Summary.Peculiarities of the course and diagnosis of deformations of the musculoskeletal system in children – congenital dysplasia of the hip joint and congenital dislocation of the hip – are presented. For the correction of disorders of calcium and phosphorus metabolism and osteopenic syndrome in young children with congenital and acquired pathology of the musculoskeletal system, the drug “Calcium D”, which belongs to the group of combined calcium and vitamin D drugs, was used.

Key words: congenital hip dysplasia, congenital hip dislocation, prevention, treatment, “Calcium D”.

Disturbances in the structure and function of organs involved in the regulation of phosphorus-calcium metabolism are the cause or burden of various diseases that develop during the child’s life. Most often in young children, rickets is caused by a deficiency of vitamin D and a violation of the regulation of phosphorus-calcium metabolism. This period of a child’s life is a critical period.

In childhood, there are several critical periods of intensive growth and formation of the skeleton, during which there are certain “risk factors” that provoke the development of osteopenic reactions of varying degrees of severity.

Critical periods of bone system development:

I — Intrauterine (I–II trimesters):

• tissue differentiation.

II — Intrauterine (III trimester):

• growth and differentiation of supporting tissues;
• saturation and deposition of protein and mineral substances.

III — Early childhood and preschool age:

• stage differentiation and modeling of the bone system;
• formation of rickets.

IV — School and adolescence:

• completion of differentiation and accumulation of bone mass;
• development of osteopenia and osteochondropathies.

According to S. Cooper (1993), “disorders of phosphorus-calcium exchange, being a widespread disease, can be considered as a frequent cause of morbidity and increased health care costs worldwide.”

The state of phosphorus-calcium metabolism is of great importance in improving the processes of osteogenesis. Prevention and treatment of its disorders and structural and functional changes of the bone system is one of the important points in the comprehensive treatment of children with congenital pathology of the musculoskeletal system [4]. Congenital dysplasia (CD) of the hip joint (CS) and congenital dislocation of the hip (VVSt) are the most common types of musculoskeletal deformity in children — 38–40 cases per 1,000 newborns [5]. The basis of the treatment of VDKS and VVSt is the fixation of the child’s hips in the position from driving in various abductor devices, depending on age (prophylactic pants, Pavlik stirrups, abductor apparatus, etc.). Treatment in the diverting device is completed only after reaching normal age-related indicators of CS development. Accelerating the formation of CS is the first and foremost task of a pediatric orthopedist in the treatment of VD and VVSt. It is known that the results and duration of treatment directly depend on the date of its initiation (the earlier it is started, the higher the effectiveness), on the degree of violations of the ratios in the CS (dysplasia, subluxation, or dislocation), as well as on a number of factors, among which disorders of calcium and vitamin D metabolism, rickets, artificial feeding, intestinal dysbacteriosis, etc. [1–3, 6].

Modern methods of diagnosing and monitoring the course of CS formation disorders make it possible to dynamically assess the process of CS formation and the need for more or less long-term treatment. Treatment of children of the first year of life is carried out under the control of ultrasound examination (ultrasound) of the state of CS, and after reaching 8–10 months. — under X-ray control. At the same time, the ratio in the CS, the angle of inclination of the roof of the acetabulum (bone and cartilaginous roof – in ultrasound), the size and shape of the nucleus of the ossification of the femoral head are evaluated.

Vitamin therapy is important for the favorable formation of CS. Hypovitaminosis D is often observed in children aged 3 months to 3 years. In addition, the peculiarities of the treatment of children with disorders of the formation of CS (stay in a hospital, restriction of mobility) contribute to metabolic disorders. Therefore, in the complex treatment of patients with VDKS and VVSt, vitamin D and calcium preparations occupy a significant place.

Recently, in practice, we have started to use the complex drug “Calcium D” in children with disorders of the formation of CS, starting from the age of 6 months.

The active components of the drug “Calcium D” (syrup) manufactured by the company “Indoco Remedies Limited” (India), in 5 ml of syrup, are calcium carbonate in a dose equivalent to 250 mg of the elemental mineral and cholecalciferol (125 IU). The therapeutic effect is due to the complex action of the components of the drug.

The children were comprehensively observed at the State University “Institute of Pediatrics, Obstetrics and Gynecology of the AMS of Ukraine” and the State University “Institute of Traumatology and Orthopedics of the AMS of Ukraine”. A total of 48 patients aged 3 months and older with disorders of CS formation were under observation during the last year. up to 3 years, which were treated conservatively with the use of diverting devices. Among them, CS dysplasia was diagnosed in 19 patients, congenital subluxation of the hip — in 17, and VVSt III–IV stage. — in 12 cases. In all patients, CS pathology was diagnosed at the age of 3–4 months. during the examination at the State University “Institute of Traumatology and Orthopedics of the Medical Academy of Ukraine” and immediately after the diagnosis was established, treatment with abductor devices was started – up to 6–7 months. in Pavlyk’s stirrups, further treatment was continued in the “Ortotech service” referral unit. In addition to treatment with diverting devices, children received vitamin D3 in a dose of 1000 IU, the duration of treatment depended on the degree of vitamin D deficiency and calcium content in blood serum. In 31 cases, vitamin D3 was used in combination with “Calcium D” from the age of 6 months. In the group of children with dysplasia, 13 children were treated with “Calcium D”, with congenital subluxation of the hip – 10, and with VVSt III-IV stage. — 9 patients. “Calcium D” was necessarily prescribed in cases of severe heredity to children born prematurely and to those patients who had a history of intestinal dysbacteriosis, or the treatment process was slow. It should be noted that the appointment of “Calcium D” in all studied patients led to the acceleration of the formation of CS. Thus, in cases where slow formation of ossification nuclei of the femoral head was observed during ultrasound of the femoral head (14 cases), the appointment of “Calcium D” contributed to positive changes (visualization of ossification nuclei or normalization of their size) in 13 patients already at the next examination after 1–1.5 months (Fig. 1, 2). Whereas in children who received only vitamin D3 (10 patients), a positive dyna mic was observed only in 4 cases and was less pronounced (Fig. 3).

Fig. 1. Ultrasound of patient T. with hip dysplasia:

a) at the beginning of treatment, age 6 months;

b) after 1.5 months. after the start of treatment with the use of “Calcium<D”.

Fig. 2. Ultrasound of the hip joints of patient S. (5.5 months) with delayed formation of the hip joints:

a) before treatment;

b) after 1.5 months. after the start of treatment with the use of “Calcium < D” – the norm.

Fig. 3. Ultrasound of patient V. (6 months) with hip dysplasia:

a) at the beginning of treatment;

b) after 2 months. after the start of treatment without the use of “Calcium-D” – the nuclei of ossification are not visualized, the bone window is rounded.

At an older age, during X-ray examination, the dynamics of the formation of nuclei of ossification of the heads of femurs in patients receiving “Calcium D” was significantly ahead of that in children with a similar initial state of CS, for which the drug was not prescribed (Figs. 4, 5, 6 ).

Calcium and vitamin D preparations are used in children’s orthopedic practice not only for congenital pathology of CS, but also for acquired, in particular, for complications of umbilical sepsis with the development of acute hematogenous osteomyelitis of the femur, purulent coxitis, as a result of which the formation of joints is disturbed with the occurrence of pathological dislocation of the hip. Treatment in such cases is aimed not only at eliminating inflammation, but also at restoring the shape and structure of the affected proximal part of the thigh. Such patients, as well as with congenital disorders of the formation of CS, need fixation in abductor devices. Calcium and vitamin D3 preparations speed up the process in such cases. When prescribing “Calcium D” during the conservative treatment of the consequences of purulent lesions of CS during the period of fixation in the abductor apparatus, a positive result was achieved in the form of restoration of the proportions and shape of the joint ends (Fig. 7).

Fig. 4. Radiographs of the hip joints of patient M. (6.5 months) with hip dysplasia

a) start of treatment;

b) after 6 months from the beginning of treatment with the use of “Calcium-D” — well-formed nuclei of ossification of the femoral heads and normalization of the angle of inclination of the roof of the acetabulum.

Fig. 5. Radiographs of the hip joints of patient K. (5.5 months) with dysplasia of the right hip joint and subluxation of the left hip:

a) before treatment;

b) after 8 months. from the beginning of treatment with the use of “Calcium-D” — well-formed nuclei of ossification of the femoral heads and normalization of the angle of inclination of the roof of the acetabulum.

Fig. 6. Radiographs of the hip joints of patient P. (6 months) with dysplasia of the hip joints and dynamics:

a) before treatment;

b) after 3 months. since the beginning of treatment (a diverting device and vitamin D3 in a preventive dose) — the nuclei of ossification of the femoral heads are barely visible and the angle of inclination of the roof of the acetabulum has hardly changed, in connection with which “Calcium < D” is prescribed;

c) after 6 months from the beginning of treatment — the nuclei of ossification of the femoral heads were better formed and the angle of inclination of the roof of the acetabulum decreased.

As shown by the conducted studies (table), in all examined children, before the course of treatment, changes in biochemical indicators in the blood were determined, the level of which depended on the severity of the course of the disease (a decrease in the content of total calcium, inorganic phosphorus, transport form vitamin D3 (25OHD3) in blood serum, increase in alkaline phosphatase activity). To correct hypocalcemia and hypovitaminosis D, children received 250 mg of calcium with the drug “Calcium D” and 2,000 IU of vitamin D3 per day for 30–45 days. The duration of treatment was determined by the severity of the disease. The main goal of the treatment was to eliminate the main symptoms of the disease from the side of the bone system and normalize the indicators of phosphorus-calcium metabolism.

After the medication course, he noted the reduction and elimination of the main clinical manifestations of the disease, the normalization of calcium and phosphorus levels, and a decrease in the activity of alkaline phosphatase in the blood serum. Considering that the content of 25 ОНD3 significantly increased, but did not normalize (the necessary level of 25 ОНD3 is more than 40 ng/ml), which also applies to the content of calcium (the normal level of calcium is 2.25–2.75 mmol/L ), we consider it expedient to extend the course by 2–4 weeks, depending on the severity of the disease.

Fig. 7. Radiographs of the hip joints of patient T. (9 months) with the consequences of bilateral purulent coxitis in the dynamics:

a) the beginning of treatment (removal device and vitamin D3 in a prophylactic dose);

b) after 3 months. in the course of treatment, “Calcium<D” is prescribed;

c) in 1 year 9 months. — complete restoration of proportions in the hip joints and normalization of the shape and structure of the femoral heads.

Table 1. Biochemical indicators of blood in children

The conducted studies make it possible to state that “Calcium D”, which contains 625 mg of calcium carbonate (250 mg of an elemental mineral) and 125 IU of cholecalciferol (vitamin D3) in 5 ml, belongs to the group of combined preparations of calcium and vitamin D. It has been proven the effectiveness of combined therapy with calcium salts and vitamin D to achieve a better effect in the prevention and treatment of disorders of calcium and phosphorus metabolism and osteopenic syndrome in young children with congenital and acquired CS pathology.

This approach makes it possible to potentiate their anti-osteoporotic properties, as well as to reduce the frequency and severity of side effects.

“Calcium-D” helps to increase the level of 25(OH) – vitamin D3 in the blood serum, enhances the intestinal absorption of calcium, and also contributes to its inclusion in the crystal lattice of hydroxyapatite.

LITERATURE

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