先天性髖關(guān)節(jié)脫位
(又稱(chēng):發(fā)育性髖關(guān)節(jié)發(fā)育不良)精選內(nèi)容
-
臨界髖關(guān)節(jié)發(fā)育不良Borderline DDH (2):疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療
臨界髖關(guān)節(jié)發(fā)育不良BorderlineDDH(2):疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療作者:MichaelCWyatt,MartinBeck.作者單位:KlinikfürOrthop?dieundUnfallchirurgieLuzernerKantonsspital6004Luzern,Switzerland.譯者:陶可(北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科)摘要在過(guò)去的幾十年里,影像技術(shù)的改進(jìn)和手術(shù)技術(shù)的進(jìn)步使得保髖手術(shù)得到了快速發(fā)展。然而,疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療仍然存在爭(zhēng)議。在這篇評(píng)論中,我們將確定相關(guān)問(wèn)題并描述患者評(píng)估和治療方案。我們將提供自己的建議,并確定未來(lái)的研究領(lǐng)域。簡(jiǎn)介在過(guò)去的幾十年里,髖關(guān)節(jié)生物力學(xué)知識(shí)的提高和手術(shù)技術(shù)的進(jìn)步使得保髖手術(shù)得到了快速發(fā)展。保髖手術(shù)適應(yīng)范圍廣泛,從髖臼淺且不穩(wěn)定的髖關(guān)節(jié)到髖臼深且患有股骨髖臼撞擊(FAI)的髖關(guān)節(jié)。雖然人們普遍認(rèn)為,不穩(wěn)定髖關(guān)節(jié)發(fā)育不良的最佳治療方法是重新定位髖臼以增加覆蓋范圍,但人們同樣認(rèn)為,必須減小過(guò)度覆蓋的髖臼臨界以消除撞擊。所有這些髖關(guān)節(jié)都可能存在凸輪畸形,需要在手術(shù)矯正時(shí)加以解決[1]。在最極端的情況下,所需的治療是顯而易見(jiàn)的。然而,有一個(gè)過(guò)渡區(qū),很難區(qū)分不穩(wěn)定性和股骨髖臼撞擊(FAI)。過(guò)去,這些髖關(guān)節(jié)被稱(chēng)為“臨界”髖關(guān)節(jié)。通常,這包括外側(cè)中心臨界(LCE)角度在20°到25°之間的髖關(guān)節(jié)[2]。然而,“臨界”一詞是有問(wèn)題的,因?yàn)樗且粋€(gè)放射學(xué)定義,只涉及描述髖關(guān)節(jié)穩(wěn)定性的幾個(gè)重要參數(shù)之一。髖臼頂傾斜角、前后覆蓋和股骨前傾是應(yīng)納入髖關(guān)節(jié)穩(wěn)定性分析的其他因素。髖關(guān)節(jié)發(fā)育不良與髖關(guān)節(jié)骨關(guān)節(jié)炎之間的關(guān)聯(lián)已經(jīng)確定[3,4],有不穩(wěn)定跡象的髖關(guān)節(jié)發(fā)育不良退化速度更快[5]。臨界髖關(guān)節(jié)可能不穩(wěn)定、撞擊或兩者兼而有之。臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性很難確定,并且容易受個(gè)人主觀影響,骨科界普遍傾向于低估不穩(wěn)定性,從而導(dǎo)致不適當(dāng)?shù)闹委煛W罱难芯勘砻?,?duì)患有臨界發(fā)育不良(LCEA?>?20°)的患者進(jìn)行關(guān)節(jié)鏡髖關(guān)節(jié)手術(shù)(包括盂唇修復(fù)和關(guān)節(jié)囊折疊縫合術(shù))可能會(huì)在短期內(nèi)帶來(lái)適當(dāng)?shù)母纳芠3,4]。然而,有證據(jù)表明,之前錯(cuò)誤的髖關(guān)節(jié)鏡檢查會(huì)對(duì)此類(lèi)髖關(guān)節(jié)的治療結(jié)果產(chǎn)生負(fù)面影響[6]。因此,疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療仍然是一個(gè)極具爭(zhēng)議的問(wèn)題。臨界性髖關(guān)節(jié)發(fā)育不良在患有髖關(guān)節(jié)疼痛的年輕人中很常見(jiàn),在選定的患者群中報(bào)告的患病率為37.6%[7]。在臨界髖關(guān)節(jié)發(fā)育不良中,可能與其他不穩(wěn)定原因(如韌帶松弛癥)有顯著重疊[8]。然而,根本問(wèn)題是難以正確分類(lèi)潛在的病理生物力學(xué)。定義第一個(gè)問(wèn)題在于定義。在前后位骨盆X線片[9](LCEA)上測(cè)量的Wiberg外側(cè)中心邊緣角傳統(tǒng)上用于將髖關(guān)節(jié)分類(lèi)為正常(LCEA?>25°)、發(fā)育不良(LCEA?<20°)或臨界(LCEA20–25°),盡管這些定義值在文獻(xiàn)中差異很大[3,10]。然而,使用外側(cè)中心邊緣角(LCEA)存在兩個(gè)問(wèn)題。首先是測(cè)量方法。為了測(cè)量外側(cè)中心邊緣角(LCEA),首先通過(guò)與股骨頭輪廓相符的圓來(lái)定義股骨頭的中心。角度的第一個(gè)分支垂直穿過(guò)旋轉(zhuǎn)中心。第二個(gè)分支由股骨頭的中心和股骨最外側(cè)點(diǎn)定義(圖1a)。重要的是不要使用髖臼的最外側(cè)點(diǎn)(圖1b),因?yàn)檫@不符合Wiberg的定義,并且會(huì)給出錯(cuò)誤的高值(外側(cè)中心邊緣角(LCEA)偏大)[11]。Fig.1.(a)CorrectmeasurementoftheLCEAusingtheedgeofthesourcil,indicatingmoderatedysplasia.(b)IncorrectmeasurementoftheLCEAinthesamehip.Usingthisvaluewouldfalselyclassifythishipasborderline.圖1(a)使用髖臼臨界正確測(cè)量外側(cè)中心邊緣角(LCEA),表明中度髖關(guān)節(jié)發(fā)育不良。(b)同一髖關(guān)節(jié)的外側(cè)中心邊緣角(LCEA)測(cè)量不正確。使用此值會(huì)錯(cuò)誤地將此髖關(guān)節(jié)歸類(lèi)為臨界。其次,實(shí)際術(shù)語(yǔ)“臨界髖關(guān)節(jié)發(fā)育不良”是由Wiberg本人首次提出的,包括外側(cè)中心邊緣角(LCEA)在20°和25°之間的髖關(guān)節(jié)[2]。外側(cè)中心邊緣角(LCEA)是一種放射學(xué)測(cè)量,本身無(wú)法預(yù)測(cè)臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性,也無(wú)法完全描述股骨頭覆蓋范圍。因此,外側(cè)中心邊緣角(LCEA)無(wú)法指導(dǎo)手術(shù)決策[12–14]。部分原因是外側(cè)中心邊緣角(LCEA)本身無(wú)法涵蓋發(fā)育不良的精確位置,并且忽略了前后股骨頭覆蓋范圍。此外,髖臼指數(shù)(AI)和股骨前傾等其他參數(shù)也與髖關(guān)節(jié)穩(wěn)定性密切相關(guān)。如果外側(cè)中心邊緣角(LCEA)減少,AI可能正常,在這種情況下很難評(píng)估髖關(guān)節(jié)的穩(wěn)定性[15]。另一方面,股骨前傾過(guò)度可能會(huì)加劇髖關(guān)節(jié)前部不穩(wěn)定[16]。根本問(wèn)題是什么?對(duì)于疼痛的臨界髖關(guān)節(jié)發(fā)育不良,很難僅通過(guò)二維射線測(cè)量將病理機(jī)制表征為撞擊(穩(wěn)定)或發(fā)育不良(不穩(wěn)定),尤其是僅由髖臼功能決定而不考慮股骨的測(cè)量。髖關(guān)節(jié)穩(wěn)定性的功能表征對(duì)于指導(dǎo)手術(shù)決策至關(guān)重要。不穩(wěn)定髖關(guān)節(jié)從邏輯上可以從髖臼重新定向截骨術(shù)中受益,而穩(wěn)定髖關(guān)節(jié)可以從撞擊手術(shù)(如股骨凸輪骨成形術(shù))中受益。那么關(guān)于髖關(guān)節(jié)內(nèi)病理學(xué)的了解有多少?應(yīng)該如何評(píng)估這些患者?有哪些治療方案?手術(shù)結(jié)果如何?這組患者的潛在隱患是什么?未來(lái)的發(fā)展方向是什么?在這篇敘述性綜述文章中,我們旨在解決這些問(wèn)題,并闡明這組具有挑戰(zhàn)性的患者的處理方法。髖關(guān)節(jié)發(fā)育不良和臨界髖關(guān)節(jié)不穩(wěn)定的潛在病理是什么?髖關(guān)節(jié)發(fā)育不良患者的關(guān)節(jié)接觸壓力異常增高,股骨頭(軟骨損傷,導(dǎo)致軟骨下)骨質(zhì)相對(duì)暴露。髖臼通常較淺且前傾,盂唇經(jīng)常有代償性增大,但同時(shí)伴有髖臼后傾的情況也很高[17]。股骨通常呈外翻,前傾度高[10]。這些異常的解剖特征會(huì)導(dǎo)致病理性髖關(guān)節(jié)生物力學(xué),表現(xiàn)為盂唇撕裂、軟骨損傷和髖關(guān)節(jié)不穩(wěn)定,這些很容易被誤解為撞擊。由于骨穩(wěn)定性受損,軟組織穩(wěn)定器(即纖維軟骨盂唇和髖關(guān)節(jié)囊)的重要性就凸顯出來(lái)[18]。一旦軟組織約束失效,髖關(guān)節(jié)就會(huì)變得不穩(wěn)定。然而,我們必須明白,主要的潛在病理是缺乏骨性穩(wěn)定性,這會(huì)導(dǎo)致髖關(guān)節(jié)失效,而不是軟組織穩(wěn)定性失效。半脫位髖關(guān)節(jié)發(fā)育不良的自然病史預(yù)后非常差,并且必然會(huì)導(dǎo)致關(guān)節(jié)退化[5]。惡化速度與半脫位嚴(yán)重程度和患者年齡直接相關(guān),通常在癥狀出現(xiàn)后約10年,就會(huì)出現(xiàn)嚴(yán)重的退行性變化[19]。在沒(méi)有半脫位的情況下,自然病史很難預(yù)測(cè)退化速度。臨界髖關(guān)節(jié)發(fā)育不良也是如此。最近的一項(xiàng)研究強(qiáng)調(diào)了髖臼覆蓋的重要性。在一項(xiàng)為期20年的大型女性隊(duì)列研究中,研究顯示,如果外側(cè)中心邊緣角(LCE)低于28°,則每降低一度,放射學(xué)OA風(fēng)險(xiǎn)就會(huì)增加13%[20]。因此,除了短期緩解癥狀外,還必須考慮長(zhǎng)期可能的發(fā)展。臨床表現(xiàn)臨界髖關(guān)節(jié)發(fā)育不良的臨床表現(xiàn)與其他年輕活躍成人髖關(guān)節(jié)疾?。ㄈ鏔AI綜合征[21])非常相似,因此,徹底的病史、體格檢查和放射學(xué)評(píng)估對(duì)于正確診斷這些患者至關(guān)重要。病史重點(diǎn)記錄病史。臨界髖關(guān)節(jié)發(fā)育不良患者的主要癥狀是疼痛。這通常發(fā)生在腹股溝和髖關(guān)節(jié)外側(cè),但也可能發(fā)生在臀部(臀后區(qū))。有必要記錄完整的疼痛病史。尋找特定的不穩(wěn)定和“避免疼痛”癥狀,這可能表明已經(jīng)達(dá)到因缺乏骨性穩(wěn)定性而需要的軟組織代償?shù)臉O限。咔嗒聲和卡住的癥狀也很常見(jiàn)。此外,還會(huì)詢問(wèn)患者是否有任何跡象表明患者已經(jīng)患上髖關(guān)節(jié)炎,例如夜間疼痛。癥狀應(yīng)結(jié)合患者的功能限制和已經(jīng)接受的醫(yī)療護(hù)理,包括物理治療、藥物、其他意見(jiàn)和手術(shù)。檢查隨后應(yīng)進(jìn)行髖關(guān)節(jié)的合理臨床檢查,包括恐懼試驗(yàn)和撞擊測(cè)試?;颊咄ǔ?huì)表現(xiàn)出“膝內(nèi)翻”步態(tài),同時(shí)伴有髖關(guān)節(jié)內(nèi)收肌力矩增加和髖關(guān)節(jié)內(nèi)旋增加,這與股骨前傾增加一致。為了功能性地增加前覆蓋,可能存在前凸過(guò)度。應(yīng)確定大轉(zhuǎn)子處有無(wú)壓痛[22]。務(wù)必記住檢查患者的旋轉(zhuǎn)輪廓、進(jìn)行神經(jīng)血管檢查以及檢查全身關(guān)節(jié)松弛的跡象,并使用Beighton評(píng)分對(duì)此進(jìn)行量化。具體關(guān)鍵目標(biāo)包括排除(i)晚期退化過(guò)程的存在,例如表現(xiàn)為固定屈曲畸形和運(yùn)動(dòng)范圍減少,以及(ii)其他病理,例如腰椎病或L5神經(jīng)根病引起的疼痛。調(diào)查診斷成像應(yīng)從骨盆的標(biāo)準(zhǔn)化AP平片和股骨頸側(cè)位片(穿桌側(cè)位、Dunn位、假斜位)[23]開(kāi)始。仔細(xì)檢查這些圖像以測(cè)量LCEA、AI、擠壓指數(shù)、股骨頸干角和FEAR指數(shù)(見(jiàn)下文)。應(yīng)確定骨關(guān)節(jié)炎的Tonnis等級(jí)以及是否存在凸輪形態(tài)。應(yīng)仔細(xì)檢查不穩(wěn)定的直接跡象,這些跡象包括股骨頭移位,可通過(guò)與髂坐線的距離增加、Shenton線斷裂和AP視圖上股骨頭重新定位來(lái)識(shí)別,髖關(guān)節(jié)處于外展?fàn)顟B(tài),使用MR關(guān)節(jié)造影時(shí)后關(guān)節(jié)間隙中有釓,這表明股骨頭向前移位,因此不穩(wěn)定。FEAR指數(shù)與不穩(wěn)定性有很高的相關(guān)性(見(jiàn)下文)。必須精確測(cè)量和記錄各種參數(shù)。有必要使用三維計(jì)算機(jī)斷層掃描(CT)進(jìn)行橫斷面成像,以獲得有關(guān)骨解剖結(jié)構(gòu)和發(fā)育不良位置的精確信息,包括髖關(guān)節(jié)周?chē)夷[的存在和位置[24-26]。此外,CT還應(yīng)包括股骨前傾的評(píng)估,如果前傾過(guò)大,可能會(huì)加劇髖關(guān)節(jié)前部不穩(wěn)定。磁共振成像(MR-關(guān)節(jié)造影)應(yīng)遵循專(zhuān)門(mén)的髖關(guān)節(jié)檢查方案,包括徑向圖像采集或重建和關(guān)節(jié)內(nèi)造影劑應(yīng)用[27],以檢查關(guān)節(jié)內(nèi)結(jié)構(gòu)和盂唇和關(guān)節(jié)軟骨的病理??梢詤^(qū)分引起類(lèi)似癥狀的其他原因,例如缺血性壞死、轉(zhuǎn)子滑囊炎或臀肌病變。其他測(cè)量包括盂唇大小[13,28]和髂關(guān)節(jié)囊體積[29]。對(duì)于這些患者,我們還提倡進(jìn)行非牽引性MR關(guān)節(jié)造影檢查,以檢查是否存在釓積聚,即所謂的“新月征”,這是軸向視圖上不穩(wěn)定的細(xì)微征兆[30]。這些測(cè)量值的價(jià)值是什么?在平片上,那些直接表明不穩(wěn)定的測(cè)量值是股骨頭移位,與髂坐線的距離增加,Shenton線斷裂,髖關(guān)節(jié)外展時(shí)AP視圖上股骨頭重新定位,以及FEAR指數(shù)。在MR關(guān)節(jié)造影中,后下關(guān)節(jié)間隙中釓的存在表明股骨頭移位,因此不穩(wěn)定。AI、NSA、AT、高髂囊體積和盂唇體積可能存在增加,但不能預(yù)測(cè)不穩(wěn)定性[30](表1)。表1.用于評(píng)估髖關(guān)節(jié)不穩(wěn)定性的各種參數(shù)概述TheFemoro-EpiphysealAcetabularRoof(FEAR)index:股骨骨骺髖臼頂指數(shù)Thefemoralneck-shaftangle(NSA):頸干角FEAR指數(shù)是最近描述的參數(shù),似乎對(duì)預(yù)測(cè)髖關(guān)節(jié)穩(wěn)定性具有很高的價(jià)值[27]。它是由髖臼頂與股骨生長(zhǎng)板中央1/3處之間的角度形成的(圖2)。其依據(jù)是:在生長(zhǎng)過(guò)程中,股骨的骨骺生長(zhǎng)板會(huì)垂直于髖關(guān)節(jié)的關(guān)節(jié)反作用力。股骨頸的生長(zhǎng)和方向受股骨頸下生長(zhǎng)板的控制[31]。Pauwels和Maquet[32]提出理論,合力作用于骨骺軟骨的中心,在生長(zhǎng)過(guò)程中,根據(jù)Heuter-Volkman原理,骨骺板會(huì)垂直于關(guān)節(jié)反作用力。Pauwels和Maquet的理論后來(lái)得到了Carter等人[33]的證實(shí),他們通過(guò)二維有限元分析研究了髖關(guān)節(jié)負(fù)荷的影響。閉合的骨骺板的角度表示跨股骨近端骨骺[34]的力的平衡,也表示跨關(guān)節(jié)力在過(guò)去的作用方式。因此,它是一個(gè)功能參數(shù),反映了髖關(guān)節(jié)在生長(zhǎng)過(guò)程中長(zhǎng)期的關(guān)節(jié)反作用力。如果FEAR<0°,則認(rèn)為髖關(guān)節(jié)穩(wěn)定。統(tǒng)計(jì)分析表明,5°的臨界值預(yù)測(cè)穩(wěn)定性的概率為80°。最近的研究表明,2°的臨界值預(yù)測(cè)穩(wěn)定性的概率為90%(Batailler等人,正在準(zhǔn)備發(fā)表中)。使用FEAR指數(shù)的案例如圖3a和b所示。Fig.2.TheFEARindex.Theangleismeasuredbetweenalineconnectingthemostmedialandlateralpointofthesourcilandalineconnectingthemedialandlateralendofthestraightpart(usuallycentralthird)ofthephysealscarofthefemoralhead.AnegativeFEARindex,withtheangleopeningmediallyasshowninFig.3a,indicatesastablehip.圖2.?FEAR指數(shù)。測(cè)量連接股骨最內(nèi)側(cè)和外側(cè)點(diǎn)的線與連接股骨頭骨骺直線部分(通常為中央三分之一)內(nèi)側(cè)和外側(cè)端的線之間的角度。如圖3a所示,角度向內(nèi)側(cè)打開(kāi)的陰性FEAR指數(shù),表示髖關(guān)節(jié)穩(wěn)定。Fig.3.(a)CaseexamplesusingtheFEARindex.17-year-oldmale,LCEA20°,FEAR0°.Hipdeemedthereforestableandpatientmanagedwithhiparthroscopy.(b)CaseexamplesusingtheFEARindex.17-year-oldfemale,LCEA20°,FEAR8°.HipdeemedthereforeunstableandpatientmanagedwithPAO.圖3.(a)使用FEAR指數(shù)的病例。17歲男性,LCEA20°,F(xiàn)EAR0°。因此髖關(guān)節(jié)穩(wěn)定,患者接受髖關(guān)節(jié)鏡治療。(b)使用FEAR指數(shù)的病例。17歲女性,LCEA20°,F(xiàn)EAR8°。因此髖關(guān)節(jié)不穩(wěn)定,患者接受PAO截骨治療。有哪些治療方案?治療取決于髖關(guān)節(jié)的穩(wěn)定性。疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療方案包括非手術(shù)治療、解決關(guān)節(jié)內(nèi)撞擊的手術(shù)治療(通過(guò)髖關(guān)節(jié)鏡或髖關(guān)節(jié)外科脫位進(jìn)行的FAI手術(shù))和解決不穩(wěn)定性的手術(shù)治療(采用PAO和/或股骨截骨術(shù)的重新定位截骨術(shù))(見(jiàn)圖2)。非手術(shù)治療包括患者教育、活動(dòng)調(diào)整、簡(jiǎn)單的止痛藥、非甾體抗炎藥和髖關(guān)節(jié)腔內(nèi)注射藥物[35]。有針對(duì)性的物理治療可以改善肌肉調(diào)節(jié)、疼痛和本體感受控制。以下段落將討論包括關(guān)節(jié)鏡和/或截骨術(shù)的臨界髖關(guān)節(jié)發(fā)育不良的手術(shù)治療方案。這組患者接受髖關(guān)節(jié)鏡檢查的結(jié)果如何?隨著髖關(guān)節(jié)鏡技術(shù)的最新發(fā)展,許多外科醫(yī)生正在使用它來(lái)治療臨界髖關(guān)節(jié)發(fā)育不良,尤其是因?yàn)槿藗冋J(rèn)為髖臼周?chē)毓切g(shù)等替代技術(shù)的風(fēng)險(xiǎn)更高,術(shù)后恢復(fù)時(shí)間更長(zhǎng)。臨界髖關(guān)節(jié)發(fā)育不良的髖關(guān)節(jié)鏡檢查還可以讓外科醫(yī)生處理髖關(guān)節(jié)內(nèi)病變,如盂唇撕裂或股骨凸輪畸形[3,12,36]。如果考慮使用PAO來(lái)解決骨穩(wěn)定性不足的問(wèn)題,那么關(guān)節(jié)鏡檢查不僅可以讓外科醫(yī)生了解髖關(guān)節(jié)的關(guān)節(jié)內(nèi)狀態(tài),還可以了解患者在隨后進(jìn)行更大規(guī)模手術(shù)時(shí)的表現(xiàn)[37]。然而,關(guān)于臨界髖關(guān)節(jié)發(fā)育不良的髖關(guān)節(jié)鏡檢查的已發(fā)表文獻(xiàn)很少,而且短期隨訪也存在局限性。在Jo等的系統(tǒng)綜述中,確定了13項(xiàng)關(guān)于髖關(guān)節(jié)發(fā)育不良的關(guān)節(jié)鏡檢查的研究[10]。這些研究各不相同,所有研究都是病例系列。僅有6項(xiàng)研究報(bào)告了主觀和/或客觀結(jié)果。關(guān)節(jié)鏡檢查的手術(shù)指征不明確,患者事先接受過(guò)多種非手術(shù)治療。此外,臨界髖關(guān)節(jié)發(fā)育不良的確切定義各不相同,只有兩項(xiàng)研究使用了Byrd和Jones的定義[36]。三項(xiàng)研究報(bào)告了髖關(guān)節(jié)鏡作為輔助工具,三項(xiàng)研究報(bào)告了髖關(guān)節(jié)鏡作為獨(dú)立治療。盂唇撕裂的總患病率為77.3%,主要位于髖臼緣的前部或前上部。髖臼軟骨病變比股骨病變更常見(jiàn)(59-75.2%比11-32%),并且位于盂唇病變的鄰近。僅有兩項(xiàng)研究檢查了臨界髖關(guān)節(jié)發(fā)育不良病例(LCEA20-25°)的關(guān)節(jié)鏡檢查結(jié)果,其中只有一項(xiàng)描述了患者報(bào)告的結(jié)果測(cè)量。后者是Byrd和Jones[36]的前瞻性臨床病例系列,其中66%的髖關(guān)節(jié)(32髖)患有臨界髖關(guān)節(jié)發(fā)育不良。關(guān)節(jié)鏡檢查后,平均改良Harris髖關(guān)節(jié)評(píng)分從50(差)改善到77(一般)。作者得出結(jié)論,髖關(guān)節(jié)鏡治療可能解決髖關(guān)節(jié)內(nèi)病理而不是發(fā)育不良的放射學(xué)證據(jù)的結(jié)果。對(duì)臨界髖關(guān)節(jié)發(fā)育不良進(jìn)行髖關(guān)節(jié)鏡檢查有什么危險(xiǎn)?臨界髖關(guān)節(jié)發(fā)育不良患者進(jìn)行關(guān)節(jié)鏡盂唇切除術(shù)和髖臼外側(cè)緣切除術(shù)可導(dǎo)致爆發(fā)性髖關(guān)節(jié)不穩(wěn)定[38]。即使修復(fù)了盂唇,也必須保留髂股韌帶和髖關(guān)節(jié)的其他靜態(tài)穩(wěn)定器,以防止不可逆的后果或?qū)е麦y關(guān)節(jié)不穩(wěn)定[39–41]。沒(méi)有確鑿的文獻(xiàn)支持在這些情況下進(jìn)行關(guān)節(jié)囊修復(fù),但這似乎是一種安全合理的做法[42]。關(guān)節(jié)囊復(fù)位技術(shù)可提高臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性[12]。如果髖關(guān)節(jié)在術(shù)前足夠不穩(wěn)定,那么僅通過(guò)髖關(guān)節(jié)鏡治療關(guān)節(jié)內(nèi)病變是不夠的,患者將需要進(jìn)行PAO截骨術(shù)[43,44]。必須記住,髖關(guān)節(jié)的穩(wěn)定性首先取決于髖骨幾何形狀。在輕微不穩(wěn)定(臨界發(fā)育不良)中,穩(wěn)定性可能由次級(jí)軟組織結(jié)構(gòu)來(lái)確保。一旦這些結(jié)構(gòu)因微創(chuàng)傷或大創(chuàng)傷而失效,髖關(guān)節(jié)就會(huì)變得不穩(wěn)定?;謴?fù)軟組織穩(wěn)定性可能只會(huì)在短時(shí)間內(nèi)改善髖關(guān)節(jié)穩(wěn)定性,但軟組織很可能再次磨損。因此,必須首先解決潛在的骨病理問(wèn)題,才能取得良好的長(zhǎng)期效果。最近的一份報(bào)告顯示,髖關(guān)節(jié)發(fā)育不良患者在髖關(guān)節(jié)鏡檢查失敗后,PAO的髖關(guān)節(jié)特定功能結(jié)果較差[6]。因此,對(duì)這組患者單獨(dú)進(jìn)行髖關(guān)節(jié)鏡檢查應(yīng)謹(jǐn)慎處理。但是,對(duì)于那些由于髖關(guān)節(jié)狀況不佳(即AI和股骨前傾正常)或高齡(即>40歲)而不適合進(jìn)行PAO的患者,它可能有用。重新定向髖臼周?chē)毓切g(shù)對(duì)這組患者有何影響?通過(guò)髖臼周?chē)毓切g(shù)進(jìn)行髖臼重新定向已成為髖關(guān)節(jié)發(fā)育不良最常見(jiàn)的治療方法,據(jù)報(bào)道術(shù)后20多年效果良好。傳統(tǒng)上,PAO時(shí)關(guān)節(jié)內(nèi)病變的處理方法是進(jìn)行前關(guān)節(jié)切開(kāi)術(shù)。然而,隨著PAO微創(chuàng)技術(shù)的發(fā)展,情況已不再如此。微創(chuàng)PAO技術(shù)縮短了術(shù)后恢復(fù)時(shí)間[45]。最近的一項(xiàng)研究表明,一些可改變的因素,例如較高的體力活動(dòng)量和較高的BMI(大于30kg/m2)可導(dǎo)致PAO的發(fā)病年齡下降[46]。此外,患有較重發(fā)育不良程度的患者患PAO的年齡也較早:LCEA是手術(shù)年齡的獨(dú)立預(yù)測(cè)因素,即LCEA較低的患者往往需要在較早的年齡接受PAO手術(shù)。但是,輕度和中度發(fā)育不良患者的PAO預(yù)后沒(méi)有差異。在本研究中,輕度發(fā)育不良被歸類(lèi)為15-25°,這涵蓋了我們對(duì)臨界髖關(guān)節(jié)發(fā)育不良的定義。最近的一項(xiàng)多中心前瞻性隊(duì)列研究檢查了患者報(bào)告的PAO結(jié)果指標(biāo),結(jié)果表明,雖然總體結(jié)果良好,但臨界髖關(guān)節(jié)發(fā)育不良患者和男性的改善程度低于發(fā)育較重的患者[47]。作者討論了小范圍矯正的危險(xiǎn),這可能導(dǎo)致過(guò)度矯正和醫(yī)源性FAI、股骨前傾增加和軟組織松弛。建議和未來(lái)方向在臨界髖關(guān)節(jié)中,關(guān)鍵步驟是確定穩(wěn)定性。關(guān)于髖關(guān)節(jié)的穩(wěn)定性,只有兩種情況:髖關(guān)節(jié)穩(wěn)定或不穩(wěn)定。沒(méi)有中間狀態(tài)。如果接受這個(gè)概念,治療就會(huì)變得相對(duì)簡(jiǎn)單。不穩(wěn)定可能與其他病癥(如FAI或超負(fù)荷/過(guò)度使用和軟骨疾?。┫嘟Y(jié)合,需要同時(shí)治療。如果髖關(guān)節(jié)不穩(wěn)定,則需要髖臼重新定位。僅解決磨損的二級(jí)穩(wěn)定器并不能解決潛在的生物力學(xué)問(wèn)題,最多只能產(chǎn)生令人滿意的短期結(jié)果。在穩(wěn)定的髖關(guān)節(jié)中,可以進(jìn)行開(kāi)放或關(guān)節(jié)鏡關(guān)節(jié)保留手術(shù)。然而,我們必須記住,低于28°的LCE角度每減少一度,骨關(guān)節(jié)炎的發(fā)病率就會(huì)增加13%[20]。因此,如果有疑問(wèn),為了最大限度地提高獲得良好長(zhǎng)期結(jié)果的機(jī)會(huì),我們主張進(jìn)行髖臼重新定向PAO截骨手術(shù)。重要的是要確定我們?nèi)狈χR(shí)的領(lǐng)域,以指導(dǎo)進(jìn)一步的研究。將對(duì)這些患者進(jìn)行長(zhǎng)期隨訪研究,比較髖臼重新定向和髖關(guān)節(jié)鏡檢查,理想情況下,將記錄所有成像參數(shù)和Beighton評(píng)分。此外,還應(yīng)獲得患者報(bào)告的結(jié)果測(cè)量和恢復(fù)時(shí)間,以及包括運(yùn)動(dòng)在內(nèi)的活動(dòng)恢復(fù)時(shí)間。?TheFEARindexisarecentlydescribedparameterthatseemstohaveahighvaluetopredictstabilityofthehip[27].Itisformedbytheanglebetweentheacetabularroofandthecentralthirdofthefemoralgrowthplate(Fig.2).Itisbasedonthefactthatduringgrowththeepiphysealgrowthplateofthefemurorientsitselfperpendicularlytothejointreactingforcesofthehip.Growthandtheorientationofthefemoralneckareunderthecontrolofthesubcapitalgrowthplate[31].PauwelsandMaquet[32]theorizedthattheresultantforceactsfromthecenteroftheepiphysealcartilageandthatduringgrowth,theepiphysealplateorientsitselfperpendiculartothejointreactionforceinaccordancewiththeHeuter–Volkmanprinciple.PauwelsandMaquet’stheorylaterwasconfirmedbyCarteretal.[33]whostudiedtheinfluenceofhiploadingbybi-dimensionalfiniteelementanalysis.Theangleoftheclosedepiphysealplateindicatesthebalanceofforcesacrosstheproximalfemoralphysis[34]andindicateshowthetransarticularforcesactedinthepast.Therefore,itisafunctionalparameterthatreflectsthejointreactingforcesoveralongperiodoftimeduringgrowthofthehip.IftheFEARis?<0°thehipisconsideredstable.Statisticalanalysishasshownthatacutoffvalueof5°predictsstabilitywith80°probability.Morerecentworkhasshownthatacutoffvalueof2°predictsstabilitywith90%probability(Batailleretal.,inpreparation).CaseexamplesofusingtheFEARindexareshowninFig.3aandb.ThemanagementofthepainfulborderlinedysplastichipAbstractImprovedimagingandtheevolutionofsurgicaltechniqueshavepermittedarapidgrowthinhippreservationsurgeryoverthelastfewdecades.Themanagementofthepainfulborderlinedysplastichiphoweverremainscontroversial.Inthisreview,wewillidentifythepertinentissuesanddescribethepatientassessmentandtreatmentoptions.Wewillprovideourownrecommendationsandalsoidentifyfutureareasforresearch.INTRODUCTIONImprovedknowledgeabouthipbiomechanicsandtheevolutionofsurgicaltechniqueshavepermittedarapidgrowthinhippreservationsurgeryoverthelastfewdecades.Thespectrumcoversawiderangefromhipswithshallowacetabuli,whichareunstable,tohipswithdeepacetabulithataresufferingfromfemoro-acetabularimpingement(FAI).Whilethereisageneralagreementthatthebesttreatmentfortheunstabledysplastichipisareorientationoftheacetabulumtoincreasecover,thereisequalagreementthattherimoftheover-coveringacetabulumhastobereducedtoremoveimpingement.Onallthosehipsacamdeformitymaybepresentthatneedstobeaddressedatthetimeofsurgicalcorrection[1].Atthefarendsofthespectrumtherequisitetreatmentisobvious.However,thereisatransitionzonewhereitisdifficulttodiscriminateinstabilityfromFAI.Inthepastthesehipswerereferredtoas‘borderline’hips.Usually,thisincludedhipswithalateralcenteredge(LCE)anglebetween20°and25°[2].However,theterm‘borderline’isproblematic,becauseitisaradiographicdefinitionandonlyaddressesoneofseveralparametersimportanttodescribehipstability.Acetabularroofobliquity,anteriorandposteriorcoverandfemoralantetorsionareotherfactorsthatshouldbeincludedintoananalysisofhipstability.Theassociationofhipdysplasiawithhiposteoarthritisisestablished[3,4]anddysplastichipswithsignsofinstabilitydegenerateatahigherrate[5].Aborderlinehipcaneitherbeunstable,impingingormaybeboth.Thestabilityoftheborderlineisdifficulttodetermineandsubjecttointerpretationwithageneraltendencyintheorthopaediccommunitytounderestimateinstabilitythatthenleadstoinappropriatetreatment.Recentstudiessuggestthatarthroscopichipsurgerywithlabralrepairandcapsularplicationinpatientswithborderlinedysplasia(LCEA?>?20°)mayresultinappropriateshort-termimprovements[3,4].However,thereisevidencethatawronglydoneprevioushiparthroscopyhasanegativeimpactontheoutcomeonthetreatmentofsuchhips[6].Therefore,themanagementofthepainfulborderlinedysplastichiphoweverremainsanissueofgreatcontroversy.Borderlinehipdysplasiaiscommoninyoungadultswithhippainwithareportedprevalenceof37.6%inselectedpatientcohorts[7].Intheborderlinedysplastichiptheremaybesignificantoverlapwithothercausesofinstabilitysuchasconnectivetissuelaxity[8].However,thefundamentalissueisthedifficultyincorrectlyclassifyingtheunderlyingpatho-biomechanics.DEFINITIONThefirstproblemliesinthedefinition.TheLateralCentreEdgeAngleofWibergasmeasuredonanAntero-posteriorpelvicradiograph[9](LCEA)hastraditionallybeenusedtoclassifyhipsasnormal(LCEA?>25°),dysplastic(LCEA?<20°)orborderline(LCEA20–25°)althoughthesedefiningvaluesvarywidelyintheliterature[3,10].However,theuseoftheLCEAhastwoproblems.Firstlythemethodbywhichitshouldbemeasured.TomeasuretheLCEAthecenterofthefemoralheadisfirstdefinedbyacirclefittingthecontourofthefemoralhead.Thefirstbranchoftheanglerunsperpendicularthroughthecenterofrotation.Thesecondbranchisdefinedbythecenterofthefemoralheadandthemostlateralpointofthesourcil(Fig.1a).Itisimportantnottousethemostlateralpointoftheacetabulum(Fig.1b),becausethisdoesnotfollowthedefinitionofWiberg,andwillgivefalsehighvalues[11].Secondlytheactualterm‘Borderlinehipdysplasia’wasfirstintroducedbyWiberghimself,includinghipswithaLCEAbetween20°and25°[2].LCEAisaradiographicmeasureandpersecannotpredictstabilityintheborderlinedysplastichipnordoesfullydescribefemoralheadcoverage.ThereforetheLCEAcannotdirectsurgicaldecisionmaking[12–14].PartofthereasonisthatLCEAalonedoesnotencompassthepreciselocationofdysplasiaanddisregardsanteriorandposteriorfemoralheadcoverage.Alsootherparameterssuchasacetabularindex(AI)andfemoralantetorsionareveryrelevantforstabilityofthehip.InthepresenceofadecreasedLCEAAImaybenormalinwhichcasethestabilityofthehipisdifficulttoassess[15].Ontheotherhand,excessivefemoralanteversionmaypotentiateanteriorhipinstability[16].WHATISTHEFUNDAMENTALISSUE?Inthepainfulborderlinedysplastichipitisdifficulttocharacterizethepathologicalmechanismasimpingement(stable)ordysplasia(unstable)byatwo-dimensionalradiographicmeasurementalone,especiallyonethatissolelyafunctionoftheacetabulumandtakesnoaccountofthefemur.Thisfunctionalcharacterizationofhipstabilityisofparamountimportancetoguidesurgicaldecision-making.Anunstablehipwouldlogicallybenefitfromacetabularreorientationosteotomywhilstastablehipwouldbenefitfromimpingementsurgerysuchasfemoralcamosteoplasty.Sowhatisknownabouttheintra-articularpathology?Howshouldthesepatientsbeassessed?Whatarethetreatmentoptions?Whatarethesurgicaloutcomes?Whatarethepotentialpitfallswiththisgroupofpatients?Whatarethefuturedirections?Inthisnarrativereviewarticleweaimtoaddressthesequestionsandelucidatethemanagementofthischallenginggroupofpatients.WHATISTHEUNDERLYINGPATHOLOGYOFHIPDYSPLASIAANDUNSTABLEBORDERLINEHIPS?Inhipdysplasia,thereareabnormallyhigharticularcontactpressuresandrelativebonyuncoveringofthefemoralhead.Theacetabulumistypicallyshallowandantevertedwithanoftencompensatoryenlargedlabrum,butthereisalsoahighprevalenceofconcomitantacetabularretroversion[17].Thefemurisclassicallyinvalguswithhighantetorsion[10].Theseabnormalanatomicalfeaturescausepathologicalhipbiomechanicswhichmanifestaslabraltears,chondrallesions,andhipinstability,whichcaneasilybemisinterpretedasimpingement.Astheosseousstabilityiscompromisedtheimportanceofthesofttissuestabilisers,namelythefibrocartilaginouslabrumandthehipcapsule,isaccentuated[18].Oncethesofttissueconstraintsfailthenthehipbecomesunstable.However,onehastounderstandthattheprincipalunderlyingpathologyisthelackofosseousstability,whichleadstofailureofthehipandnotthefailingsofttissuestability.Thenaturalhistoryofthesubluxingdysplastichipisaverypoorprognosisandinvariablyleadstojointdegeneration[5].Therateofdeteriorationisdirectlyrelatedtosubluxationseverityandpatientageandusuallyabout10?yearsafteronsetofsymptomsseveredegenerativechangeshavedeveloped[19].Thenaturalhistoryintheabsenceofsubluxationismoredifficulttopredictconcerningthespeedofdegeneration.Thesameaccountsforborderlinedysplastichips.Arecentstudyhighlightstheimportanceofacetabularcover.Inalargecohortoffemales,followedfor20?years,itwasshownthateachdegreereductioninLCEbelow28°isassociatedwith13%increasedriskofradiographicOA[20].Therefore,besidesshort-termreliefofsymptoms,thelong-termpossibleevolutionhastobekeptinmind.CLINICALPRESENTATIONTheclinicalpresentationofborderlineacetabulardysplasiaisverysimilartothatofotheryoungactiveadulthipdisorders,suchasFAIsyndrome[21]soathoroughhistory,physicalexamination,andradiographicevaluationareessentialtoproperlydiagnosethesepatients.HISTORYAfocusedhistoryistaken.Theprimarysymptominpatientswithborderlinehipdysplasiaispain.Thisistypicallyperceivedingroinandlateralhipbutcanalsobeinthebuttock.Afullpainhistoryiswarranted.Particularsymptomsofinstabilityand‘givingway’aresoughtthatmayindicatethatthelimitsofsofttissuecompensationforalackofosseousstabilityhavebeenreached.Symptomsofclickingandcatchingarealsocommon.Furthermoreanyindicationsthatthepatienthasestablishedhiparthritis,suchasnightpain,areaskedfor.Thesymptomsshouldbeputintothecontextofthepatient’sfunctionallimitationsandmedicalattentionalreadyreceivedincludingphysiotherapy,medications,otheropinionsandsurgery.EXAMINATIONAlogicalclinicalexaminationofthehipshouldfollowincludingapprehensionandimpingementtests.Thepatientwilloftendisplaya‘kneeing-in’gaitinassociationwithanincreasedhipadductormomentandincreasedinternalhiprotationconsistentwithincreasedfemoralantetorsion.Hyperlordosismaybepresentinordertofunctionallyincreaseanteriorcover.Tendernessoverthegreatertrochantershouldbedetermined[22].Itiscrucialtoremembertoexaminethepatient’srotationalprofile,performaneurovascularexaminationandtocheckforsignsofgeneralizedjointlaxityandquantifythisusingBeighton’sscore.Specifickeyaimsincluderefutingthepresenceof(i)anadvanceddegenerativeprocessmanifestforexamplewithfixedflexiondeformityanddecreasedrangeofmotionand(ii)alternativepathologysuchaspainreferredfromlumbarspondylosisorL5radiculopathy.INVESTIGATIONSDiagnosticimagingshouldcommencewithstandardizedplainAPradiographofthepelvisandalateralfemoralneckviews(lateralcrosstable,Dunnview,falseprofileviews)[23].TheseimagesarescrutinizedtomeasuretheLCEA,AI,extrusionindex,femoralneck-shaftangleandFEARindex(seebelow).TheTonnisgradeofosteoarthritisshouldbedeterminedalongwithwhetherthereiscammorphology.Directsignsofinstabilityshouldbescrutinizedforandthesecomprisefemoralheadmigration,recognizedbyanincreaseddistancefromtheilioischialline,abreakinShenton’slineandrecenteringofthefemoralheadonanAPviewwiththehipinabductionandGadoliniumintheposteriorjointspacewhenusingMR-arthrography,thatindicatesanteriormigrationandthusinstabilityofthefemoralhead.TheFEARindexhasahighassociationwithinstability(seebelow).Thevariousparametershavetobemeasuredpreciselyandrecorded.Cross-sectionalimagingwiththree-dimensionalcomputerizedtomography(CT)forpreciseinformationonbonyanatomyandlocationofdysplasiaincludingthepresenceandlocationofperiarticularcystsiswarranted[24–26].FurthermoreCTshouldincludeestimationoffemoralantetorsionwhich,ifhighmaypotentiateanteriorhipinstability.Magneticresonanceimaging(MR-arthrography)shouldfollowadedicatedprotocolfortheexaminationofthehip,includingradialimageacquisitionorreconstructionandintra-articularapplicationofcontrast[27]toexamineforintra-articularstructuresandpathologyofbothlabrumandarticularcartilage.Othercausesforsimilarsymptomssuchasavascularnecrosis,trochantericbursitisorglutealpathologycanbedifferentiated.Additionalmeasurementsincludelabralsize[13,28]andiliocapsularisvolume[29].Inthesepatients,wealsoadvocatenon-tractionMRarthrographytoexamineforaaccumulationofgadoliniumknownasa‘crescentsign’whichisasubtlesignofinstabilityontheaxialview[30].WHATISTHEVALUEOFTHESEMEASUREMENTS?Onplainfilmsthosemeasurementsthataredirectsignsofinstabilityarefemoralheadmigrationwithanincreaseofthedistancefromtheilioischialline,abreakinShenton’slineandrecenteringofthefemoralheadontheAPviewwithhipsinabductionandtheFEARindex.OnMR-arthrographythepresenceofGadoliniuminthepostero-inferiorjointspaceindicatesmigrationofthefemoralheadandthusinstability.TheAI,NSA,AT,highiliocapsularisvolumeandincreasedlabralvolumemaybepresentbutarenotpredictiveofinstability[30](Table1).WHATARETHETREATMENTOPTIONS?Treatmentdependsonthestabilityofthehip.Thetreatmentalternativesforthepainfulborderlinedysplastichipincludenon-operativetreatment,surgicaltreatmenttoaddressintra-articularimpingement(FAIsurgerybyeitherhiparthroscopyorsurgicalhipdislocation)andsurgicaltreatmenttoaddressinstability(reorientationosteotomywithPAOand/orfemoralosteotomy)(seeFig.2).Non-operativemanagementincludespatienteducation,activitymodification,simpleanalgesics,non-steroidalanti-inflammatorymedications,andintra-articularinjections[35].Targetedphysiotherapycanimprovemuscularconditioning,painandproprioceptivecontrol.Thesurgicaltreatmentoptionsfortheborderlinedysplastichipwhichcomprisearthroscopyand/orosteotomywillbediscussedinthefollowingparagraphs.WHATARETHERESULTSOFHIPARTHROSCOPYINTHISGROUPOFPATIENTS?Withtherecentevolutioninhiparthroscopymanysurgeonsareusingthistoaddressborderlinedysplastichips,notleastbecauseofperceivedhigherrisksandlongerpost-operativerecoveryassociatedwithalternativetechniquessuchasperiacetabularosteotomy.Hiparthroscopyinborderlinedysplastichipspermitsthesurgeontoaddressintra-articularpathologysuchasalabraltearorfemoralcamdeformity[3,12,36].IfPAOisbeingconsideredtoaddresstheinadequatebonystabilitythenarthroscopymaygivethesurgeonvaluableinsightsnotonlyintotheintra-articularstatusofthehipbutalsohowthepatientislikelytofarewithamuchlargersubsequentoperation[37].However,thereislittlepublishedliteratureonhiparthroscopyinborderlinedysplastichipsandwhatthereislimitedbyshort-termfollow-up.InthesystematicreviewbyJoetal.,13studieslookingatarthroscopyindysplastichipswereidentified[10].Thestudieswereheterogeneousandallstudieswerecaseseries.Onlysixstudiesreportedonsubjectiveand/orobjectiveoutcomes.Thesurgicalindicationsforarthroscopywereambiguousandpatientshadreceivedvariablenon-operativemanagementapriori.FurthermoretheprecisedefinitionofborderlinehipdysplasiavariedandonlytwostudiesusedthedefinitionofByrdandJones[36].Threestudiesreportedonhiparthroscopyasanadjuvanttoolandthreeasastand-alonetreatment.Labraltearshadanoverallprevalenceof77.3%andtheseweremostlylocatedintheanteriororanterosuperiorportionoftheacetabularrim.Acetabularchondrallesionsweremorecommonthanfemorallesions(59–75.2%versus11–32%)andlocatedadjacenttothatofthelabralpathology.Therewereonlytwostudiesthatexaminedtheoutcomesofarthroscopyinborderlinehipdysplasticcases(LCEA20–25°)ofwhichonlyonedescribedpatientreportedoutcomemeasures.Thelatter,aprospectiveclinicalcaseseriesbyByrdandJones[36],had66%ofhips(32hips)withborderlinedysplasia.ThemeanmodifiedHarrisHipscoreimprovedfrom50(poor)to77(fair)followingarthroscopy.Theauthorsconcludedthatthetreatmentresponseislikelyafunctionofaddressingtheintra-articularpathologyratherthantheradiographicevidenceofdysplasia.WHATARETHEDANGERSWITHDOINGHIPARTHROSCOPYINBORDERLINEDYSPLASTICHIPS?Arthroscopiclabralresectionandremovaloflateralacetabularriminborderlinehipdysplasiacanleadtofulminantjointinstability[38].Evenifthelabrumisrepaireditisimperativetopreservetheiliofemoralligamentandotherstaticstabilizersofthehiptopreventtheirreversibleconsequencesorrenderingthehipunstable[39–41].Thereisnoconclusiveliteraturetosupportcapsularrepairinthesecasesbutthisseemsasafeandsensiblepractice[42].Capsularreductiontechniquestoimprovestabilityhavebeendescribedinborderlinedysplastichips[12].Ifthehipissufficientlyunstablepre-operativelythenaddressingtheintra-articularpathologyalonebyhiparthroscopywillbeinsufficientandthepatientwillrequireaPAO[43,44].Onehastobearinmindthatstabilityofthehipfirstlinedependsontheosseousgeometry.Insubtleinstability(borderlinedysplasia)stabilitymaybesecuredbysecondarysofttissuestructures.Oncethesefailduetomicro-ormacrotraumathehipbecomesunstable.Restoringsofttissuestabilitymayimprovehipstabilityforashortperiodoftimeonly,butitislikelythatthesofttissueswearoutagain.Thereforetheunderlyingosseouspathologyhastobeaddressedfirsttoachievegoodlong-termresults.ArecentreportshowedaninferiorhipspecificfunctionaloutcomeofPAOafterfailedhiparthroscopyinhipdysplasia[6].Hiparthroscopyaloneinthisgroupofpatientsshouldbethereforeapproachedwithcaution.However,itmayhavearoleinthosepatientswhoareeitherunsuitableforPAOeitherbecausetheirhipsareunfavourable(i.e.haveanormalAIandnormalfemoralanteversion)orbecausetheiradvancedage(i.e.>40years).WHATARETHERESULTSOFREORIENTINGPERIACETABULAROSTEOTOMYINTHISGROUPOFPATIENTS?Acetabularreorientationviatheperiacetabularosteotomyhasbecomethemostcommontreatmentforacetabulardysplasiawithgoodoutcomesreportedatover20?yearspostoperatively.Traditionallyintra-articularpathologywasaddressedatthetimeofPAObyperformingananteriorarthrotomy.HoweverwiththedevelopmentofminimallyinvasivetechniquesforPAOthisisnolongernecessarilythecase.LessinvasivePAOtechniqueshavedecreasedthetimetopostoperativerecovery[45].ArecentstudyshowedmodifiablefactorssuchashigherphysicalactivityandhigherBMIgreaterthan30?kg/m2leadtoadecreasedageofpresentationforPAO[46].FurthermorepatientsalsopresentedearlierforPAOwithworsedegreesofdysplasia:theLCEAwasindependentlypredictiveofageatsurgery,i.e.patientswithalowerLCEAtendedtorequirePAOsurgeryatanearlierage.However,therewasnodifferenceinoutcomesfollowingPAObetweenmildandmoderatedysplasia.Inthisstudymilddysplasiawasclassifiedas15–25°whichencompassesourdefinitionofborderlinehipdysplasia.Arecentmulticenterprospectivecohortstudythatexaminedpatient-reportedoutcomemeasuresofPAOshowedthat,althoughoverallresultsweregood,improvementsinborderlinehipdysplasticsandmaleswerelessthaninthosepatientswhohadmoreseveredysplasia[47].TheauthorsdiscussedthiswiththedangerofasmallcorrectionthatmayleadtoovercorrectionandiatrogenicFAI,increasedfemoralantetorsionandsofttissuelaxity.RECOMMENDATIONSANDFUTUREDIRECTIONSInborderlinehipsthecrucialstepistodefinestability.Regardingthestabilityofthehipthereareonlytwoconditions:Thehipiseitherstableorunstable.Thereisnothinginbetween.Ifthisconceptisaccepted,thetreatmentgetscomparablysimple.InstabilitymaybecombinedwithotherpathologieslikeFAIoroverload/overuseandcartilagediseasewhichneedconcomitanttreatment.Ifthehipisunstable,acetabularreorientationisnecessary.Addressingonlywornoutsecondarystabilizersdoesnotsolvetheunderlyingbiomechanicproblemandatbestwillyieldsatisfactoryshorttermresults.Instablehips,openorarthroscopicjointpreservingsurgerymaybeperformed.However,wehavetokeepinmindthateachdegreedecreaseoftheLCEanglebelow28°isassociatedwitha13%increaseofosteoarthrosis[20].Therefore,ifindoubt,inordertomaximizethechanceofgoodlong-termresults,wewouldadvocateforanacetabularreorientationoperation.Itisimportanttoidentifytheareaswherewelackknowledgeinordertoguidefurtherresearch.Longer-termfollow-upstudiescomparingacetabularreorientationandhiparthroscopyinthesepatients,ideallyinwhichallimagingparametersandBeightonscoresarerecordedwouldbeperformed.Inadditionpatient-reportedoutcomemeasuresandtimetorecoveryandresumptionofactivitiesincludingsportshouldbeattained.文獻(xiàn)出處:MichaelCWyatt,MartinBeck.Themanagementofthepainfulborderlinedysplastichip.ReviewJHipPreservSurg.2018Apr5;5(2):105-112.doi:10.1093/jhps/hny012.
北大人民醫(yī)院科普號(hào)2024年08月14日 79 0 2 -
髖關(guān)節(jié)發(fā)育不良保髖手術(shù)常見(jiàn)問(wèn)題
問(wèn):髖關(guān)節(jié)發(fā)育不良可不可以保守治療,是否必須手術(shù)?答:首先,保守治療無(wú)非控制活動(dòng)量、控制體重、吃止疼藥、加強(qiáng)肌肉鍛煉,一定程度可以緩解疼痛癥狀,但是根本的骨頭畸形并沒(méi)有改變,也就是說(shuō),保守治療只能一定程度延緩病情進(jìn)展,無(wú)法解決根本問(wèn)題。手術(shù)的目的是為了緩解疼痛、延長(zhǎng)自身關(guān)節(jié)的使用壽命,從根本上解決問(wèn)題。如果本身關(guān)節(jié)不疼,或者疼痛非常非常輕,可以暫且保守治療。但是,如果關(guān)節(jié)疼痛比較頻繁或者比較重,手術(shù)可能是解決當(dāng)前問(wèn)題的最佳方式。?問(wèn):保髖術(shù)后我的關(guān)節(jié)能用多少年?答:這個(gè)問(wèn)題很難回答。影響關(guān)節(jié)使用壽命的因素太多了,比如手術(shù)時(shí)關(guān)節(jié)軟骨磨損重不重、自身的軟骨耐磨程度如何、自身的關(guān)節(jié)畸形重不重、手術(shù)醫(yī)生的水平好不好、術(shù)后體重控制得好不好、術(shù)后關(guān)節(jié)保養(yǎng)的好不好。理論上講,通過(guò)手術(shù)糾正畸形可以讓關(guān)節(jié)的使用壽命盡可能延長(zhǎng),最好的效果就是用一輩子,當(dāng)然,少術(shù)患者也有術(shù)后幾年、十幾年后出現(xiàn)關(guān)節(jié)磨損嚴(yán)重,進(jìn)而換關(guān)節(jié)的??傮w上講,找一個(gè)靠譜的醫(yī)生,術(shù)后自己好好保養(yǎng),剩下的就交給天意了。?問(wèn):手術(shù)后我應(yīng)該怎么保養(yǎng)自身的關(guān)節(jié)?答:手術(shù)的目的還是希望大家回歸正常的生活。有的極端的患者,為了減少關(guān)節(jié)負(fù)重會(huì)走極端,比如坐輪椅,甚至少穿衣服,其實(shí)大可不必,該干嘛干嘛。如果可以的話,適當(dāng)避免長(zhǎng)時(shí)間重體力勞動(dòng)或者劇烈運(yùn)動(dòng)。當(dāng)然,如果你覺(jué)得運(yùn)動(dòng)是生命中不可缺少的一部分,那也不用刻意壓抑,這一點(diǎn)國(guó)外是比較積極的,很多患者手術(shù)就是為了后續(xù)運(yùn)動(dòng)時(shí)不疼。當(dāng)然,如果能把體重控制在理想的區(qū)間肯定是最好的。?問(wèn):我想手術(shù)了,術(shù)前應(yīng)該做哪些準(zhǔn)備?答:1、異地就醫(yī),提前進(jìn)行醫(yī)保備案,具體需要詢問(wèn)當(dāng)?shù)蒯t(yī)保部門(mén);2、準(zhǔn)備一副拐杖,肘拐腋拐都可以,調(diào)整拐杖高度,練習(xí)拄拐單腿走路;3、術(shù)前可以按醫(yī)生的建議進(jìn)行功能鍛煉,改善肌力,加速術(shù)后康復(fù);4、帶著之前拍的片子及病歷;5、酌情準(zhǔn)備個(gè)人生活物品。?問(wèn):髖臼周?chē)毓鞘中g(shù)風(fēng)險(xiǎn)高不高?答:這個(gè)手術(shù)確實(shí)難度很大,被譽(yù)為骨科的珠穆朗瑪,手術(shù)的入門(mén)門(mén)檻很高,學(xué)習(xí)曲線很長(zhǎng),目前全國(guó)只有為數(shù)不多的醫(yī)生可以做這類(lèi)手術(shù)。記得我在美國(guó)學(xué)習(xí)的時(shí)候,看過(guò)兩個(gè)醫(yī)生做這個(gè)手術(shù),一個(gè)醫(yī)生平均需要三四個(gè)小時(shí),另一個(gè)醫(yī)生需要6-8個(gè)小時(shí)。對(duì)于我們來(lái)說(shuō),絕大多術(shù)的手術(shù)可以在1小時(shí)出頭的時(shí)間完成,手術(shù)不但做得快,質(zhì)量也是絕對(duì)有保證。?問(wèn):手術(shù)需要輸血嗎?答:這個(gè)手術(shù)的出血確實(shí)偏多,但是隨著手術(shù)技術(shù)的提高和相關(guān)藥物的應(yīng)用,再加上手術(shù)中使用血液回收設(shè)備(可以將出血量的大概一般進(jìn)行重新回收利用),目前在我中心手術(shù)的患者,90%以上的患者不需要異體輸血。而且,我們中心現(xiàn)在術(shù)前不需要常規(guī)備自體血。?問(wèn):術(shù)后恢復(fù)期大概多久?答:手術(shù)中我們需要將骨頭截?cái)?,調(diào)整好位置后進(jìn)行固定,截?cái)嗟墓穷^長(zhǎng)好需要大概3個(gè)月的時(shí)間。所以,術(shù)后3個(gè)月內(nèi)需要小心保護(hù)自己的髖關(guān)節(jié),不要摔,一定要拄雙拐,拄雙拐,拄雙拐!一般我會(huì)讓患者術(shù)后6-8周內(nèi)術(shù)腿不負(fù)重,6-8周后從0開(kāi)始逐漸逐漸增加踩地的重量,注意,是勻速逐漸的增加,到3個(gè)月的時(shí)候可以負(fù)重身體重量1/3-1/2,具體以醫(yī)生通知為準(zhǔn)。過(guò)早扔拐,過(guò)早過(guò)多負(fù)重可能導(dǎo)致骨頭移位,影響手術(shù)效果。3個(gè)月后門(mén)診復(fù)查,評(píng)估骨頭生長(zhǎng)情況。?問(wèn):術(shù)后如何進(jìn)行康復(fù)鍛煉?答:康復(fù)鍛煉很重要,鍛煉不好,走路十有八九會(huì)瘸。我的患者我一般會(huì)給每人一個(gè)康復(fù)計(jì)劃,由于每個(gè)人的手術(shù)不一樣,畸形不一樣,骨頭質(zhì)量不一樣,所以方案不會(huì)完全一樣,大家按照自己的方案去做鍛煉即可。大家認(rèn)真閱讀鍛煉資料,保證動(dòng)作做對(duì),一旦動(dòng)作做錯(cuò),就可能練錯(cuò)肌肉。3個(gè)月復(fù)查時(shí)人要過(guò)來(lái),很重要,我會(huì)根據(jù)查體結(jié)果和骨頭愈合情況調(diào)整康復(fù)方案。復(fù)查方式參考:保髖術(shù)后門(mén)診復(fù)查注意事項(xiàng)
航天中心醫(yī)院骨科科普號(hào)2024年06月30日 402 0 0 -
保髖從娃娃抓起——全面推進(jìn)髖關(guān)節(jié)發(fā)育不良早期篩查
髖關(guān)節(jié)發(fā)育不良(Developmentaldysplasiaofthehips,DDH)是兒童最常見(jiàn)的肌肉骨骼先天缺陷之一,各地報(bào)道的DDH發(fā)病率在1‰~3.4‰。DDH是導(dǎo)致髖關(guān)節(jié)骨關(guān)節(jié)炎的重要原因,延誤診治或治療不當(dāng),都將嚴(yán)重的影響成年后生活質(zhì)量。既往文獻(xiàn)報(bào)告,近40%接受髖關(guān)節(jié)置換病人和“髖關(guān)節(jié)發(fā)育不良”有關(guān)。近年來(lái),全髖關(guān)節(jié)置換術(shù)(THA)是當(dāng)今最成功的骨科手術(shù)之一。多種原因?qū)е碌捏y部疼痛時(shí),THA都可緩解疼痛、恢復(fù)功能并提高生存質(zhì)量。但是,有個(gè)重大的問(wèn)題是技術(shù)本身克服不了的,那就是,“全髖關(guān)節(jié)置換”的“年限”和初次關(guān)節(jié)置換時(shí)年齡密切相關(guān),與之相反的是,“翻修手術(shù)”難度大風(fēng)險(xiǎn)高,但效果反而不如初次置換。因此,對(duì)于髖關(guān)節(jié)發(fā)育不良這樣長(zhǎng)病程的疾患,“保髖”是“全生命周期治療”中不可或缺的一個(gè)重要環(huán)節(jié)。青少年、兒童期嚴(yán)重型髖關(guān)節(jié)發(fā)育不良/脫位,通過(guò)規(guī)范手術(shù)治療可以獲得滿意的中期效果。對(duì)于行走期(walkingage)及以前發(fā)現(xiàn)的髖關(guān)節(jié)脫位孩子,可以通過(guò)“閉合復(fù)位石膏褲固定”保守治療的方法,不過(guò),存在一定的“殘余髖關(guān)節(jié)發(fā)育不良”的幾率,部分病例需行二期手術(shù)矯正。和很多與發(fā)育相關(guān)的疾病一樣,髖關(guān)節(jié)脫位同樣需要盡可能早的發(fā)現(xiàn)、診斷,及時(shí)復(fù)位,讓髖臼-股骨頭維持良好對(duì)位,才能讓兒童髖關(guān)節(jié)沿著正?!败壍馈卑l(fā)育,從而“治愈”它。而早期針對(duì)髖關(guān)節(jié)脫位/發(fā)育不良的篩查是解決“早期診斷”的唯一出路?;仡櫩磥?lái),最早從1879年WilhelmRoser、后來(lái)Ortolani等醫(yī)生更多是通過(guò)體格檢查的方法檢查出兒童期“脫位”的髖關(guān)節(jié)。在我國(guó),以上海新華醫(yī)院吳守義教授等為代表的小兒骨科前輩也陸續(xù)開(kāi)展了針對(duì)髖關(guān)節(jié)脫位的篩查工作。自上世紀(jì)80年代,以?shī)W地利Graf、美國(guó)Harcke、挪威的Rosendahl、Terjesen醫(yī)生為代表,開(kāi)始利用髖關(guān)節(jié)超聲技術(shù)來(lái)評(píng)估髖關(guān)節(jié)形態(tài),并逐漸形成了早期髖關(guān)節(jié)超聲檢查技術(shù)及分型系統(tǒng)。從而,將針對(duì)DDH的早期檢出時(shí)間大大提前。并使基于這項(xiàng)技術(shù)的、針對(duì)人群的DDH篩查成為可能。奧地利是最早針對(duì)DDH實(shí)行全民篩查(universalscreeningprogram)的國(guó)家之一,他們的數(shù)據(jù)表明,早期全民篩查可以大大降低后期需手術(shù)的比例。從衛(wèi)生經(jīng)濟(jì)學(xué)角度來(lái)說(shuō),整體上也大大降低了政府的醫(yī)療支出。我國(guó)已從政策層面高度重視,國(guó)家衛(wèi)健委在《健康兒童行動(dòng)提升計(jì)劃(2021-2025年)》中再次強(qiáng)調(diào),要“逐步將先天性髖脫位等疾病納入篩查病種”,從而整體提升兒童骨骼發(fā)育健康。然而,西京醫(yī)院嚴(yán)亞波主任的一項(xiàng)針對(duì)兒科、兒保、婦產(chǎn)科、小兒骨科等7個(gè)專(zhuān)業(yè)醫(yī)生,共466份有效問(wèn)卷的調(diào)查發(fā)現(xiàn),會(huì)對(duì)嬰幼兒常規(guī)進(jìn)行髖關(guān)節(jié)查體的比例為37.9%,而常規(guī)進(jìn)行髖關(guān)節(jié)超聲的比例僅為20%。理想是豐滿的,而現(xiàn)實(shí)是骨感的。目前,以上海、北京為代表的大城市,實(shí)行的是基于危險(xiǎn)因素的“選擇性篩查”或“區(qū)域性全民篩查”,不過(guò),仍面臨諸如政策、運(yùn)營(yíng)協(xié)調(diào)等多方面的問(wèn)題亟待解決??祻?fù)醫(yī)學(xué)會(huì)修復(fù)重建外科專(zhuān)委會(huì)保髖學(xué)組張洪教授、羅殿中教授、程徽和楊劼教授等,在西藏地區(qū)克服重重困難、開(kāi)展針對(duì)髖關(guān)節(jié)脫位的系統(tǒng)性早期篩查工作,星星之火已被點(diǎn)燃。在以天津醫(yī)院小兒骨科楊建平主任、天津市婦女兒童保健中心劉功姝主任為代表的兒保、小兒骨科醫(yī)生持續(xù)努力下,在上海第六人民醫(yī)院陳博昌主任等的技術(shù)支持下,新生兒期針對(duì)髖關(guān)節(jié)發(fā)育不良的早期篩查,和先心病、白內(nèi)障等一樣被納入“早期篩查項(xiàng)目”。天津市自2008年開(kāi)始實(shí)行全市范圍內(nèi)“全民篩查”,將針對(duì)髖關(guān)節(jié)發(fā)育不良的超聲篩查納入到“天津市兒童保健手冊(cè)”、“天津市預(yù)防接種手冊(cè)”(小紅本)內(nèi),基于信息化管理,采用“2+1”的模式,確保了篩查覆蓋率及良好的質(zhì)量控制。天津市婦女兒童保健中心潘蕾主任總結(jié)了天津市2013~2020年的“天津髖篩經(jīng)驗(yàn)”,題為“天津市嬰兒發(fā)育性髖關(guān)節(jié)發(fā)育不良的篩查結(jié)果及危險(xiǎn)因素分析”的文章發(fā)表于2022年《中華骨科雜志》上。新生兒期檢出,及時(shí)規(guī)范治療,是從臨床、影像學(xué)上“治愈”髖關(guān)節(jié)脫位/發(fā)育不良的前提。有意思的是,天津市的人群數(shù)據(jù)顯示,經(jīng)超聲確診髖關(guān)節(jié)發(fā)育不良的孩子中,僅有不足12%存在例如臀位、家族史等“危險(xiǎn)因素”。上海第六人民醫(yī)院陳博昌主任、揚(yáng)州市婦幼保健院王加寬主任積極探索利用AI技術(shù),提高髖關(guān)節(jié)超聲檢查的效率、精準(zhǔn)度和同質(zhì)化。針對(duì)髖關(guān)節(jié)發(fā)育不良的早期篩查,意義重大,但仍需多方持續(xù)努力、協(xié)作。不讓每一名孩子輸在起跑線上,保髖,真的需要大家一起努力、從娃娃抓起啊。
張中禮醫(yī)生的科普號(hào)2024年05月30日 244 0 6 -
臀中肌核心鍛煉(2):漸進(jìn)式臀中肌抗阻力康復(fù)訓(xùn)練,髖臼發(fā)育不良DDH/股骨頭壞死——保髖截骨術(shù)后康復(fù)
臀中肌鍛煉(2):漸進(jìn)式臀中肌抗阻力康復(fù)訓(xùn)練,髖臼發(fā)育不良DDH/股骨頭壞死——保髖截骨術(shù)后康復(fù)指導(dǎo)作者:JayREbert,PeterKEdwards,DanielPFick,GregoryCJanes.作者單位:SchoolofSportScience,ExerciseandHealth,UniversityofWesternAustralia,Crawley,Perth,WesternAustralia.譯者:陶可(北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科)摘要背景:鑒于臀中肌在骨盆和下肢穩(wěn)定性中的作用,以及臀中肌無(wú)力與許多下肢疾病之間已知的聯(lián)系,臀中肌康復(fù)至關(guān)重要。目的:系統(tǒng)地回顧文獻(xiàn)并提出一系列循證的漸進(jìn)式臀中肌負(fù)荷練習(xí)。證據(jù)獲?。?016年1月進(jìn)行了系統(tǒng)文獻(xiàn)檢索,以確定報(bào)告康復(fù)鍛煉期間臀中肌活動(dòng)占最大等長(zhǎng)收縮(MVIC)百分比的研究。其中包括調(diào)查無(wú)受傷參與者的研究。對(duì)鍛煉的類(lèi)型或方式?jīng)]有限制,但排除了無(wú)法在獨(dú)立環(huán)境中準(zhǔn)確復(fù)制或進(jìn)行的鍛煉。未將肌電活動(dòng)標(biāo)準(zhǔn)化為側(cè)臥MVIC的研究被排除。根據(jù)運(yùn)動(dòng)類(lèi)型和%MVIC對(duì)運(yùn)動(dòng)進(jìn)行分層:低(0%至20%)、中(21%至40%)、高(41%至60%)和極高(>61%)。證據(jù)綜合:本次綜述納入了20項(xiàng)研究,報(bào)告了33項(xiàng)練習(xí)(以及同一練習(xí)的一系列變體)的結(jié)果。俯臥、四足和雙側(cè)橋式練習(xí)通常產(chǎn)生低或中等負(fù)荷。據(jù)報(bào)告,特定的髖部外展/旋轉(zhuǎn)練習(xí)為中等、高或極高負(fù)荷。存在對(duì)側(cè)肢體運(yùn)動(dòng)的單側(cè)站立練習(xí)通常是高負(fù)荷或極高負(fù)荷的活動(dòng),而一系列功能性負(fù)重練習(xí)則存在高變異性。結(jié)論:這篇綜述概述了康復(fù)環(huán)境中常用的一系列練習(xí),根據(jù)運(yùn)動(dòng)類(lèi)型和臀中肌激活程度進(jìn)行分層。這將有助于臨床醫(yī)生從術(shù)后早期到康復(fù)后期為患者量身定制臀中肌負(fù)荷方案。ASystematicReviewofRehabilitationExercisestoProgressivelyLoadtheGluteusMediusAbstractContext:Gluteusmediusrehabilitationisofcriticalimportancegivenitsroleinpelvicandlowerlimbstability,andtheknownlinkbetweengluteusmediusweaknessandmanylowerlimbconditions.Objective:Tosystematicallyreviewtheliteratureandpresentanevidence-basedgraduatedseriesofexercisestoprogressivelyloadgluteusmedius.Evidenceacquisition:AsystematicliteraturesearchwasconductedinJanuary2016toidentifystudiesreportinggluteusmediusmuscleactivityasapercentageofmaximalvolitionalisometriccontraction(MVIC),duringrehabilitationexercises.Studiesthatinvestigatedinjuryfreeparticipantswereincluded.Norestrictionswereplacedonthetypeormodeofexercise,thoughexercisesthatcouldnotbeaccuratelyreplicatedorperformedwithinanindependentsettingwereexcluded.StudiesthatdidnotnormalizeelectromyographicactivitytoasidelyingMVICwereexcluded.Exerciseswerestratifiedbasedonexercisetypeand%MVIC:low(0%to20%),moderate(21%to40%),high(41%to60%),andveryhigh(>61%).Evidencesynthesis:20studieswereincludedinthisreview,reportingoutcomesin33exercises(andarangeofvariationsofthesameexercise).Prone,quadruped,andbilateralbridgeexercisesgenerallyproducedlowormoderateload.Specifichipabduction/rotationexerciseswerereportedasmoderate,high,orveryhighload.Unilateralstanceexercisesinthepresenceofcontralaterallimbmovementwereoftenhighorveryhighloadactivities,whilehighvariabilityexistedacrossarangeoffunctionalweight-bearingexercises.Conclusions:Thisreviewoutlinedaseriesofexercisescommonlyemployedinarehabilitationsetting,stratifiedbasedonexercisetypeandthemagnitudeofgluteusmediusmuscularactivation.Thiswillassistcliniciansintailoringgluteusmediusloadingregimenstopatients,fromtheearlypostoperativethroughtolaterstagesofrehabilitation.Jiànjìnshìtúnzhōngjīfùhèkāngfùxùnliàn文獻(xiàn)出處:JayREbert,PeterKEdwards,DanielPFick,GregoryCJanes.ASystematicReviewofRehabilitationExercisestoProgressivelyLoadtheGluteusMedius.ReviewJSportRehabil.2017Sep;26(5):418-436.doi:10.1123/jsr.2016-0088.視頻資料來(lái)源:Youtube,Googleimage.
陶可醫(yī)生的科普號(hào)2024年05月06日 254 0 2 -
髖關(guān)節(jié)發(fā)育不良——年輕人髖關(guān)節(jié)疼痛常見(jiàn)原因之二
髖關(guān)節(jié)發(fā)育不良(developmentaldysplasiaofthehip,簡(jiǎn)稱(chēng)DDH)是一種常見(jiàn)的骨骼畸形,指的是髖關(guān)節(jié)的形態(tài)或位置異常,導(dǎo)致股骨頭和髖臼的不穩(wěn)定或不匹配。髖關(guān)節(jié)是人體最大的球窩關(guān)節(jié),由股骨頭和髖臼組成,正常情況下,股骨頭應(yīng)該完全覆蓋在髖臼內(nèi),形成一個(gè)同心圓的關(guān)系,保證關(guān)節(jié)的穩(wěn)定性和功能性。髖關(guān)節(jié)發(fā)育不良的機(jī)制尚不完全清楚,可能與遺傳、環(huán)境、激素等多種因素有關(guān)。一般認(rèn)為,髖關(guān)節(jié)發(fā)育不良可以分為兩種類(lèi)型:先天性和后天性。先天性髖關(guān)節(jié)發(fā)育不良是指出生時(shí)就存在的髖關(guān)節(jié)異常,可能與胎兒在子宮內(nèi)的位置、姿勢(shì)、空間、營(yíng)養(yǎng)等有關(guān),也可能與家族史、母親的年齡、孕期用藥等有關(guān)。后天性髖關(guān)節(jié)發(fā)育不良是指出生后由于某些原因?qū)е碌捏y關(guān)節(jié)異常,可能與嬰兒的包裹方式、抱姿、營(yíng)養(yǎng)、生長(zhǎng)速度等有關(guān),也可能與某些疾病如神經(jīng)肌肉病、感染、創(chuàng)傷等有關(guān)。髖關(guān)節(jié)發(fā)育不良的癥狀因年齡、類(lèi)型和程度不同而異。在嬰兒期,髖關(guān)節(jié)發(fā)育不良可能沒(méi)有明顯的癥狀,或者表現(xiàn)為臀紋、大腿紋不對(duì)稱(chēng),下肢不等長(zhǎng),髖關(guān)節(jié)活動(dòng)受限,髖關(guān)節(jié)彈響等。在兒童期,髖關(guān)節(jié)發(fā)育不良可能表現(xiàn)為跛行、髖關(guān)節(jié)疼痛、髖關(guān)節(jié)畸形、髖關(guān)節(jié)功能障礙等。需要早期發(fā)現(xiàn)、早期治療。在成人期,髖關(guān)節(jié)發(fā)育不良可能導(dǎo)致髖關(guān)節(jié)炎的發(fā)生,表現(xiàn)為髖關(guān)節(jié)疼痛、僵硬、腫脹、活動(dòng)受限等,嚴(yán)重影響生活質(zhì)量。髖關(guān)節(jié)發(fā)育不良的分型有多種方法,常用的有以下幾種:?嬰幼兒時(shí)期,根據(jù)髖關(guān)節(jié)的穩(wěn)定性,分為不穩(wěn)定型、半脫位型和脫位型。不穩(wěn)定型指股骨頭在髖臼內(nèi)可以移動(dòng),但不會(huì)脫出;半脫位型指股骨頭在髖臼內(nèi)部分脫出,但仍有一部分覆蓋在髖臼內(nèi);脫位型指股骨頭完全脫出髖臼,與髖臼分離。?成人后,根據(jù)股骨頭的上移程度,分為CroweI型、II型、III型和IV型。上移越多,畸形越嚴(yán)重。CroweI型指股骨頭上移程度小于50%;CroweII型指股骨頭上移程度在50%到74%之間;CroweIII型指股骨頭上移程度在75%到100%之間;CroweIV型指股骨頭上移程度大于100%。髖關(guān)節(jié)發(fā)育不良的保守治療主要適用于早期、輕度或無(wú)癥狀的患者,目的是減輕疼痛,延緩病情進(jìn)展,保護(hù)關(guān)節(jié)功能。保守治療的方法包括:?控制體重,減少關(guān)節(jié)的負(fù)荷,避免過(guò)度的運(yùn)動(dòng)和勞累,選擇適當(dāng)?shù)倪\(yùn)動(dòng)方式,如游泳、騎自行車(chē)等。?加強(qiáng)髖周肌肉的鍛煉,增加關(guān)節(jié)的穩(wěn)定性,改善關(guān)節(jié)的血液循環(huán),促進(jìn)軟骨的營(yíng)養(yǎng),預(yù)防肌肉萎縮和關(guān)節(jié)僵硬。?口服或外用非甾體抗炎藥,緩解關(guān)節(jié)的炎癥和疼痛,改善關(guān)節(jié)的活動(dòng)度,注意藥物的副作用和禁忌,避免長(zhǎng)期或過(guò)量使用。?理療、按摩、熱敷等,促進(jìn)關(guān)節(jié)的血液循環(huán),緩解肌肉的緊張和痙攣,提高關(guān)節(jié)的柔韌性,注意不要過(guò)度或不適當(dāng)?shù)牟僮?,以免加重關(guān)節(jié)的損傷。?使用輔助器具,如拐杖、支具、鞋墊等,調(diào)整雙下肢的長(zhǎng)度,減少跛行,改善步態(tài),減輕關(guān)節(jié)的負(fù)荷,注意選擇合適的器具,定期檢查和調(diào)整。髖關(guān)節(jié)發(fā)育不良的手術(shù)治療主要適用于中晚期、重度或有癥狀的患者,目的是糾正關(guān)節(jié)的畸形,恢復(fù)關(guān)節(jié)的功能,改善生活質(zhì)量。手術(shù)治療的方法包括:?髖關(guān)節(jié)周?chē)毓鞘中g(shù),通過(guò)對(duì)髖臼或股骨進(jìn)行截骨,改變髖關(guān)節(jié)的方向或位置,增加髖臼的覆蓋,提高關(guān)節(jié)的穩(wěn)定性,延緩關(guān)節(jié)炎的發(fā)生,適用于輕度或中度的髖關(guān)節(jié)發(fā)育不良。?髖關(guān)節(jié)置換手術(shù),通過(guò)移除病變的股骨頭和髖臼,植入人工的假體,重建髖關(guān)節(jié)的結(jié)構(gòu)和功能,適用于重度或晚期的髖關(guān)節(jié)發(fā)育不良,股骨頭和髖臼已經(jīng)嚴(yán)重變形或壞死,關(guān)節(jié)間隙消失,年齡大于45歲的患者。髖關(guān)節(jié)置換手術(shù)的效果較好,可以明顯緩解疼痛,改善步態(tài),提高生活質(zhì)量,但也有一定的風(fēng)險(xiǎn)和并發(fā)癥,如感染、假體松動(dòng)、脫位、下肢不等長(zhǎng)等,需要定期復(fù)查和更換。髖關(guān)節(jié)發(fā)育不良的預(yù)后取決于多種因素,如發(fā)病年齡、類(lèi)型、程度、治療方法、治療效果等。一般來(lái)說(shuō),越早發(fā)現(xiàn)越早治療,預(yù)后越好。如果能在嬰兒期就進(jìn)行有效的保守治療,可以使髖關(guān)節(jié)發(fā)育正常,避免后期的并發(fā)癥。如果在兒童期或成人期才發(fā)現(xiàn),需要進(jìn)行手術(shù)治療,預(yù)后就要視手術(shù)的時(shí)機(jī)、方法和效果而定。如果手術(shù)能夠成功地糾正髖關(guān)節(jié)的畸形,恢復(fù)髖關(guān)節(jié)的功能,可以延緩或防止髖關(guān)節(jié)炎的發(fā)生,提高生活質(zhì)量。如果手術(shù)不能完全糾正髖關(guān)節(jié)的畸形,或者已經(jīng)發(fā)生了髖關(guān)節(jié)炎,可能需要進(jìn)行髖關(guān)節(jié)置換手術(shù),或者終身服用止痛藥,生活質(zhì)量會(huì)受到影響。
唐浩醫(yī)生的科普號(hào)2024年02月13日 157 0 0 -
髖關(guān)節(jié)發(fā)育不良:PAO髖臼周?chē)毓切g(shù)后髖關(guān)節(jié)是如何發(fā)展變化的?(不同嚴(yán)重程度的發(fā)育不良髖關(guān)節(jié)在PAO
髖關(guān)節(jié)發(fā)育不良:PAO髖臼周?chē)毓切g(shù)后髖關(guān)節(jié)是如何發(fā)展變化的?(不同嚴(yán)重程度的發(fā)育不良髖關(guān)節(jié)在PAO截骨術(shù)后能有效保髖多少年?)作者:CodyCWyles,JuanSVargas,MarkJHeidenreich,KristinCMara,ChristopherLPeters,JohnCClohisy,RobertTTrousdale,RafaelJSierra.作者單位:DepartmentofOrthopedicSurgery(C.C.W.,J.S.V.,M.J.H.,R.T.T.,andR.J.S.)andDivisionofBiomedicalStatisticsandInformatics(K.C.M.),MayoClinic,Rochester,Minnesota.譯者:陶可(北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科)摘要背景:髖臼周?chē)毓切g(shù)(PAO)是骨骼成熟患者中癥狀性髖臼發(fā)育不良或發(fā)育性髖關(guān)節(jié)發(fā)育不良(DDH)的最常見(jiàn)治療方法。這項(xiàng)多中心隊(duì)列研究的目的是描繪髖臼周?chē)毓切g(shù)(PAO)后髖關(guān)節(jié)發(fā)育不良的長(zhǎng)期放射學(xué)自然史。方法:我們?cè)u(píng)估了1996年至2012年在美國(guó)3個(gè)學(xué)術(shù)機(jī)構(gòu)接受髖臼周?chē)毓切g(shù)(PAO)的所有患者。納入標(biāo)準(zhǔn)是DDH的髖臼周?chē)毓切g(shù)(PAO)并至少進(jìn)行5年的影像學(xué)隨訪。排除標(biāo)準(zhǔn)為單純髖臼后傾、神經(jīng)源性發(fā)育不良、Legg-Calvé-Perthes病以及既往髖關(guān)節(jié)手術(shù)(包括截骨術(shù)和關(guān)節(jié)鏡檢查)的髖臼周?chē)毓切g(shù)(PAO)。共有288名患者,其中83%是女性;平均年齡和體重指數(shù)(BMI)分別為29歲和25kg/m。平均臨床和放射學(xué)隨訪時(shí)間為9.2年(范圍為5.0至21.1年)。對(duì)每張術(shù)前和術(shù)后髖關(guān)節(jié)X線片進(jìn)行評(píng)估,根據(jù)T?nnis分類(lèi)確定骨關(guān)節(jié)炎的程度。通過(guò)多狀態(tài)建模對(duì)生存率進(jìn)行分析,從而能夠通過(guò)T?nnis等級(jí)評(píng)估進(jìn)展,而不僅僅是像Kaplan-Meier技術(shù)那樣的個(gè)體轉(zhuǎn)變。結(jié)果:截至最終隨訪時(shí),144名患者(50%)進(jìn)展至少1T?nnis級(jí),其中42名患者(14.6%)接受全髖關(guān)節(jié)置換術(shù)。髖臼周?chē)毓切g(shù)(PAO)后每個(gè)T?nnis等級(jí)的平均存留年數(shù)為:T?nnis1級(jí)為19年,T?nnis2級(jí)為8年,T?nnis3級(jí)為4年。在初始T?nnis較高的基礎(chǔ)上,進(jìn)展為全髖關(guān)節(jié)置換術(shù)的可能性顯著增加(p<0.001)。最顯著的差異發(fā)生在T?nnis0級(jí)或1級(jí)與T?nnis2級(jí)之間;對(duì)于T?nnis1級(jí),5年和10年進(jìn)展為全髖關(guān)節(jié)置換術(shù)的概率分別為2%和11%,而T?nnis2級(jí)分別為23%和53%。結(jié)論:髖臼周?chē)毓切g(shù)(PAO)有效地改變了DDH的自然史?,F(xiàn)在可以使用基于T?nnis分級(jí)的精確放射學(xué)進(jìn)展來(lái)確定自然髖關(guān)節(jié)的預(yù)后。重要的是,這項(xiàng)研究表明,與T?nnis0級(jí)或1級(jí)骨關(guān)節(jié)炎患者相比,術(shù)前T?nnis2級(jí)骨關(guān)節(jié)炎患者在髖臼周?chē)毓切g(shù)(PAO)后10年內(nèi)進(jìn)展到全髖關(guān)節(jié)置換術(shù)的幾率明顯增加。表I入組隊(duì)列的患者特征在每個(gè)參與地點(diǎn)獲得當(dāng)?shù)貦C(jī)構(gòu)審查委員會(huì)批準(zhǔn)后,我們?cè)u(píng)估了1996年至2012年在3個(gè)學(xué)術(shù)機(jī)構(gòu)接受髖臼周?chē)毓切g(shù)(PAO)的所有患者,包括梅奧診所(明尼蘇達(dá)州羅徹斯特)、華盛頓大學(xué)(密蘇里州圣路易斯)和猶他州大學(xué)(猶他州鹽湖城)。納入標(biāo)準(zhǔn)為因髖關(guān)節(jié)發(fā)育不良(DDH)或髖關(guān)節(jié)發(fā)育不良(DDH)同時(shí)伴有髖臼后傾而行髖臼周?chē)毓切g(shù)(PAO),且至少進(jìn)行5年影像學(xué)隨訪。排除標(biāo)準(zhǔn)為包括因單純髖臼后傾、神經(jīng)源性發(fā)育不良、Legg-Calv′e-Perthes病而行髖臼周?chē)毓切g(shù)(PAO),以及任何先前的髖關(guān)節(jié)手術(shù),包括關(guān)節(jié)鏡檢查和兒童截骨術(shù)。最終隊(duì)列中有288名患者,其中139名來(lái)自梅奧診所,119名來(lái)自華盛頓大學(xué),30名來(lái)自猶他大學(xué)。總體而言,83%的患者為女性,平均年齡為29歲,平均體重指數(shù)(BMI)為25kg/m2(表I)。平均臨床和影像學(xué)隨訪時(shí)間為9.2年(范圍為5.0至21.1年)。137例患者在髖臼周?chē)毓切g(shù)(PAO)時(shí)進(jìn)行了同期其他手術(shù),包括88例骨軟骨成形術(shù)、31例盂唇清理術(shù)、19例盂唇修復(fù)術(shù)、11例股骨截骨術(shù)和1例轉(zhuǎn)子上移術(shù)。46例患者在髖臼周?chē)毓切g(shù)(PAO)后進(jìn)行了其他手術(shù),包括38例內(nèi)固定物移除、6例髖關(guān)節(jié)鏡探查、4例沖洗和清創(chuàng)、3例盂唇修復(fù)、1例血腫清除和1例腰肌腱松解。每張可用的術(shù)前和術(shù)后骨盆或髖關(guān)節(jié)前后位X線片均由2名評(píng)審員獨(dú)立評(píng)估,根據(jù)T?nnis分類(lèi)(0至3級(jí))確定骨關(guān)節(jié)炎的程度。當(dāng)評(píng)審者評(píng)估X線片上的T?nnis等級(jí)時(shí),根據(jù)先前描述的分類(lèi)系統(tǒng)標(biāo)準(zhǔn),將患者分配到可能的最高等級(jí)。評(píng)估人員采用以下標(biāo)準(zhǔn):T?nnis0級(jí)表示不存在退行性變化;T?nnis1級(jí)(輕度),關(guān)節(jié)間隙輕度變窄,硬化區(qū)擴(kuò)大,表現(xiàn)為輕度硬化,邊緣有小骨贅;T?nnis2級(jí)(中度),關(guān)節(jié)間隙中度變窄,股骨頭或髖臼中度硬化,股骨頭或髖臼內(nèi)存在軟骨下小的骨囊腫,股骨頭球形度中度喪失;T?nnis3級(jí)(重度),關(guān)節(jié)間隙嚴(yán)重變窄(<1mm)或關(guān)節(jié)間隙閉塞,股骨頭或髖臼上有大軟骨下骨囊腫的證據(jù),股骨頭嚴(yán)重失去球形度,以及晚期骨壞死。對(duì)每張放射學(xué)照片的評(píng)估對(duì)于通過(guò)多狀態(tài)建模進(jìn)行生存分析至關(guān)重要。與Kaplan-Meier技術(shù)相比,該方法結(jié)合了所有單獨(dú)的放射學(xué)照相數(shù)據(jù)點(diǎn)來(lái)定義疾病進(jìn)展,精度更高。分析中總共納入了288名患者的2,024張X線片,每位患者中位數(shù)為7張X線片(范圍為2至17張X線片)。除了T?nnis等級(jí)評(píng)估之外,術(shù)前和術(shù)后還評(píng)估了骨盆前后位以及髖關(guān)節(jié)前后位和側(cè)位X線片,以確定如前所述的以下參數(shù):最小關(guān)節(jié)間隙(以毫米為單位)、側(cè)向中心邊緣角(LCEA)、T?nnis角、前中心-邊緣角(ACE)和髖臼后傾(表I)。將多狀態(tài)模型確定的疾病進(jìn)展與歷史對(duì)照患者隊(duì)列進(jìn)行比較,這些患者要么患有DDH,但未接受保髖手術(shù),要么具有正常形態(tài)的髖關(guān)節(jié)(由LCEA定義為25°至40°和T?nnis角0°至10°)。這些歷史對(duì)照采用相同的統(tǒng)計(jì)技術(shù)進(jìn)行評(píng)估,并跟蹤長(zhǎng)達(dá)35年。BMI=體重指數(shù),LCEA=外側(cè)中心邊緣角,ACE=前方中心邊緣角。?數(shù)值以平均值和標(biāo)準(zhǔn)差形式給出,范圍在括號(hào)內(nèi)。?數(shù)值以平均值和標(biāo)準(zhǔn)差的形式給出?!熳罱K隨訪時(shí)的T?nnis等級(jí)。圖1?研究中所有288名患者的T?nnis分級(jí)。最終隨訪時(shí)向各種T?nnis等級(jí)或全髖關(guān)節(jié)置換術(shù)(THA)的過(guò)渡用箭頭顯示。在最終隨訪時(shí){9.2年(范圍為5.0至21.1年)},144名患者(50%)進(jìn)展至少1個(gè)T?nnis級(jí),其中42名患者(14.6%)接受全髖關(guān)節(jié)置換術(shù)(圖1)。具體如下:術(shù)前,150個(gè)T?nnis0級(jí)髖中,有76(50.67%)髖進(jìn)展到T?nnis1級(jí)髖,有2(1.33%)髖進(jìn)展到T?nnis2級(jí)髖,有0(0.00%)髖進(jìn)展到T?nnis3級(jí)髖,有1(0.67%)髖進(jìn)展到全髖關(guān)節(jié)置換術(shù)(THA);191個(gè)T?nnis1級(jí)髖中,有52(27.23%)髖進(jìn)展到T?nnis2級(jí)髖,有5(2.62%)髖進(jìn)展到T?nnis3級(jí)髖,有4(2.09%)髖進(jìn)展到全髖關(guān)節(jié)置換術(shù)(THA);75個(gè)T?nnis2級(jí)髖中,有25(33.33%)髖進(jìn)展到T?nnis3級(jí)髖,有14(18.67%)髖進(jìn)展到全髖關(guān)節(jié)置換術(shù)(THA);32個(gè)T?nnis3級(jí)髖中,有23(71.88%)髖進(jìn)展到全髖關(guān)節(jié)置換術(shù)(THA)。?表II根據(jù)髖關(guān)節(jié)形態(tài)學(xué)和手術(shù)干預(yù)劃分的在每個(gè)T?nnis等級(jí)中停留的平均年數(shù)髖臼周?chē)毓切g(shù)(PAO)后每個(gè)T?nnis等級(jí)的平均年數(shù)非常接近具有正常髖關(guān)節(jié)形態(tài)的歷史隊(duì)列。然而,歷史隊(duì)列中未經(jīng)治療的髖關(guān)節(jié)發(fā)育不良(DDH)患者比形態(tài)正常的患者和當(dāng)前研究中接受髖臼周?chē)毓切g(shù)(PAO)的患者髖關(guān)節(jié)骨關(guān)節(jié)炎(OA)進(jìn)展更快(表II)。對(duì)于通過(guò)髖臼周?chē)毓切g(shù)(PAO)的髖關(guān)節(jié)發(fā)育不良(DDH)患者,在每個(gè)T?nnis等級(jí)中停留的平均年數(shù)(近似理解為:保髖術(shù)后髖關(guān)節(jié)成功存留年數(shù))為:T?nnis1級(jí)為19年,T?nnis2級(jí)為8年,T?nnis3級(jí)為4年;對(duì)于患有髖關(guān)節(jié)發(fā)育不良(DDH)而未接受髖臼周?chē)毓切g(shù)(PAO)的患者,T?nnis1級(jí)髖關(guān)節(jié)存活12年,T?nnis2級(jí)髖關(guān)節(jié)存活6年,T?nnis3級(jí)髖關(guān)節(jié)存活2年;對(duì)于(股骨頭)形態(tài)正常的髖關(guān)節(jié)發(fā)育不良(DDH)且未接受髖臼周?chē)毓切g(shù)(PAO)的患者,分別為18、9和0年(表II)。圖2?多狀態(tài)建模分析顯示基于任何給定時(shí)間點(diǎn)的T?nnis等級(jí)的無(wú)全髖關(guān)節(jié)置換術(shù)(THA)的存活率。因此,當(dāng)患者進(jìn)展到更嚴(yán)重的T?nnis等級(jí)時(shí),他們會(huì)假定指示曲線所歸因的自然歷史是從時(shí)間零開(kāi)始。髖臼周?chē)毓切g(shù)(PAO)手術(shù)前T?nnis分級(jí)較高,進(jìn)展為全髖關(guān)節(jié)置換術(shù)的可能性顯著增加(p<0.001)(圖2)。?表III?基于當(dāng)前T?nnis等級(jí)進(jìn)展到嚴(yán)重T?nnis等級(jí)或全髖關(guān)節(jié)置換術(shù)的概率。自然史最顯著的差異發(fā)生在髖臼周?chē)毓切g(shù)(PAO)時(shí)T?nnis0級(jí)或1級(jí)患者與T?nnis2級(jí)患者之間。對(duì)于T?nnis1級(jí)患者,5年和10年進(jìn)展為全髖關(guān)節(jié)置換術(shù)的概率分別為2%和11%,而T?nnis2級(jí)患者則分別為23%和53%(p<0.001)(表III)。髖臼周?chē)毓切g(shù)(PAO)后,進(jìn)展率和模式與歷史隊(duì)列中形態(tài)正常的患者相似,但與未處理的髖關(guān)節(jié)發(fā)育不良(DDH)患者相比顯著改善(所有比較p<0.05)(表III)。表IV?Cox比例風(fēng)險(xiǎn)回歸模型評(píng)估患者人口統(tǒng)計(jì)特征對(duì)髖臼周?chē)毓切g(shù)(PAO)后進(jìn)展至嚴(yán)重T?nnis等級(jí)的影響在髖關(guān)節(jié)發(fā)育不良(DDH)組中,根據(jù)形態(tài)學(xué)和/或手術(shù)干預(yù),髖臼周?chē)毓切g(shù)(PAO)10年后T?nnis1級(jí)或2級(jí)患者進(jìn)展為全髖關(guān)節(jié)置換術(shù)的概率:T?nnis1級(jí)患者為11%,T?nnis2級(jí)患者為53%;沒(méi)有髖臼周?chē)毓切g(shù)(PAO)的髖關(guān)節(jié)發(fā)育不良(DDH)組中:T?nnis1級(jí)患者進(jìn)展為全髖關(guān)節(jié)置換術(shù)為25%,T?nnis2級(jí)患者進(jìn)展為全髖關(guān)節(jié)置換術(shù)為74%;在沒(méi)有髖臼周?chē)毓切g(shù)(PAO)的(股骨頭)形態(tài)正常組中,這一比例為18%和68%(表III)。Cox比例風(fēng)險(xiǎn)回歸模型表明,年齡、性別或BMI與髖臼周?chē)毓切g(shù)(PAO)后進(jìn)展至更嚴(yán)重T?nnis階段之間沒(méi)有顯著的總體關(guān)系(表IV)。??NaturalHistoryoftheDysplasticHipFollowingModernPeriacetabularOsteotomy.AbstractBackground:Periacetabularosteotomy(PAO)isthemostcommontreatmentforsymptomaticacetabulardysplasia,ordevelopmentaldysplasiaofthehip(DDH),inskeletallymaturepatients.Thepurposeofthismulticentercohortstudywastodelineatethelong-termradiographicnaturalhistoryofthedysplastichipfollowingPAO.Methods:WeevaluatedallpatientsundergoingPAOfrom1996to2012at3academicinstitutionsintheUnitedStates.InclusioncriteriawerePAOforDDHwithaminimum5-yearradiographicfollow-up.ExclusioncriteriawerePAOforisolatedacetabularretroversion,neurogenicdysplasia,Legg-Calvé-Perthesdisease,andpriorhipsurgeryincludingosteotomiesandarthroscopy.Therewere288patients,83%ofwhomwerewomen;themeanageandbodymassindex(BMI)were29yearsand25kg/m,respectively.Themeanclinicalandradiographicfollow-upwas9.2years(range,5.0to21.1years).EverypreoperativeandpostoperativehipradiographwasassessedtodeterminethedegreeofosteoarthritisaccordingtotheT?nnisclassification.Survivorshipwasanalyzedbymultistatemodeling,enablingassessmentofprogressionthroughtheT?nnisgradesratherthanjustindividualtransitionsaswithKaplan-Meiertechniques.Results:Atthetimeoffinalfollow-up,144patients(50%)hadprogressedatleast1T?nnisgrade,with42patients(14.6%)undergoingtotalhiparthroplasty.ThemeannumberofyearsspentineachT?nnisgradefollowingPAOwas19forT?nnisgrade1,8forT?nnisgrade2,and4forT?nnisgrade3.TheprobabilityofprogressiontototalhiparthroplastyincreasedsignificantlyonthebasisofahigherinitialT?nnisgrade(p<0.001).ThemostmarkeddifferenceoccurredbetweenT?nnisgrade0or1andT?nnisgrade2;forT?nnisgrade1,theprobabilityofprogressiontototalhiparthroplastyat5and10yearswas2%and11%,respectively,comparedwith23%and53%,respectively,forT?nnisgrade2.Conclusions:PAOeffectivelyaltersthenaturalhistoryofDDH.PreciseradiographicprogressionbasedontheT?nnisgradecannowbeusedtoascribeprognosisforthenativehip.Importantly,thisinvestigationdemonstratesastarkincreaseinprogressiontototalhiparthroplastywithin10yearsofPAOforpatientswithpreoperativeT?nnisgrade-2osteoarthritiscomparedwiththosewithT?nnisgrade-0or1osteoarthritis.?TABLEIPatientCharacteristicsofCohortFollowinglocalinstitutionalreviewboardapprovalateachparticipatingsite,weevaluatedallpatientsundergoingPAO,from1996to2012,at3academicinstitutionsincludingtheMayoClinic(Rochester,Minnesota),WashingtonUniversity(St.Louis,Missouri),andtheUniversityofUtah(SaltLakeCity,Utah).InclusioncriteriawerePAOforDDHorforDDHandconcomitantacetabularretroversionwithaminimum5-yearradiographicfollow-up.ExclusioncriteriawerePAOforisolatedacetabularretroversion,neurogenicdysplasia,Legg-Calv′e-Perthesdisease,andanypriorsurgeryaboutthehipincludingarthroscopyandchildhoodosteotomies.Therewere288patientsinthefinalcohort,with139fromtheMayoClinic,119fromWashingtonUniversity,and30fromtheUniversityofUtah.Overall,83%ofthepatientswerewomen,themeanagewas29years,andthemeanbodymassindex(BMI)was25kg/m2(TableI).Themeanclinicalandradiographicfollowupwas9.2years(range,5.0to21.1years).ConcomitantproceduresatthetimeofPAOwereperformedin137patientsandincluded88osteochondroplasties,31labraldebridements,19labralrepairs,11femoralosteotomies,and1trochantericadvancement.AdditionalprocedureswereperformedfollowingPAOin46patientsandincluded38hardwareremovals,6arthroscopicexplorations,4irrigationanddebridements,3labralrepairs,1hematomaevacuation,and1psoastendonrelease.Everyavailablepreoperativeandpostoperativeanteroposteriorradiographofthepelvisorhipwasindependentlyassessedby2reviewerstodeterminethedegreeofosteoarthritisaccordingtotheT?nnisclassification(grade0to3).WhenthereviewersassessedforT?nnisgradesonradiographs,patientswereassignedtothehighestgradepossibleonthebasisofpreviouslydescribedcriteriafortheclassificationsystem.Thefollowingcriteriawereappliedbytheassessors:T?nnisgrade0indicatedtheabsenceofdegenerativechanges;T?nnisgrade1(mild),mildjoint-spacenarrowing,mildsclerosisevidencedbywideningofthescleroticzone,andsmallmarginalosteophytes;T?nnisgrade2(moderate),moderatejoint-spacenarrowing,moderatesclerosisofthefemoralheadoracetabulum,presenceofsmallsubchondralcystswithinthefemoralheadoracetabulum,andmoderatelossoffemoralheadsphericity;andT?nnisgrade3(severe),severejoint-spacenarrowing(<1mm)orobliterationofthejointspace,evidenceoflargesubchondralcystsonthefemoralheadoracetabulum,severelossofsphericityofthefemoralhead,andadvancedosteonecrosis.Evaluationofeveryradiographwasessentialtoenablesurvivorshipanalysisbymultistatemodeling.ThismethodincorporatesallindividualradiographicdatapointsfordefinitionofdiseaseprogressionwithenhancedprecisioncomparedwithKaplan-Meiertechniques.Atotalof2,024radiographsofthe288patientswereincludedintheanalysis,withamedianof7radiographs(range,2to17radiographs)perpatient.InadditiontoT?nnisgradeevaluation,anteroposteriorpelvicandanteroposteriorandlateralradiographsofthehipwereassessedbothpreoperativelyandpostoperativelytodeterminethefollowingparametersaspreviouslydescribed:minimumjointspaceinmillimeters,lateralcenteredgeangle(LCEA),T?nnisangle,anteriorcenter-edgeangle(ACE),andacetabularretroversion(TableI)14.ProgressionofdiseaseasdeterminedbymultistatemodelingwascomparedwithahistoricalcontrolcohortofpatientswhoeitherhadDDHanddidnotundergohippreservationsurgeryorhadahipwithnormalmorphologyasdefinedbyanLCEAbetween25°and40°andaT?nnisangleof0°to10°.Thesehistoricalcontrolswereevaluatedbythesamestatisticaltechniquesandwerefollowedforupto35years.BMI=bodymassindex,LCEA=lateralcenter-edgeangle,andACE=anteriorcenter-edgeangle.?Thevaluesaregivenasthemeanandthestandarddeviation,withtherangeinparentheses.?Thevaluesaregivenasthemeanandthestandarddeviation.§T?nnisgradeatthetimeoffinalfollow-up.Fig.1TheT?nnisgradeofall288patientsinthestudy.TransitionstovariousT?nnisgradesortotalhiparthroplasty(THA)atthetimeoffinalfollow-upareshownwitharrows.Atthetimeoffinalfollow-up,144patients(50%)hadprogressionofleast1T?nnisgrade,with42patients(14.6%)undergoingtotalhiparthroplasty(Fig.1).TABLEIIMeanYearsSpentinEachT?nnisGradebyHipMorphologyandSurgicalInterventionThemeannumberofyearsspentineachT?nnisgradefollowingPAOcloselyapproximatedahistoricalcohortwithnormalhipmorphology12.However,patientswithunmanagedDDHfromthehistoricalcohorthadmorerapidprogressionthanpatientswhohadnormalmorphologyandpatientsfromthecurrentstudywhounderwentPAO(TableII).ThemeannumberofyearsspentineachT?nnisgradebymorphologyand/orsurgicalinterventionwas19yearsinT?nnisgrade1,8yearsinT?nnisgrade2,and4yearsinT?nnisgrade3forpatientswithDDHwhohadPAO;12,6,and2years,respectively,forpatientswithDDHandnoPAO;and18,9,and0years,respectively,forpatientswithnormalmorphologyandnoPAO(TableII).Fig.2Multistatemodelinganalysisdemonstratingsurvivorshipfreeoftotalhiparthroplasty(THA)basedontheT?nnisgradeatanygivenpointintime.Thus,themomentapatienttransitionstoamoreadvancedT?nnisgrade,theyassumethenaturalhistoryascribedbytheindicatedcurve,beginningattimezero.TheprobabilityofprogressiontototalhiparthroplastyincreasedsignificantlyonthebasisofahigherT?nnisgradeatthetimeofPAO(p<0.001)(Fig.2).TABLEIIIProbabilityofTransitiontoSubsequentT?nnisGradesorTotalHipArthroplastyBasedonCurrentT?nnisGrade.ThemostmarkeddifferenceinnaturalhistoryoccurredbetweenpatientswhohadT?nnisgrade0or1andthosewhohadT?nnisgrade2atthetimeofPAO.ForpatientswithT?nnisgrade1,theprobabilityofprogressiontototalhiparthroplastyat5and10yearswas2%and11%,respectively,comparedwith23%and53%forpatientswithT?nnisgrade2(p<0.001)(TableIII).FollowingPAO,therateandpatternofprogressionapproximatedthoseforpatientswithnormalmorphologyfromthehistoricalcohortbutweresignificantlyimprovedcomparedwithpatientswithunmanagedDDH(p<0.05forallcomparisons)(TableIII).TABLEIVCoxProportionalHazardsRegressionModelsAssessingInfluenceofPatientDemographicsonProgressiontoMoreAdvancedT?nnisGradesFollowingPAOThe10-yearprobabilityofpatientswithT?nnisgrade1or2progressingtototalhiparthroplastyaccordingtomorphologyand/orsurgicalinterventionwas11%forpatientswithT?nnisgrade1and53%forthosewithT?nnisgrade2inthegroupwhohadDDHwithPAO;25%and74%,respectively,inthegroupwithDDHwithoutPAO;and18%and68%inthegroupwithnormalmorphologywithoutPAO(TableIII).Coxproportionalhazardsregressionmodelsdemonstratednosignificantoverallrelationshipofage,sex,orBMIwithprogressiontomoreadvancedT?nnisstagesfollowingPAO(TableIV).文獻(xiàn)出處:CodyCWyles,JuanSVargas,MarkJHeidenreich,KristinCMara,ChristopherLPeters,JohnCClohisy,RobertTTrousdale,RafaelJSierra.NaturalHistoryoftheDysplasticHipFollowingModernPeriacetabularOsteotomy.JBoneJointSurgAm.2019May15;101(10):932-938.doi:10.2106/JBJS.18.00983.
陶可醫(yī)生的科普號(hào)2023年12月26日 301 1 5 -
髖臼發(fā)育不良,不想關(guān)節(jié)置換怎么辦?
髖關(guān)節(jié)發(fā)育不良,是指髖臼小沒(méi)有正常覆蓋股骨頭。也可以伴有股骨頭變扁。目前原因不清。在我國(guó)東北同一地區(qū)朝鮮族孩子先天性髖脫位和發(fā)育不良明顯比漢族少,就是因?yàn)槌r族媽媽用蛙式背帶背著寶寶,而漢族寶寶被捆直雙腿。說(shuō)明有后天因素。因?yàn)轶y發(fā)育不良,股骨頭和髖臼接觸面積變小,局部壓強(qiáng)增大造成軟骨磨損。大概在患者40歲左右出現(xiàn)越來(lái)越厲害的疼痛。遺憾的是很多骨科醫(yī)生會(huì)建議患者等待磨損嚴(yán)重再做關(guān)節(jié)置換。問(wèn)題是從出現(xiàn)疼痛到置換,可能要在痛苦中等待二十年甚至更久。就沒(méi)有盡快解除痛苦的辦法嗎?答案是有辦法!中山大學(xué)附屬第八醫(yī)院運(yùn)動(dòng)醫(yī)學(xué)科的張文濤教授團(tuán)隊(duì),開(kāi)展了關(guān)節(jié)鏡微創(chuàng)修復(fù)軟骨缺損,同時(shí)增加髖臼覆蓋的方法。根本上處理了疼痛的原因,減少了后期關(guān)節(jié)置換的可能。
張文濤醫(yī)生的科普號(hào)2023年12月21日 107 0 0 -
發(fā)育性髖關(guān)節(jié)發(fā)育不良
葛翼華醫(yī)生的科普號(hào)2023年11月20日 88 0 0 -
減少關(guān)節(jié)置換,任重道遠(yuǎn)
陳珽醫(yī)生的科普號(hào)2023年11月07日 44 0 0 -
髖關(guān)節(jié)為什么是最重要的關(guān)節(jié)
張中禮醫(yī)生的科普號(hào)2023年08月30日 66 0 2
相關(guān)科普號(hào)
張紅安醫(yī)生的科普號(hào)
張紅安 主治醫(yī)師
廣東省第二人民醫(yī)院
創(chuàng)傷骨科
22粉絲4980閱讀
方芳醫(yī)生的科普號(hào)
方芳 副主任醫(yī)師
上海交通大學(xué)醫(yī)學(xué)院附屬新華醫(yī)院
發(fā)育行為兒童保健科
460粉絲5.1萬(wàn)閱讀
李金松醫(yī)生的科普號(hào)
李金松 主任醫(yī)師
山東中醫(yī)藥大學(xué)附屬醫(yī)院
關(guān)節(jié)骨科
2196粉絲45.7萬(wàn)閱讀
-
推薦熱度5.0張中禮 主任醫(yī)師天津醫(yī)院 小兒骨科
先天性髖關(guān)節(jié)脫位 81票
小兒骨折 59票
小兒股骨頭壞死 22票
擅長(zhǎng):兒童髖關(guān)節(jié)發(fā)育不良早期篩查及規(guī)范治療 兒童髖關(guān)節(jié)脫位早期規(guī)范化保守及手術(shù)治療 大齡兒童/青少年、復(fù)雜髖關(guān)節(jié)疾患保髖及翻修手術(shù) 兒童股骨頭壞死(Perthes病)規(guī)范保守及手術(shù)治療 軟骨發(fā)育不良類(lèi)髖關(guān)節(jié)畸形綜合評(píng)估與手術(shù)矯正 兒童髖內(nèi)翻手術(shù)矯正 股骨頭骨骺滑脫手術(shù)治療 保守及微創(chuàng)手術(shù)治療兒童骨關(guān)節(jié)骨折 兒童四肢畸形評(píng)估與矯正 兒童骨代謝/發(fā)育疾?。ü抢w維異常增殖癥、成骨不全癥、軟骨發(fā)育不良等)綜合治療 兒童良惡性骨腫瘤綜合治療 -
推薦熱度4.4彭建平 副主任醫(yī)師上海新華醫(yī)院 骨科
先天性髖關(guān)節(jié)脫位 25票
髖關(guān)節(jié)脫位 18票
人工關(guān)節(jié)置換術(shù) 10票
擅長(zhǎng):青少年及成人髖關(guān)節(jié)發(fā)育不良、髖股撞擊,盂唇損傷,彈響髖,股骨頭壞死,髖膝骨關(guān)節(jié)炎,四肢骨折 -
推薦熱度4.2劉利君 主任醫(yī)師華西醫(yī)院 小兒骨科
先天性髖關(guān)節(jié)脫位 19票
髖關(guān)節(jié)脫位 10票
小兒股骨頭壞死 1票
擅長(zhǎng):小兒骨科各種先天畸形(先天性髖脫位,馬蹄足畸形,多指并指)、骨折、骨腫瘤,斜頸,骨關(guān)節(jié)炎等疾病的診治。局麻下對(duì)各種體表包塊,腱鞘炎,多指手術(shù)