DDH闭合复位术后痊愈预测模型。该模型中所有因素的总分为-11~17分,对应痊愈概率为0.02~1.0。在该模型下,ROC曲线分析显示,术后第1、2、3、4年总分小于2.5、1.5、2.5、1.5分时,患儿痊愈概率显著较高(81.4%~96.1%),ROC曲线下面积为0.808~0.910,Kappa系数为0.497~0.618。相反,当总分大于1.5~2.5分时,RAD发生率显著升高,建议行骨盆截骨术。 结论 本研究构建的痊愈预测模型可以有效预测RAD,并指导骨盆截骨手术时机的选择。在该模型下,如果术后第1、2、3、4年时模型中所有因素总分大于2.5、1.5、2.5、1.5分,则RAD发生率显著升高。
- Abstract:
- Objective To establish a prediction model for residual acetabular dysplasia (RAD) following closed reduction in developmental dysplasia of the hip (DDH),so as to guide the selection of timing for secondary pelvic osteotomy.Methods A retrospective analysis was performed on 449 patients (522 hips,mean age: 16.3±5.1 months) with DDH treated by closed reduction from 2004 to 2015.On pelvic radiograph,the degree of dislocation according to International Hip Dysplasia Institute (IHDI) classification and the appearance of ossified nuclei were evaluated prior to reduction,and acetabular index (AI),Centre-edge angle of Wiberg (CEA) and Reimer index (RI) were measured at the time of 1,2,3,4 years postoperation.and final follow up visit.Avascular necrosis of the femoral head (AVN) was also assessed.Patients were divided into two groups according to Severin’s grade at last follow-up and whether they underwent secondary pelvic osteotomy: those with Severin Ⅰ/Ⅱ hips were classied into the recovered group and those with Severin Ⅲ/Ⅳ hips or already having undergone pelvic osteotomy were classified into the RAD group.Cox regression was used to establish a predictive model for recovery of the hip after closed reduction,and the receiver operating characteristic curve (ROC) analysis was used to verify the established model.Results Of these 522 hips,70 hips (13.4%) were IHDI type Ⅱ,223 (44.6%) were type Ⅲ and 219 (42%) were type IV.Prior to reduction,the ossified nuclei of the femoral head appeared in 410 hips (78.5%).The overall incidence of AVN was 12.8%.There were 329 hips (63%) involved in recovered group.Of these 329 hips,the mean recovery time was 33.3±14.7 months,and 93.6% of these patients recovered within 5 years after surgery.Cox regression analysis showed that IHDI classification,ossification nucleus of the femoral head,age of reduction,and current AI,CEA,RI and AVN were factors affecting the cumulative probability of recovery after closed reduction of DDH.Based on Cox regression analysis,this study successfully constructed a predictive model for recovery after closed reduction.The total scores of this model ranged from -11 to 17,with corresponding cumulative probability of recovery ranged from 0.02 to 1.0.Under this model,if the total score was less than or equal to 2.5,1.5,2.5,or 1.5 points at 1,2,3,and 4 years after CR,respectively,the patient had a significantly higher rate of recovery (81.4%-96.1%),the area under the curve of ROC was 0.808 to 0.910,and the Kappa coefficient was 0.497 to 0.618.On the other hand,if the total score was larger than 1.5-2.5,the risk of RAD significantly increased,and pelvic osteotomy was recommended under this condition.Conclusions The model established in this study can be effectively used to predict the development of RAD,so as to guide the timing of pelvic osteotomy.Under this model,the child is very likely to develop RAD if the total score is greater than 2.5,1.5,2.5,or 1.5 points at 1,2,3,and 4 years after CR,respectively.
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备注/Memo
收稿日期:2024-04-28。
基金项目:广州市妇女儿童医疗中心/儿科研究所临床研究基金(GWCMC2020-6-005)
通信作者:徐宏文,Email:xuhongwen@gwcmc.org