先天性髖關(guān)節(jié)脫位
（又稱：發(fā)育性髖關(guān)節(jié)發(fā)育不良）
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兒童髖關(guān)節(jié)發(fā)育不良如何正確佩戴吊帶
張中禮醫(yī)生的科普號(hào)
2025年03月27日
86
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4
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嬰幼兒髖關(guān)節(jié)彩超如何看？
一、正常髖關(guān)節(jié)（I型）的特點(diǎn)及治療特點(diǎn)：Ⅰ型髖關(guān)節(jié)發(fā)育正常，其中又分Ia型和Ib型。Ia型β角小于55度，Ib型β角在55-77度，兩者α角都大于60度。髖臼角30°，α角60°，β角55°。髖臼對(duì)股骨頭有良好的覆蓋，骨頂外緣銳利成角（Ⅰa型）或輕度變鈍（Ⅰb型），臼頂軟骨狹窄呈三角形1。治療：對(duì)于Ⅰ型髖關(guān)節(jié)，通常不需要特殊治療，只需定期進(jìn)行復(fù)查，觀察髖關(guān)節(jié)的發(fā)育情況。因?yàn)檫@是正常的髖關(guān)節(jié)發(fā)育狀態(tài)，在日常的生長(zhǎng)發(fā)育過(guò)程中，正常的活動(dòng)和生活不會(huì)對(duì)其產(chǎn)生不良影響。但家長(zhǎng)也需要關(guān)注孩子的一些日常行為，例如孩子的活動(dòng)是否自如等，若發(fā)現(xiàn)異常情況應(yīng)及時(shí)就醫(yī)進(jìn)一步檢查。二、髖關(guān)節(jié)發(fā)育稍差（Ⅱ型）的特點(diǎn)與治療特點(diǎn)：Ⅱ型髖關(guān)節(jié)發(fā)育稍差，分為Ⅱa、Ⅱb、Ⅱc、Ⅱd四個(gè)亞型。Ⅱa型指出生12周以內(nèi)嬰兒，α角為50°-59°，β角小于55度；Ⅱb型指12周以上嬰兒髖，α角50°-59°，β角55°；Ⅱc型α角43°-49°，β角小于77度；Ⅱd型α角同Ⅱc型，β角大于77度。髖臼角在30°-43°之間，α角55°-60°，β角55°。該型髖的骨性髖臼外上緣缺少鈣化，骨頂輪廓發(fā)育缺陷的部分由軟骨頂增寬充填，覆蓋在股骨頭上25。治療：對(duì)于Ⅱ型髖關(guān)節(jié)，尤其是Ⅱa和Ⅱb型，因?yàn)樘幱隗y關(guān)節(jié)發(fā)育的臨界狀態(tài)或者骨化延遲狀態(tài)，在早期通常采取觀察和定期復(fù)查的策略。如果沒有進(jìn)一步的惡化或者有好轉(zhuǎn)的趨勢(shì)，可以繼續(xù)觀察。而對(duì)于Ⅱc和Ⅱd型髖臼發(fā)育不良的情況，可采用軟式支具矯治，如Pavlik吊帶等。通過(guò)支具將髖關(guān)節(jié)保持在合適的位置，促進(jìn)髖臼的正常發(fā)育。在使用支具期間，需要定期進(jìn)行超聲檢查來(lái)評(píng)估治療效果，并且要注意支具的佩戴是否合適，避免對(duì)孩子的皮膚等造成損傷。三、髖關(guān)節(jié)發(fā)育不良（Ⅲ型）的特點(diǎn)與治療特點(diǎn)：Ⅲ型髖關(guān)節(jié)發(fā)育不良，分為Ⅲa和Ⅲb型。Ⅲ型髖關(guān)節(jié)髖臼角43°-55°，α角40°-55°，β角55°-77°。兩類髖中股骨頭均向上外方脫位，Ⅲa軟骨頂為無(wú)回聲結(jié)構(gòu)，是透明軟骨成分，Ⅲb的軟骨頂可見有程度不同回聲，說(shuō)明透明軟骨可能發(fā)生了纖維化或變性改變。在單一冠狀聲像上，脫位的股骨頭和髖臼不能同時(shí)完整顯現(xiàn)，參考測(cè)量點(diǎn)難以辨認(rèn)5。治療：對(duì)于Ⅲ型髖關(guān)節(jié)發(fā)育不良，早期（6-7個(gè)月以下）可采用保守治療，如使用Pavlik吊帶、支具等。從經(jīng)驗(yàn)和文獻(xiàn)的報(bào)道來(lái)說(shuō)，這種保守治療對(duì)于這個(gè)年齡段的孩子成功率可以達(dá)到90%以上。在使用支具或吊帶期間，需要密切關(guān)注孩子髖關(guān)節(jié)的復(fù)位情況，定期進(jìn)行超聲檢查。如果保守治療不成功，可以改用麻醉下石膏復(fù)位。經(jīng)過(guò)復(fù)位的關(guān)節(jié)對(duì)髖臼的刺激，局部發(fā)育就會(huì)逐步的改善。同時(shí)，在治療過(guò)程中，還需要關(guān)注孩子下肢的血液循環(huán)、神經(jīng)功能等情況，避免因治療導(dǎo)致其他并發(fā)癥的出現(xiàn)。四、髖關(guān)節(jié)脫位（Ⅳ型）的特點(diǎn)與治療特點(diǎn)：Ⅳ型髖關(guān)節(jié)脫位，髖臼角55°，α角40°，β角77°。此型髖的聲學(xué)特點(diǎn)是股骨頭脫位，表面只有薄層關(guān)節(jié)囊覆蓋，髖臼唇盂和軟骨頂也向原始髖臼的內(nèi)下方移位。在B超下α角甚至測(cè)量不出，屬于髖關(guān)節(jié)高位脫位的情況212。治療：對(duì)于Ⅳ型髖關(guān)節(jié)脫位，因?yàn)槊撐磺闆r較為嚴(yán)重，一般需要積極治療。對(duì)于6-7個(gè)月以下的嬰兒，如果保守治療（如Pavlik吊帶等）效果不佳，可考慮麻醉下石膏復(fù)位。而對(duì)于年齡較大的孩子（7-18個(gè)月），可能需要進(jìn)行麻醉下閉合復(fù)位或者切開復(fù)位，然后用石膏固定。在復(fù)位過(guò)程中，要確保股骨頭準(zhǔn)確復(fù)位到髖臼內(nèi)，并且要關(guān)注復(fù)位后髖關(guān)節(jié)的穩(wěn)定性。在術(shù)后，需要長(zhǎng)期的康復(fù)隨訪，觀察髖關(guān)節(jié)的發(fā)育情況以及孩子的下肢功能恢復(fù)情況，預(yù)防股骨頭壞死、髖關(guān)節(jié)僵硬等并發(fā)癥的發(fā)生。五、髖關(guān)節(jié)半脫位（Ⅴ型）的特點(diǎn)與治療特點(diǎn)：Ⅴ型髖關(guān)節(jié)半脫位，髖臼角55°，α角40°，β角77°-90°。髖關(guān)節(jié)處于半脫位狀態(tài)，股骨頭部分脫離髖臼，關(guān)節(jié)的穩(wěn)定性受到影響，髖臼對(duì)股骨頭的覆蓋不完全，這會(huì)影響髖關(guān)節(jié)的正常發(fā)育和功能1。治療：對(duì)于Ⅴ型髖關(guān)節(jié)半脫位的治療與Ⅲ型髖關(guān)節(jié)發(fā)育不良類似。在早期可嘗試保守治療，如使用Pavlik吊帶或支具，并且定期復(fù)查超聲，觀察髖關(guān)節(jié)復(fù)位情況。如果保守治療失敗，根據(jù)孩子的年齡可選擇麻醉下石膏復(fù)位（6-7個(gè)月以下）或者其他更復(fù)雜的復(fù)位手術(shù)（年齡較大時(shí)）。在整個(gè)治療過(guò)程中，同樣要關(guān)注髖關(guān)節(jié)的功能恢復(fù)和發(fā)育情況，避免出現(xiàn)并發(fā)癥。
董堯醫(yī)生的科普號(hào)
2024年12月21日31
0
2
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臨界髖關(guān)節(jié)發(fā)育不良Borderline DDH (5)：MRI上的股骨骨骺髖臼頂指數(shù)（FEAR）測(cè)量
臨界髖關(guān)節(jié)發(fā)育不良BorderlineDDH(5)：MRI上的股骨骨骺髖臼頂指數(shù)（FEAR）測(cè)量是否預(yù)測(cè)臨界髖關(guān)節(jié)發(fā)育不良的不穩(wěn)定性？作者：CécileBatailler,JanWeidner,MichaelWyatt,DominikPfluger,MartinBeck作者單位:CHULyonCroix-Rousse,HospicesCivilsdeLyon,Lyon,France.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要目的：臨界髖關(guān)節(jié)發(fā)育不良型既可以表現(xiàn)為穩(wěn)定，也可以表現(xiàn)為不穩(wěn)定，這使得手術(shù)決策具有挑戰(zhàn)性。雖然不穩(wěn)定髖關(guān)節(jié)最好通過(guò)髖臼重新定位來(lái)治療，但穩(wěn)定的髖關(guān)節(jié)可以通過(guò)關(guān)節(jié)鏡治療。幾個(gè)成像參數(shù)可以幫助確定適當(dāng)?shù)闹委煼椒?，包括在普通X線片上測(cè)量的股骨-骨骺髖臼頂(FEAR)指數(shù)。本研究的目的是評(píng)估MRI上FEAR指數(shù)與其放射學(xué)測(cè)量相比的可靠性和敏感性?；颊吆头椒ǎ憾x了在MRI上測(cè)量FEAR指數(shù)的技術(shù)并驗(yàn)證了其可靠性。一項(xiàng)回顧性研究評(píng)估了三組20名患者：一組不穩(wěn)定的“臨界發(fā)育不良型髖關(guān)節(jié)”，其外側(cè)中心邊緣角(LCEA)小于25°，通過(guò)髖臼周圍截骨術(shù)成功治療；一組穩(wěn)定的“臨界發(fā)育不良型髖關(guān)節(jié)”，其LCEA小于25°，通過(guò)撞擊手術(shù)成功治療；另一組無(wú)癥狀對(duì)照組，其LCEA在25°至35°之間。在標(biāo)準(zhǔn)X線片和MRI上均進(jìn)行了以下測(cè)量：LCEA、髖臼指數(shù)、股骨前傾角和FEAR指數(shù)。結(jié)果：FEAR指數(shù)在MRI和X線片上均表現(xiàn)出極好的觀察者內(nèi)和觀察者間可靠性。X線片上的FEAR指數(shù)比MRI上的更可靠。與不穩(wěn)定臨界組（平均7.9°（標(biāo)準(zhǔn)差6.8°））相比，穩(wěn)定臨界組的MRI上的FEAR指數(shù)較低。在FEAR指數(shù)截止值為2°的情況下，使用放射學(xué)FEAR指數(shù)可以正確識(shí)別90%的患者為穩(wěn)定或不穩(wěn)定，而使用MRI上的FEAR指數(shù)則為82.5%。與MRI相比，F(xiàn)EAR指數(shù)在普通X線片上更能預(yù)測(cè)不穩(wěn)定性。結(jié)論：MRI上測(cè)量的FEAR指數(shù)比X線片上測(cè)量的FEAR指數(shù)更不可靠，靈敏度也更低。放射學(xué)FEAR指數(shù)的2°臨界值預(yù)測(cè)髖關(guān)節(jié)穩(wěn)定性的概率為90%。討論本研究的主要結(jié)果是，在普通骨盆X線片上測(cè)量FEAR指數(shù)比在MRI上具有更高的靈敏度和可靠性。當(dāng)LCEA在20°和25°之間時(shí)，區(qū)分穩(wěn)定和不穩(wěn)定髖關(guān)節(jié)可能具有挑戰(zhàn)性。決定采用哪種手術(shù)治療主要取決于髖關(guān)節(jié)的穩(wěn)定性或不穩(wěn)定性。通過(guò)新的影像學(xué)征象來(lái)改善診斷不僅有意義，而且必不可少。隨著關(guān)節(jié)鏡實(shí)踐的進(jìn)步，在同側(cè)關(guān)節(jié)鏡髖關(guān)節(jié)手術(shù)失敗后，隨后接受PAO截骨以矯正癥狀性髖關(guān)節(jié)發(fā)育不良的患者比例從2008年到2015年增加了1.92倍。臨界髖關(guān)節(jié)發(fā)育不良患者的手術(shù)選擇包括關(guān)節(jié)鏡盂唇修復(fù)和關(guān)節(jié)囊閉合/折疊，有時(shí)還伴有凸輪切除術(shù)，或伴有或不伴有盂唇修復(fù)/凸輪切除術(shù)的PAO截骨術(shù)。治療方案的選擇受到多種因素的影響，包括患者年齡、患者偏好，尤其是外科醫(yī)生是否認(rèn)為髖關(guān)節(jié)不穩(wěn)定。在骨性結(jié)構(gòu)覆蓋不足的情況下，進(jìn)行髖關(guān)節(jié)鏡檢查的風(fēng)險(xiǎn)是因不穩(wěn)定、髖關(guān)節(jié)脫位或關(guān)節(jié)炎進(jìn)展而導(dǎo)致的持續(xù)疼痛。這必須與PAO截骨并發(fā)癥的風(fēng)險(xiǎn)相平衡，即使是由經(jīng)驗(yàn)豐富的外科醫(yī)生進(jìn)行手術(shù)，輕度發(fā)育不良患者的臨床改善效果也會(huì)較低。有報(bào)道稱，臨界髖關(guān)節(jié)的保髖手術(shù)失敗，因?yàn)榇_定不穩(wěn)定或穩(wěn)定的髖關(guān)節(jié)可能很困難，并可能導(dǎo)致治療不當(dāng)。如果在髖關(guān)節(jié)發(fā)育不良的同時(shí)發(fā)現(xiàn)潛在的FAI，那么不適當(dāng)?shù)淖矒羰中g(shù)，不注意發(fā)育不良，可能會(huì)增加不穩(wěn)定的癥狀。需要制定嚴(yán)格的患者選擇標(biāo)準(zhǔn)，才能考慮對(duì)臨界髖關(guān)節(jié)發(fā)育不良進(jìn)行髖關(guān)節(jié)鏡檢查。最近的一項(xiàng)研究回顧了1368例髖臼發(fā)育不良髖關(guān)節(jié)鏡檢查，發(fā)現(xiàn)在某些明確和選定的臨界髖關(guān)節(jié)發(fā)育不良病例中，可以考慮單獨(dú)使用髖關(guān)節(jié)鏡檢查，但必須仔細(xì)注意保存盂唇和關(guān)節(jié)囊。然而，許多研究表明，如果發(fā)育不良為中度或重度，且患者選擇不太嚴(yán)格，則臨床結(jié)果不佳，并且存在醫(yī)源性不穩(wěn)定的風(fēng)險(xiǎn)。髖關(guān)節(jié)的穩(wěn)定性通常使用LCEA進(jìn)行評(píng)估；然而，僅憑這種測(cè)量不足以評(píng)估臨界髖關(guān)節(jié)，需要使用其他評(píng)估參數(shù)。一些放射學(xué)或MRI參數(shù)直接由股骨頭移位引起，因此高度提示髖關(guān)節(jié)不穩(wěn)定，例如髂坐線距離增加、Shenton線斷裂或后下關(guān)節(jié)間隙存在釓（髖關(guān)節(jié)造影檢查）。不穩(wěn)定髖關(guān)節(jié)可能存在其他放射學(xué)或MRI征象，但預(yù)測(cè)性較差，例如LCEA介于20°和25°之間、AI大于10°、髖外翻、股骨前傾或盂唇體積增大。其他參數(shù)可評(píng)估髖關(guān)節(jié)發(fā)育不良的嚴(yán)重程度，尤其是全髖關(guān)節(jié)置換術(shù)的實(shí)施。Wyatt等描述的放射學(xué)FEAR指數(shù)表示髖關(guān)節(jié)生長(zhǎng)過(guò)程中股骨近端骨骺板的合力。該指數(shù)反映了髖關(guān)節(jié)在生長(zhǎng)過(guò)程中的功能行為（穩(wěn)定或不穩(wěn)定）。Wyatt等報(bào)道稱，如果患者出現(xiàn)髖關(guān)節(jié)疼痛和臨界發(fā)育不良（定義為L(zhǎng)CEA20°至25°），則放射學(xué)FEAR指數(shù)小于5°表示髖關(guān)節(jié)穩(wěn)定的可能性為80%。FEAR指數(shù)的可靠性非常好，至少與LCEA或AI的可靠性一樣好。FEAR指數(shù)優(yōu)于LCEA的原因可能是難以定義髖臼源邊緣，正如已經(jīng)提到的。在本研究中，放射學(xué)FEAR指數(shù)的截止值為2°可預(yù)測(cè)穩(wěn)定性，90%的患者被正確判斷為穩(wěn)定或不穩(wěn)定。隨著這種測(cè)量方法在臨界髖關(guān)節(jié)發(fā)育不良的X線片上的應(yīng)用越來(lái)越廣泛，正常值和截止值的定義也越來(lái)越明確。有時(shí)，F(xiàn)EAR指數(shù)很難在X線片上測(cè)量。事實(shí)上，骨骺瘢痕的界限有時(shí)很難確定，并可能導(dǎo)致測(cè)量誤差。因此，我們?cè)u(píng)估了FEAR指數(shù)的可靠性，并由兩名獨(dú)立觀察員進(jìn)行評(píng)估。在我們的研究和Wyatt等的研究中，X線片和MRIFEAR指數(shù)表現(xiàn)出極好的觀察者間和觀察者內(nèi)可靠性，并且被證明優(yōu)于AI或LCEA。FEAR指數(shù)的假陽(yáng)性或陰性率主要是由于在某些情況下難以進(jìn)行測(cè)量。MRI是一種非常準(zhǔn)確的檢查，尤其是帶有放射狀切口的MR關(guān)節(jié)造影，這是目前評(píng)估原生髖關(guān)節(jié)關(guān)節(jié)內(nèi)病變的最佳術(shù)前成像研究。骨骺瘢痕在MRI上很容易被看到，這似乎是提高該參數(shù)靈敏度的有希望的途徑。然而，我們的研究表明，MRI的可靠性和靈敏度低于普通的放射學(xué)測(cè)量?？梢蕴岢鰩追N解釋。在X線片上，骺板瘢痕代表每個(gè)額葉切片的不同骺板瘢痕的平均值，因此也代表生長(zhǎng)過(guò)程中作用于整個(gè)股骨頭的力量平衡的平均值。對(duì)于MRI上的FEAR指數(shù)，為了獲得一個(gè)簡(jiǎn)單可靠的指數(shù)，我們選擇僅在一個(gè)圖像切片上測(cè)量FEAR指數(shù)。增加測(cè)量次數(shù)會(huì)增加出錯(cuò)的風(fēng)險(xiǎn)。與靜態(tài)X線片相比，3DMRI重建的準(zhǔn)確性會(huì)降低。然而，根據(jù)所選的額葉切片，骺板瘢痕的形狀在各個(gè)切片之間可能有所不同，并且骺板瘢痕的方向可能會(huì)發(fā)生幾度的變化。髖臼也可能出現(xiàn)同樣的問題，因?yàn)樗赡軙?huì)根據(jù)與髖臼窩的距離而發(fā)生顯著變化。此外，Wyatt等指出，F(xiàn)EAR指數(shù)代表髖關(guān)節(jié)的力量平衡。僅使用股骨頭中部骨骺瘢痕的軸線主要考慮股骨頭上部和頂部之間施加的力量。如果患者因不穩(wěn)定而出現(xiàn)股骨頭輕微半脫位，則矢狀圖上位于髖臼12點(diǎn)鐘位置的切片與位于股骨頭12點(diǎn)鐘位置的切片不同（圖4）。因此，骨骺瘢痕中央部分的測(cè)量可能不正確。股骨旋轉(zhuǎn)或外展可能引起的變化與X線片相同。我們的研究有一些局限性。首先，納入的患者數(shù)量很少，無(wú)法匹配某些參數(shù)（LCEA、性別）。盡管如此，有癥狀的臨界髖關(guān)節(jié)患者并不常見，需要進(jìn)行完整的影像學(xué)檢查才能比較X線片和MRI。不穩(wěn)定是由多種因素和手術(shù)后癥狀的發(fā)展決定的。因此，該診斷是根據(jù)參數(shù)關(guān)聯(lián)進(jìn)行的，并構(gòu)成了不穩(wěn)定性的功能定義。這項(xiàng)研究是回顧性的，因此我們可以顯示關(guān)聯(lián)但不能做出預(yù)測(cè)。此外，沒有評(píng)估某些參數(shù)，例如全身韌帶松弛、肌肉調(diào)節(jié)或體重指數(shù)。兩年的隨訪似乎太短了。然而，當(dāng)康復(fù)沒有進(jìn)展時(shí)，通常會(huì)在3到6個(gè)月內(nèi)懷疑結(jié)果不佳。相反，1到1年半后，髖關(guān)節(jié)通常在功能和疼痛方面達(dá)到穩(wěn)定狀態(tài)。因此，兩年的限制似乎是合理的，盡管可能更傾向于更長(zhǎng)的隨訪時(shí)間?？傊?，MRI上測(cè)量的FEAR指數(shù)不如X線片上測(cè)量的FEAR指數(shù)可靠。此外，與MRI相比，F(xiàn)EA指數(shù)是X線片上不穩(wěn)定性的更好的預(yù)測(cè)指標(biāo)。放射學(xué)FEAR指數(shù)的2°截止值預(yù)測(cè)髖關(guān)節(jié)穩(wěn)定性的概率為90%。放射學(xué)FEAR指數(shù)是輔助復(fù)雜髖關(guān)節(jié)不穩(wěn)定診斷的可靠參數(shù)。需要前瞻性評(píng)估該測(cè)量值以預(yù)測(cè)漸進(jìn)性不穩(wěn)定。?Fig1a)Anteroposteriorpelvicradiographandb)hipMRIinfrontalandsagittalviewswithapositiveFemoro-EpiphysealAcetabularRoof(FEAR)index(anglebetweenthephysealscarandthesclerosisofthesourcil)forapatientwithaborderlinedysplastichip(lateralcentre-edgeangle=17.2°,acetabularindex=12.6°)treatedwithperiacetabularosteotomy.圖1?a)前后位骨盆X線片和b)髖關(guān)節(jié)正位和矢狀位MRI，股骨-骨骺髖臼頂(FEAR)指數(shù)（骨骺瘢痕與髖臼硬化之間的角度）為陽(yáng)性，適用于接受髖臼周圍截骨術(shù)治療的臨界髖關(guān)節(jié)發(fā)育不良患者（外側(cè)中心邊緣角=17.2°，髖臼指數(shù)=12.6°）。Fig2a)Anteroposteriorpelvicradiographandb)hipMRIinfrontalandsagittalviewswithanegativeFemoro-EpiphysealAcetabularRoof(FEAR)index(anglebetweenthephysealscarandthesclerosisofthesourcil)forapatientwithaborderlinedysplastichip(lateralcentre-edgeangle=24°,acetabularindex=9°)treatedwithimpingementsurgery.圖2?a)前后位骨盆X線片和b)髖關(guān)節(jié)正面和矢狀面MRI，股骨-骨骺髖臼頂(FEAR)指數(shù)（骨骺瘢痕與髖臼硬化之間的角度）為陰性，適用于接受撞擊手術(shù)治療的臨界髖關(guān)節(jié)發(fā)育不良患者（外側(cè)中心邊緣角=24°，髖臼指數(shù)=9°）。Fig3Boxplotsofa)theradiologicalFemoro-EpiphysealAcetabularRoof(FEAR)indexandb)theFEARindexonMRI,comparingallthreegroups.Theboxplotsareconstitutedofseveraldata.Themedian(middlequartile)marksthemid-pointofthedataandisshownbythelinethatdividestheboxintotwoparts.Themiddleboxrepresentsthemiddle50%ofscoresforthegroup,delineatedbythelowerandtheupperquartiles.Theupperandlowerwhiskersrepresentthehighestandlowestvalueexcludingoutliers.Thetriangularplotpointsaretheoutliersortheextremes.圖3?箱線圖，a)放射學(xué)股骨-骨骺髖臼頂(FEAR)指數(shù)和b)MRI上的FEAR指數(shù)，比較所有三組。箱線圖由多個(gè)數(shù)據(jù)組成。中位數(shù)（中間四分位數(shù)）標(biāo)記數(shù)據(jù)的中點(diǎn)，由將箱子分成兩部分的線表示。中間框代表該組中間50%的分?jǐn)?shù)，由下四分位數(shù)和上四分位數(shù)劃定。上下頂部代表不包括異常值的最高值和最低值。三角形圖點(diǎn)是異常值或極值。Fig4MRIinsagittalandfrontalviewofaborderlinedysplastichip.Thefrontalslideislocatedat12o’clockontheacetabulumonthesagittalview.Thisdidnotcorrespondtothe12o’clockpositionofthefemoralhead,duetosmallsubluxationofthefemoralhead.圖4?臨界髖關(guān)節(jié)發(fā)育不良的矢狀位和正位MRI。正面滑動(dòng)位于矢狀位上髖臼的12點(diǎn)鐘位置。由于股骨頭有輕微的半脫位，這與股骨頭的12點(diǎn)鐘位置不符。?FemoralosteotomyforosteonecrosisofthefemoralheadAbstractAims:Aborderlinedysplastichipcanbehaveaseitherstableorunstableandthismakessurgicaldecisionmakingchallenging.Whileanunstablehipmaybebesttreatedbyacetabularreorientation,stablehipscanbetreatedarthroscopically.Severalimagingparameterscanhelptoidentifytheappropriatetreatment,includingtheFemoro-EpiphysealAcetabularRoof(FEAR)index,measuredonplainradiographs.TheaimofthisstudywastoassessthereliabilityandthesensitivityofFEARindexonMRIcomparedwithitsradiologicalmeasurement.Patientsandmethods:ThetechniqueofmeasuringtheFEARindexonMRIwasdefinedanditsreliabilityvalidated.Aretrospectivestudyassessedthreegroupsof20patients:anunstablegroupof'borderlinedysplastichips'withlateralcentreedgeangle(LCEA)lessthan25°treatedsuccessfullybyperiacetabularosteotomy;astablegroupof'borderlinedysplastichips'withLCEAlessthan25°treatedsuccessfullybyimpingementsurgery;andanasymptomaticcontrolgroupwithLCEAbetween25°and35°.ThefollowingmeasurementswereperformedonbothstandardizedradiographsandonMRI:LCEA,acetabularindex,femoralanteversion,andFEARindex.Results:TheFEARindexshowedexcellentintraobserverandinterobserverreliabilityonbothMRIandradiographs.TheFEARindexwasmorereliableonradiographsthanonMRI.TheFEARindexonMRIwaslowerinthestableborderlinegroup(mean-4.2°(sd9.1°))comparedwiththeunstableborderlinegroup(mean7.9°(sd6.8°)).WithaFEARindexcut-offvalueof2°,90%ofpatientswerecorrectlyidentifiedasstableorunstableusingtheradiologicalFEARindex,comparedwith82.5%usingtheFEARindexonMRI.TheFEARindexwasabetterpredictorofinstabilityonplainradiographsthanonMRI.Conclusion:TheFEARindexmeasuredonMRIislessreliableandlesssensitivethantheFEARindexmeasuredonradiographs.Thecut-offvalueof2°forradiologicalFEARindexpredictedhipstabilitywith90%probability.Citethisarticle:BoneJointJ2019;101-B:1578-1584.DiscussionThemainresultofthisstudyisthattheFEARindexismeasuredwithgreatersensitivityandreliabilityonplainpelvicradiographsthanonMRI.DifferentiatingastableversusunstablehipcanbechallengingwhentheLCEAisbetween20°and25°.Decidinguponaparticularsurgicaltreatmentdependsprincipallyonthestabilityorinstabilityofthehip.5-7Improvingthediagnosisbynewimagingsignsisnotonlyinterestingbutisalsoessential.Asarthroscopypracticehasadvanced,theproportionofpatientsundergoingasubsequentPAOforthecorrectionofsymptomaticacetabulardysplasiafollowingafailedipsilateralarthroscopichipprocedure,hasincreasedby1.92-foldfrom2008to2015.8Surgicaloptionsforpatientswithaborderlinedysplastichipincludearthroscopiclabralrepairwithcapsularclosure/plication,andsometimeswithcamresection,orPAOwithorwithoutconcomitantlabralrepair/camresection.Thetreatmentchosenisinfluencedbymultiplefactorsincludingpatientage,patientpreference,andespeciallywhetherthesurgeonbelievesthehipisunstableornot.10Theriskofhiparthroscopyinthesettingofinadequatebonecoverageispersistentpainduetoinstability,hipdislocation,orarthriticprogressionofthejoint.18ThismustbebalancedwiththeriskofcomplicationswithPAO,evenwhenperformedbyexperiencedsurgeons,andlowerincrementalclinicalimprovementinpatientswithmilddysplasia.Therearereportcasesoffailureofhippreservationsurgeryonborderlinehips,becausedeterminationofanunstableorstablehipcanbedifficultandmayleadtoincorrecttreatment.8,19-21IfpotentialFAIisfoundconcurrentlywithhipdysplasiatheninappropriateimpingementsurgery,withoutattentiontothedysplasia,canincreasethesymptomsfrominstability.Stringentcriteriaforpatientselectionareneededtoconsiderhiparthroscopyforborderlinedysplastichips.22,23Arecentreview,on1368hiparthroscopiesonacetabulardysplasia,foundthattheisolateduseofhiparthroscopymaybeconsideredinsomedefinedandselectedcasesofborderlineacetabulardysplasia,whencarefulattentionispaidtolabralandcapsularpreservation.24However,manystudieshavedescribedpoorclinicaloutcomesandtheriskofiatrogenicinstability,ifthedysplasiaismoderateorsevere,andifthepatientselectionisnotveryrestricted.24StabilityofthehipisclassicallyassessedbyusingtheLCEA;18nevertheless,thismeasurementaloneisinsufficientforborderlinehipandtheuseofotherassessmentparametersisrequired.SomeradiologicalorMRIparametersaredirectlyduetofemoralheadmigrationandarethereforehighlyindicativeofhipinstability,suchasanincreaseofthedistancefromtheilioischialline,abreakinShenton’sline,orthepresenceofGadoliniumintheposteroinferiorjointspace.24OtherradiologicalorMRIsignscanbepresentinunstablehipbutarelesspredictive,suchasLCEAbetween20°and25°,AIgreaterthan10°,coxavalga,femoralanteversion,orincreasedlabralvolume.Otherparametersassesstheseverityofhipdysplasia,inparticularfortheimplementationoftotalhiparthroplasty.25TheradiologicalFEARindex,describedbyWyattetal,13representstheresultantoftheforcesacrosstheproximalfemoralphysisduringhipgrowth.Thisindexreflectsthefunctionalbehaviour(stableorunstable)ofthehipduringgrowth.Wyattetal13reportedthatifapatientpresentswithhippainandborderlinedysplasia(definedasaLCEA20°to25°),aradiologicalFEARindexlessthan5°indicatesan80%probabilitythatthehipisstable.ThereliabilityoftheFEARindexwasexcellentandatleastasgoodasthereliabilityofLCEAorAI.ThesuperiorityoftheFEARindexcomparedwithLCEAmaybebecauseofdifficultyindefiningtheedgeoftheacetabularsourcil,ashasbeenalludedto.26Inthisstudy,acut-offvalueof2°forradiologicalFEARindexpredictsstability,with90%ofpatientscorrectlyidentifiedasstableorunstable.Withthewideruseofthismeasurementonradiographsforborderlinedysplastichip,normalandcut-offvaluesarebecomingbetterdefined.Occasionally,theFEARindexisdifficulttomeasureonradiographs.Indeed,thelimitsofthephysealscararesometimeshardtodetermineandcanleadtomeasurementserrors.Accordingly,weassessedthereliabilityoftheFEARindexwasassessedwithtwoindependentobservers.TheradiographicandMRIFEARindicesshowedexcellentinter-andintraobserverreliabilityinourstudyandinthestudybyWyattetal,13andwasshowntobesuperiortotheAIorLCEA.ThefalsepositiveornegativeratesoftheFEARindexaremainlyduetothedifficultyintakingmeasurementsinsomecases.TheMRIisaveryaccurateinvestigation,particularlytheMRarthrogramwithradialcuts,whichispresentlythebestavailablepreoperativeimagingstudytoevaluateintra-articularlesionsofnativehip.27-30ThephysealscariseasilyvisualizedonMRIanditseemedapromisingroutetoimprovethesensitivityofthisparameter.Nevertheless,ourstudyhasdemonstratedthatMRIislessreliableandlesssensitivethanplainradiologicalmeasurement.Severalexplanationscanbeproposed.Onradiographs,thephysealscarrepresentsameanofdifferentphysealscarsofeachfrontalslice,andthusameanofthebalanceofforcesactingonthewholefemoralheadduringgrowth.FortheFEARindexonMRI,inordertoobtainaneasyandreliableindex,wehavechosentomeasuretheFEARindexononlyoneimageslice.Increasingthenumberofmeasurementsincreasestheriskoferrors.MRIreconstructionin3Dlosesaccuracycomparedwithastaticradiograph.However,accordingtothechosenfrontalslice,theshapeofthephysealscarcanvarybetweenslicesandtheorientationofthephysealscarcanchangebyseveraldegrees.Thesameproblemcanarisefortheacetabularsourcil,whichcanchangemarkedlyaccordingtothedistancetotheacetabularfossa.Additionally,Wyattetal13statedthattheFEARindexrepresentsthebalanceofforcesonthehip.Usingonlytheaxisofthephysealscarinthemiddleofthefemoralheadmainlyconsiderstheforcesexertedbetweenthesuperiorpartofthefemoralheadandthesuperiorpartoftheroof.Ifthepatienthasasmallsubluxationofthefemoralheadduetoinstability,theslicelocatedat12o’clockontheacetabulumonthesagittalviewisnotthesameastheslidelocatedat12o’clockonthefemoralhead(Fig.4).Thus,themeasureofthecentralpartofthephysealscarcanbeincorrect.Thevariationspotentiallyinducedbythefemoralrotationorabductionarethesameaswithradiographs.Ourstudyhassomelimitations.First,thenumberofpatientsincludedwaslow,withoutpossiblematchingofsomeparameters(LCEA,sex).Nevertheless,patientswithsymptomaticborderlinehipsareuncommonandcompleteimagingexaminationswerenecessarytocompareradiographsandMRI.Theinstabilitywasdeterminedbyseveralfactorsandbytheevolutionofsymptomsafterthesurgery.Thus,thisdiagnosiswasperformedonanassociationofparametersandconstituteafunctionaldefinitionofinstability.Thisstudywasretrospective,andthusallowsustoshowassociationsbutnottomakepredictions.Moreover,someparameterswerenotassessed,suchasthegeneralizedligamentouslaxity,muscularconditioning,orbodymassindex.Thefollow-upoftwoyearsmayseemtooshort.However,apoorresultusuallyissuspectedwithinthreetosixmonths,whenrehabilitationisnotprogressing.Incontrast,afteroneto1.5yearsthehiphasusuallyreachedasteadystateconcerningfunctionandpain.Therefore,atwo-yearlimitseemsrational,althoughalongerfollow-upmightbepreferred.Inconclusion,theFEARindexmeasuredonMRIislessreliablethantheFEARindexmeasuredonplainradiographs.Moreover,theFEARindexisabetterpredictorofinstabilityonplainradiographscomparedwithMRI.Thecut-offvalueof2°fortheradiologicalFEARindexpredictedhipstabilitywith90%probability.ThisradiologicalFEARindexconstitutesareliableparametertoaidthecomplexdiagnosisofhipinstability.Thismeasurementneedstobeassessedprospectivelyforthepredictionofprogressiveinstability.文獻(xiàn)出處：CécileBatailler,JanWeidner,MichaelWyatt,DominikPfluger,MartinBeck.IstheFemoro-EpiphysealAcetabularRoof(FEAR)indexonMRIarelevantpredictivefactorofinstabilityinaborderlinedysplastichip?BoneJointJ.2019Dec;101-B(12):1578-1584.doi:10.1302/0301-620X.101B12.BJJ-2019-0502.R1.
陶可醫(yī)生的科普號(hào)
2024年09月01日101
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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，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，根本問題是難以正確分類潛在的病理生物力學(xué)。定義第一個(gè)問題在于定義。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。此外，還會(huì)詢問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)周圍囊腫的存在和位置[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)遵循專門的髖關(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)為髖臼周圍截骨術(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（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。重新定向髖臼周圍截骨術(shù)對(duì)這組患者有何影響？通過(guò)髖臼周圍截骨術(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)后沒有差異。在本研究中，輕度發(fā)育不良被歸類為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，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212
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臨界髖關(guān)節(jié)發(fā)育不良Borderline DDH：什么時(shí)候、怎么判定為異常？
臨界髖關(guān)節(jié)發(fā)育不良BorderlineDDH：什么時(shí)候、怎么判定為異常？作者：SarahDBixby,MichaelBMillis.作者單位:DepartmentofRadiology,BostonChildren'sHospital,Main2,300LongwoodAve.,Boston,MA,02115,USA.sarah.bixby@childrens.harvard.edu.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要臨界髖關(guān)節(jié)發(fā)育不良是指髖臼形狀和覆蓋范圍輕度低于正常范圍，可能導(dǎo)致兒童易患機(jī)械功能障礙和不穩(wěn)定。臨界發(fā)育不良通常包括外側(cè)中心邊緣角(CEA)為18-24°的兒童。一些具有臨界X線測(cè)量值的兒童具有正常的關(guān)節(jié)力學(xué)和功能，而其他兒童則需要進(jìn)行髖臼截骨手術(shù)。雖然臨界髖關(guān)節(jié)發(fā)育不良的X線檢查結(jié)果可能表明不穩(wěn)定，但最終診斷基于病史和體格檢查以及影像學(xué)相結(jié)合?；加信R界髖關(guān)節(jié)發(fā)育不良的兒童有時(shí)還需要進(jìn)行其他橫斷面成像研究，如MRI成像，以評(píng)估不穩(wěn)定的次要證據(jù)，包括沿髖臼邊緣的損傷或盂唇退化和肥大。CT也有助于描繪3-D髖臼形態(tài)，以進(jìn)行術(shù)前評(píng)估和規(guī)劃。兒童放射科醫(yī)生通常是第一個(gè)在X線片上發(fā)現(xiàn)邊緣性或輕度發(fā)育不良的人。兒童放射科醫(yī)生必須充當(dāng)有效的顧問，并作為針對(duì)這一復(fù)雜患者群體的連貫多學(xué)科診療團(tuán)隊(duì)的一部分提供適當(dāng)?shù)慕ㄗh。圖1?一名16歲女孩的髖關(guān)節(jié)X線片顯示了外側(cè)中心邊緣角(CEA)、髖臼指數(shù)和前CEA的測(cè)量方法。a標(biāo)記了三個(gè)點(diǎn)以便進(jìn)行后續(xù)測(cè)量：點(diǎn)1位于股骨頭(旋轉(zhuǎn))中心，點(diǎn)2位于股骨髖關(guān)節(jié)(負(fù)重關(guān)節(jié)面的)內(nèi)側(cè)邊緣，點(diǎn)3位于股骨髖關(guān)節(jié)(負(fù)重關(guān)節(jié)面的)外側(cè)邊緣。b右髖關(guān)節(jié)的前后位X線片展示了測(cè)量外側(cè)CEA的方法。外側(cè)CEA是連接點(diǎn)1和點(diǎn)3的線與垂直線之間形成的夾角（正常為25-40°）。c髖臼指數(shù)由連接點(diǎn)2和點(diǎn)3的線與水平線之間形成的夾角決定（正常為0-10°）。d右髖關(guān)節(jié)的假斜位片顯示了確定前CEA的測(cè)量方法。前側(cè)CEA由點(diǎn)1到點(diǎn)4（在髖臼前緣）的連線與垂直線之間的角度決定（正常值為25–40°）圖2?一名19歲女性嚴(yán)重雙側(cè)髖關(guān)節(jié)發(fā)育不良。a骨盆前后位X線片顯示右側(cè)髖關(guān)節(jié)外側(cè)中心邊緣角(CEA)為5°，b髖臼指數(shù)為16°。左髖關(guān)節(jié)同樣發(fā)育不良。c右髖關(guān)節(jié)假斜位X線片顯示前方中心邊緣角為8°。圖3?一名右側(cè)髖關(guān)節(jié)疼痛的16歲女孩的外側(cè)中心邊緣角(CEA)。a前后位(AP)骨盆X線片顯示外側(cè)CEA為19°。左側(cè)髖關(guān)節(jié)正常。b同一女孩的假斜位X線片顯示前方CEA為19°。c延遲釓增強(qiáng)軟骨MRI(dGEMRIC)檢查的冠狀T1圖顯示軟骨正常。女孩沒有不穩(wěn)定的跡象，接受了腰肌勞損治療，癥狀在沒有手術(shù)的情況下得到改善。由于腰肌勞損仍然可能與潛在的微不穩(wěn)定有關(guān)，女孩在髖關(guān)節(jié)外科醫(yī)生的護(hù)理下接受長(zhǎng)期觀察。圖4?一名有髖關(guān)節(jié)發(fā)育不良家族史的11歲女性足球運(yùn)動(dòng)員的左側(cè)髖關(guān)節(jié)疼痛。a前后位(AP)X線片顯示為正常。b女孩現(xiàn)在13歲，仍然有左側(cè)髖關(guān)節(jié)疼痛。雙側(cè)髖關(guān)節(jié)被認(rèn)為是淺的，左側(cè)測(cè)量的外側(cè)中心邊緣角(CEA)為16°，右側(cè)為23°。左側(cè)髖臼指數(shù)也被認(rèn)為是升高的13°。陽(yáng)性恐懼測(cè)試反映了體格檢查中左側(cè)髖關(guān)節(jié)的不穩(wěn)定，右側(cè)沒有發(fā)現(xiàn)不穩(wěn)定。C假斜位X線片顯示前方覆蓋充分，前方CEA為27°。d左側(cè)髖臼周圍截骨術(shù)后前后位AP骨盆X線片狀態(tài)顯示側(cè)方覆蓋改善。女孩報(bào)告癥狀有所改善。e一年后的前后位AP骨盆X線片，癥狀緩解并恢復(fù)正?；顒?dòng)。她右側(cè)有輕微間歇性疼痛，并定期監(jiān)測(cè)癥狀。圖5?股骨骨骺髖臼頂(FEAR)指數(shù)。a與圖1中相同的16歲女孩的髖關(guān)節(jié)前后位(AP)X線片。FEAR指數(shù)是沿髖臼頂連接點(diǎn)2和點(diǎn)3的線（黑線）與沿股骨骨骺線中央三分之一繪制的線（白線）之間形成的角度。陽(yáng)性FEAR指數(shù)定義為向外側(cè)傾斜的角度，頂點(diǎn)指向內(nèi)側(cè)。這個(gè)女孩的FEAR指數(shù)小于5°。與FEAR指數(shù)<5°相比，F(xiàn)EAR指數(shù)>5°與不穩(wěn)定性具有更大的相關(guān)性。b一名13歲女孩的髖關(guān)節(jié)前后位X線片顯示左側(cè)髖臼外側(cè)輕微上翻（箭頭）。c一名13歲男孩的右側(cè)髖關(guān)節(jié)疼痛的左側(cè)髖關(guān)節(jié)正常前后位X線片顯示外側(cè)正常。黑線表示髖臼頂部，白線表示骨骺線的中央三分之一。此正常髖關(guān)節(jié)的FEAR指數(shù)顯示FEAR指數(shù)，角度頂點(diǎn)指向外側(cè)。圖6?一名18歲女子田徑運(yùn)動(dòng)員的右側(cè)髖關(guān)節(jié)疼痛影像。a前后位(AP)骨盆X線片顯示右側(cè)髖關(guān)節(jié)發(fā)育不良，左髖關(guān)節(jié)正常。b右側(cè)髖臼周圍截骨術(shù)后前后位(AP)骨盆狀態(tài)顯示外側(cè)覆蓋增加，但該女性報(bào)告癥狀惡化。c術(shù)前（回顧性）進(jìn)行的右髖關(guān)節(jié)矢狀質(zhì)子密度脂肪抑制MR圖像顯示前髖臼內(nèi)有骨樣骨瘤（箭頭）。射頻消融后，該患者的癥狀得到緩解。?Theborderlinedysplastichip:whenandhowisitabnormal?AbstractBorderlineacetabulardysplasiareferstomildlysub-normalpatternsofacetabularshapeandcoveragethatmightpredisposechildrentomechanicaldysfunctionandinstability.Borderlinedysplasiagenerallyincludeschildrenwithalateralcenteredgeangle(CEA)of18-24°.Somechildrenwithborderlineradiographicmeasurementshavenormaljointmechanicsandfunctionwhileothersbenefitfromacetabularreorientingsurgery.Althoughradiographicfindingsofborderlinedysplasiamightsuggestinstability,theultimatediagnosisisbasedonhistoryandphysicalexaminadditiontoimaging.Childrenwithborderlineacetabulardysplasiasometimesbenefitfromothercross-sectionalimagingstudiessuchasMRimagingtoevaluateforsecondaryevidenceofinstability,includingdamagealongtheacetabularrim,orlabraldegenerationandhypertrophy.CTisalsohelpfulfordepictionof3-Dacetabularmorphologyforpreoperativeassessmentandplanning.Pediatricradiologistsareoftenthefirsttoidentifyborderlineormilddysplasiaonradiographs.Itisimperativethatpediatricradiologistsserveaseffectiveconsultantsandofferappropriaterecommendationsaspartofacohesivemultidisciplinaryapproachtothiscomplexpatientpopulation.Fig.1Radiographsofthehipina16-year-oldgirldemonstratemeasurementtechniqueforlateralcenteredgeangle(CEA),acetabularindex,andanteriorCEA.aThreepointsaremarkedforsubsequentmeasurements:Point1atthecenterofthefemoralhead,Point2atthemedialedgeofthesourcil,Point3atthelateraledgeofthesourcil.BAnteroposteriorpelvicradiographconeddowntotherighthipdemonstratestechniqueformeasuringlateralCEA.ThelateralCEAistheangleformedbetweenthelineconnectingPoint1toPoint3andaverticalline(normal25–40°).cAcetabularindexisdeterminedbytheangleformedbetweenalineconnectingPoint2toPoint3andahorizontalline(normal0–10°).dFalseprofileviewoftherighthipdemonstratesmeasurementtechniquefordetermininganteriorCEA.AnteriorCEAisdeterminedbytheanglebetweenalinefromPoint1toPoint4(attheanteriormarginofthesourcil)andaverticalline(normal25–40°)Fig.2Severebilateralhipdysplasiaina19-year-oldwoman.aAnteroposteriorradiographofthepelvisdemonstratesalateralcenteredgeangle(CEA)oftherighthipof5°and(b)acetabularindexof16°.Thelefthipissimilarlydysplastic.cFalseprofileradiographoftherighthipdemonstratesanteriorcenteredgeangleof8°.Fig.3Borderlinelateralcenteredgeangle(CEA)ina16-year-oldgirlwithrighthippain.aAnteroposterior(AP)pelvisradiographrevealsborderlinelateralCEAof19°.Thelefthipisnormal.bFalseprofileradiographofthesamegirlrevealsanteriorCEAof19°.cCoronalT1mapfromdelayedgadolinium-enhancedMRIofcartilage(dGEMRIC)examinationrevealsnormalcartilage.Thegirldidnothavesignsofinstability,wastreatedforpsoasstrain,andsymptomsimprovedwithoutsurgery.Becausepsoasstraincouldstillberelatedtounderlyingmicroinstability,thegirlwasunderlong-termobservationundercareofahipsurgeon.Fig.4Lefthippaininan11-year-oldfemalesoccerplayerwithafamilyhistoryofhipdysplasia.aAnteroposterior(AP)radiographinterpretedasnormal.bGirlnowisage13years,stillwithlefthippain.Bilateralhipswereconsideredshallow,withlateralcenteredgeangle(CEA)measuredat16°ontheleftand23°ontheright.Acetabularindexontheleftwasalsoconsideredelevatedat13°.Positiveapprehensiontestreflectedinstabilityofthelefthiponphysicalexamination,withnoinstabilitynotedontheright.cFalseprofileradiographrevealsadequateanteriorcoverage,withanteriorCEAof27°.dAPpelvisradiographstatuspostleft-sideperiacetabularosteotomydemonstratesimprovedlateralcoverage.Thegirlreportedimprovedsymptoms.eAPpelvisradiograph1yearlater,afterreliefofsymptomsandreturntonormalactivity.Shehadmildintermittentpainontherightandwasbeingmonitoredperiodicallyforsymptoms.Fig.5Femoro-epiphysealacetabularroof(FEAR)index.AAnteroposterior(AP)radiographofthehipinthesame16-year-oldgirlasinFig.1.TheFEARindexistheangleformedbetweenalineconnectingPoint2andPoint3alongtheacetabularroof(blacklines),andalinedrawnalongthecentralthirdofthefemoralphysealscar(whiteline).ApositiveFEARindexisdefinedbyalaterallydirectedanglewiththeapexpointingmedially.TheFEARindexinthisgirlislessthan5°.AFEARindex>5°hasagreatercorrelationwithinstabilitycomparedtoFEARindex<5°.bAPradiographofthehipina13-year-oldgirlwithmildleftacetabularsourcildemonstratesamildlyupturnedlateralsourcil(arrow).cNormalAPradiographofthelefthipina13-year-oldboywithrighthippaindemonstratesanormallateralsourcilforcomparison.Theblacklineindicatestheacetabularroofandthewhitelineindicatesthecentralthirdofthephysealscar.TheFEARindexisdemonstratedinthisnormalhiptoillustrateanegativeFEARindexwiththeapexoftheangledirectedlaterally.Fig.6Imaginginan18-year-oldfemaletrackathletewithrighthippain.aAnteroposterior(AP)pelvisradiographreportedasborderlinerightacetabulardysplasiaandnormallefthip.bAPpelvisstatuspostrightperiacetabularosteotomydemonstratesincreasedlateralcoverage,thoughthewomanhadreportedworseningsymptoms.cSagittalproton-densityfat-suppressedMRimageoftherighthipperformedpreoperatively(retrospectively)revealsanosteoidosteomawithintheanterioracetabulum(arrow).Thewoman’ssymptomsresolvedafterradiofrequencyablation.?AdvancinginvestigationTheterm“borderlinedysplasia”isalsofallingoutoffavor.Advancedimagingmodalitieshaverevealedpatternsofdysplasiathatarenotapparentonradiographs.FocalanteriorandposteriordysplasiagroupshaveanormallateralCEAontheAPradiograph[9].Refinedandupdatedradiographicmeasurementshavebeenproposedthatwouldenablebetteridentificationofchildrenwithfocaldysplasia,suchastheanteriorwallindexandposteriorwallindex[48].Earlystudiesdemonstrateddifferencesintheanteriorandposteriorwallindicesinsymptomaticdysplasticpatientscomparedtothosewithanormalacetabulum[48].Subsequentinvestigationrevealedthatevenasymptomaticpeoplehaveradiographicanteriorandposteriorwallindexmeasurementsthatoverlapthoseofpeoplewithdysplasia[49].Thisindicatesthatsomedegreeofvariationinthe3-Dmorphologyoftheacetabulumisnormal.Furthervalidationoftheseindiceswithcross-sectionalimagingandlongitudinalfollow-upisnecessarybeforethesenewreferencestandardscanbeconsideredreliableindicatorsofdisease.Inthepresenceofinstabilityrelatedtoacetabulardysplasia,thereisoftenovergrowthofsoft-tissuestructuresthatcompensatesforthedeficientbonysupport.Thisincludesenlargementoftheacetabularlabrum[50,51],evenintheabsenceoflabraltearordegeneration.Focalmuscleenlargementhasalsobeennotedinunstablepatients,specificallytheiliocapsularismuscle[52].MRImightbeusefulinidentifyingthesesecondarysignsofinstability.Still,noclearlypositivefindingsconfirmthepresenceofinstability.Femoralversionisalsoakeycomponentindetermininghipstability,asanantevertedfemurisbemoreanteriorlyuncoveredthananeutralfemur[53].Overtfeaturesofacetabularrimdamagealsosupportthediagnosisofdysplasia,includinglabraldegenerationandtearingandcartilageloss,thoughadolescentswhohaveborderlinedysplasiamightnotyethavevisiblemanifestationsofosteoarthritis,evenifinstabilityisthepaingenerator.Giventheseareasofinvestigationanduncertainty,theborderlinedysplastichiphasattractedwell-deservedattentionintheliterature.Specificconcernshavebeenraisedaroundwhethertheterm“borderlinedysplasia”isanadequatelabelandwhetherthisisasinglecondition.ItismorelikelythatchildrenwithaborderlinelateralCEAof18–24°consistofclustersofpatients,someofwhommighthavecamimpingement,andsomeofwhomhavefocalacetabulardeficiency[13].Specificpatternsofacetabulardeficiencyandfemoralmorphologyarebestcharacterizedwithcross-sectionalimagingexaminations,suchasMRIorCT,whichmightalsodetectothercausesforhippain.ItisrecommendedthatanychildinwhomthereisconcernfordysplasiaundergoanMRIaspartofacompleteevaluationbecausetheremightbeanotherfindingthatexplainsthechild’ssymptoms(Fig.6),orevidenceofintra-articulardamagethatsupportsrimloading.MRIiswellsuitedfordetectingcartilageandlabralabnormalitiesaswellasmarrowlesionsthatarepresentinthesettingofalteredbiomechanicsandearlyosteoarthritis[8].Low-dosepelvicCTisalsovaluableforpreoperativeassessmentofthehipmorphologywithprecisecharacterizationofthebonydeficienciesinthreedimensions.Itiscrucialthatthesechildrenaredirectedtoanexperiencedhipspecialistwhoisabletocontextualizetheimagingfindingswithacomprehensivephysicalexamandanappropriatehistory.Thesechildrenshouldbeinterrogatedwithrespecttothenatureandlocationoftheirpainwithspecificquestionsaroundinstability.Acomprehensivephysicalexamshouldfollow,includingattentiontothechild’sgait,pelvicpositionandrotationalprofile.ConclusionTheterm“borderlinedysplasia”referstopatternsofacetabularcoveragethatmightpredisposechildrentoinstability.Somechildrenwithborderlineradiographicmeasurementshavenormaljointmechanicsandfunction(Fig.1ShouldsayFigure3),whileothersbenefitfromacetabularreorientingsurgery(Fig.2ShouldsayFigure4)[11].Itisimportantthatradiologistsreflectthisuncertaintyintheirreportswithappropriatemanagementrecommendations.Instabilitymightbesuggestedbyradiographs,butultimatediagnosisisconfirmedonthebasisofhistoryandphysicalexamassessingforinstability.Thesechildrenshouldundergohigh-resolutionMRimagingofthehiptoevaluateforjointdamage,andCTmightbehelpfulforbetter3-Dcharacterizationofthebonyshapeandcontour.Dynamicultrasonographyhasbeenvalidatedasahelpfuladjunctinthedeterminationofinstabilitybymeasuringanteriorfemoralheadtranslationwithdynamicmaneuversreplicatingtheapprehensiontest[54].Aspediatricradiologists,weareoftenthefirsttoidentifyborderlineormilddysplasiaonthebasisofradiographs.Itisimperativethatweserveaseffectiveconsultantsandofferappropriaterecommendationsaspartofacohesivemultidisciplinaryapproachtothiscomplexpatientpopulation.?文獻(xiàn)出處：SarahDBixby,MichaelBMillis.Theborderlinedysplastichip:whenandhowisitabnormal?ReviewPediatrRadiol.2019Nov;49(12):1669-1677.doi:10.1007/s00247-019-04468-4.Epub2019Nov4.??IntroductionDevelopmentalhipdysplasia(DDH)isoneofthemostimportantandmostcommonpediatricmusculoskeletalconditions.Whileasmanyas80%ofcasesarepresentatbirth,manyremainundiagnosed.Whenpresentininfancy,DDHmightbedetectedonthebasisofphysicalexaminationfindings(i.e.BarlowandOrtolanimaneuvers)andstaticanddynamicultrasoundfeaturesoriginallydescribedbyGraf[1,2].Thelong-termimplicationsofDDHaresignificantbecausetheconditionleadstodevelopmentofosteoarthritisin25–50%ofpatientsbytheageof50years[3].Thereducedsizeandtheincreasedobliquityoftheacetabularweight-bearingsurfacecreateshearingforcesonthearticularcartilageandcausechronicoverloadingoftheanteriorandanterolateralacetabularrim[4].Thismechanicaldysfunction,ifuncorrected,leadsinadulthoodtopain,abductorfatigueandoftensymptomsofinstability,culminatingingradualfailureofthecartilageandleadingtoprogressiveosteoarthritis.Treatmentstrategiesdependonthemechanicalstabilityofthehipandthetypeanddegreeofbonydeformity.IninfantswithmildDDH,capsularlaxityandmildacetabulardysplasiaaretheissues,andsimplepositioningofthehipsinabductionandflexioninaprotectivebraceorPavlikharnessusuallyleadstotighteningofthecapsuleandresolutionofthedysplasia.Inchildrenwithfullcongenitaldislocations,particularlyifdiagnosedafterinfancy,aformalmanipulativereductionmightberequired,withspicacastingforseveralmonths.Atanyage,treatmentisfocusedonreducingandmaintainingthefemoralheadtoaconcentricpositionwithintheacetabulum.IfbonymalalignmentispresentintheolderchildwithDDH,realignmentsurgeryisoftenneededtorestorestability.Infantsandchildrenwithdevelopmentalhipdysplasiamightbetreatedtocurebyvirtueoftheseearlystrategies,ortheymighthavepersistentsubluxationthatrequiresfurthersurgerylaterinadolescenceoryoungadulthood.DysplasiainadolescentsAdolescentsandyoungadultswhohadbeenasymptomaticwithrespecttothehipmightalsohavemildformsofacetabulardysplasiadetectedonradiographsbasedoncriteriaoriginallydefinedbyWiberg(Figs.1and2)[5].Inmanychildrentheindicationforradiographsishippain,thoughforsomechildrenradiographsareperformedforotherindications.Intheabsenceofadedicatedexaminationbyahipspecialistwhocanassessforsignsorsymptomsofinstability,itisnotknownwhethermildorsubtleradiographicabnormalitiesarethesourceofthechild’ssymptoms.Radiographicmeasurementsoffemoralheadcoverageandpositionmightsuggestthepossibilityofmechanicaldysfunctionofthehip,thoughitisthemechanicsthatdefinetheunderlyingdisease,nottheradiographs.IncontrasttoinfantileDDH,adolescentdysplasiahasahighermalepredominanceandismoreoftenbilateral[6].Thedifferenceindemographicsbetweengroupshaspromptedmanytoquestionwhetheradolescentandinfantilehipdysplasiasaretwodistinctentities.Thestandinganteroposterior(AP)radiographofthepelvisremainsthegoldstandardofimagingforadolescenthipdysplasia,supplementedbyotherviewsincludingthefalseprofileradiograph[4].Anumberofradiographicmeasurementshavebeendescribedthatdefinethedysplastichip,thethreemostfundamentalincludingthelateralcenteredgeangle(CEA),theacetabularindexandtheanteriorCEA[7].ThelateralCEAandtheacetabularindexarebothmeasuredonaproperlypositionedstandingAPradiographofthepelvis,whereastheanteriorCEAismeasuredonthefalseprofileradiograph(Figs.1and2).In1939Wiberg[5]definedanormallateralCEAasbeingover25°,anabnormalangleaslessthan20°(Fig.2)andeverythinginbetweenasuncertain.Theserangeswerevalidatedinsubsequentinvestigations[8,9].SimilarcriteriaexistfortheanteriorCEAasmeasuredonafalseprofileradiograph,wherethisangleisconsiderednormalabove25°,borderlineat20–24°anddeficientbelow20°(Fig.2)[10].Incertainchildrentheanterioracetabularroofinsufficiencyismoreseverethanthelateralroofinsufficiency,andthefalseprofileviewmighthelptoidentifythesechildren,withthecaveatthattheanteriorCEAisthemostdependentonradiographictechnique[11].Theacetabularindexisconsiderednormalat0–10°[7],thoughsomehavesuggestedthatanglesupto13°arenormal[8].Valuesabovethisareconsideredindicativeofdysplasia.BorderlinemeasurementsWhilefloridacetabulardysplasiaisincontrovertiblewhenidentifiedradiographically(Fig.2),thecorrectdiagnosisbecomesmoredifficultwhenthemeasurementanglesareonlymildlyoutofthenormalrange,leadingtothecreationofan“uncertain”or“borderline”category(Figs.3and4).Thesechildrenremainasourceofconfusionandcontroversyamongradiologistsandhipspecialists.Ultimately,achildfallingintoanuncertaincategoryhaseitherahealthyoranunhealthyhip,andthisdistinctiondependsonavarietyoffactorsuniquetoeachchildthatgobeyondasimpleradiographicmeasurement.Thelabel“borderlinedysplasia”hasbeenadoptedtodefineagroupthatfallsintoanuncertainmeasurementcategorywithlateralCEAof18–24°[12–14],inwhomfurtherevaluationisnecessarybeforeadiagnosiscanbemade.Giventhemechanicalbasisforthejointdamageinacetabulardysplasia,itisareasonableassertionthathipswithslightlydiminishedcoveragearepredisposedtojointdamagerelatedtoincreasedwearontheacetabularrim.Childrenwithmilddysplasiaareknowntohaveevidenceoflabralandcartilagedamageathiparthroscopy[15].ThisdoesnotmeanthatallchildrenwithalateralCEAof18–24°developosteoarthritis.Earlystudiesevaluatingtherelationshipbetweencenteredgeangleanddysplasiafocusedprimarilyonhipfunctionratherthanspecificevidenceofjointdamage[16],thoughitislikelythatnormallyfunctionalhipsmightovertimealsohavelabraltearsandcartilagelesions.Delayedgadolinium-enhancedMRIofcartilage(dGEMRIC)measurementsDelayedgadolinium-enhancedMRIofcartilage(dGEMRIC)wasdevelopedtoidentifyhipswithearlybiomechanicaldamagetothecartilagematrixinadvanceofmorphologiccartilageloss[17].Whenintroducedviaintravenousorintraarticularinjection,ananionicmoleculesuchasgadopentetate?2(Gd-DTPA?2)distributesovertimeincartilageinverselytotheconcentrationofnegativelychargedglycosaminoglycans.TheconcentrationofGd-DTPA?2canbeindirectlydeterminedwithmeasurementsofT1andisexpectedtobelowerinnormalcartilagecomparedtodegradedcartilagewithlossofglycosaminoglycans.Thismeasurementisreferredtoasthe“dGEMRICindex”(Fig.3).EvaluationofthedGEMRICindexinpeoplewithnoormilddysplasiarevealedthatthedGEMRICindexofmildlydysplastichipsdidnotdiffersignificantlyfromthatofnormalhips[17].ItshouldbenotedthatinthisstudypeoplewithmilddysplasiaweredefinedbyalateralCEA>15°,whichislowerthanwhatwouldnowbeconsideredthethresholdofmilddysplasia.Thesedatasuggestthatchildrenwithmildorborderlinedysplasiamightnotbeatincreasedriskofdevelopingend-stageosteoarthritis,thoughbecausethesepeoplewerenotfollowedlongitudinallyovertimeitisunknownwhethercartilagedegenerationevolvedovertime.ThedGEMRICindexalsodoesnotaddresswhetherchildrenhavesignsorsymptomsofinstability,whichmightbewhatbringsthemtomedicalattention.RadiographiclandmarksMeasurementsobtainedfromconventionalradiographsrelyonidentificationofpreciselandmarks,includingthecenterofthefemoralhead,themedialmarginoftheacetabularsourcil,andthelateralmarginoftheacetabularsourcil(Fig.1).Thesourcilisnotalwayswell-defined,especiallyinchildrenyoungerthan15years.Inyoungerchildrenitisuncommonforthelateralmarginofthesourciltoalsobethelateralmarginoftheacetabulum,promptingsomeinvestigatorstodevelopa“modifiedlateralCEA”thatincludesonlythescleroticportionoftheacetabularsourcil.ThisisincontrasttothetraditionalCEA,whichismeasuredtothelateralacetabularmargin[18].Therangeofnormaldependsontechniquebecausethemodifiedanglehasalowerstandardrange(15–20°)comparedtothetraditionalangle.Withoutstrictattentiontoradiographiclandmarksthevariabilitybetweenmeasurementscanbeextreme[19–21].Themostreliablemethodistoautomatetheprocesswithcomputer-aidedsoftware,eitherbyincorporatingacomputerizedmeasurementprogram[22]orbystandardizingtheprojectionoftheradiograph[23].Unlessrigorouscriteriaarebeingusedformeasurement,amildlyabnormalmeasurementshouldnotbeconsideredamarkofdiseaseunlessthereareothercompellingimagingandclinicalfindings.Anadhocmeasurementperformedby“eyeballing”theradiographisunlikelytobeaccurate.Itisbesttomeasuremultipletimes,especiallyintheabsenceofcomputer-aidedsystems.NormalvariantsCrossoversignRadiologistsarewisetoproceedcautiouslyaroundthehip,giventhefrequencywithwhichpreviouslyreportedradiographicmeasurementsorfindingshavebeensubsequentlydeterminedtorepresentnormalvariants.AnexampleofthisisthecrossoversignontheAPpelvisradiographs.In2007itwasdemonstratedthatthepresenceofacrossoversignwasahighlyreliableindicatorofcranial(superioracetabular)anteversionoflessthan4°[24].Forreference,thesuperioraspectoftheacetabulumisantevertedapproximately10–14°.Atangleslessthan0°,theanteriorwallislateraltotheposteriorwall,leadingtothecrossoversignonradiographswherethetwowallsoverlap.ItbecamestandardforradiologistsandhipspecialiststocommentonthepresenceofacrossoversignonAPradiographsofthepelvisassuggestiveofacetabularretroversion.Inclinicalpractice,however,thesechildrendidnotalwayshavesignsorsymptomsofretroversion,nordidcross-sectionalimagingconfirmretroversion.Overtime,theliteraturerefutedanassociationbetweencrossoversignandclinicallyconfirmedacetabularretroversion.Evenasymptomaticchildrenwithouthipdiseaseorsymptomatologydemonstratedacrossoversignonawellpositionedradiograph,reflectingvariationsinpatientpositioningaswellasthevariablemorphologyoftheanteriorinferioriliacspine[25,26].CoxaprofundaInsimilarfashion,theterm“coxaprofunda”fellinandoutoffavoralmostasquickly.Coxaprofundaisdefinedaspresentiftheflooroftheacetabularfossaliesmedialtotheilioischialline.Itisconsideredanindirectsignofacetabularovercoverageofthefemoralheadandwasproposedasanimagingfeatureofpincer-typefemoroacetabularimpingementin2007[27].Withthisawareness,radiologistsreadilyofferedthisimagingfindingasevidenceofanunderlyingcondition:acetabularover-coverage.Overtime,coxaprofundawasclaimedtobeanormalradiographicfindingthatdoesnotsupportadiagnosisofpincerimpingement[28–30].CamdeformityFinally,thedefinitionof“cam”deformityinchildrenwithfemoroacetabularimpingementhasbeenasubjectofinterestanddebateformanyyears.Camlesionsarebonyprotuberancesalongthefemoralhead/neckjunctionthatimpingeagainsttheacetabularriminhipflexion.Themostobjectivemeansofmeasuringthesizeofacamdeformityisthealphaangle,anangleformedbyalineconnectingthecenterofthefemoralheadtothecenterofthefemoralneck,andalinefromthecenterofthefemoralheadtothepointatwhichthefemoralneckfallsoutsideabest-fitcirclearoundthehead.Intheearly2000sitwasacceptedthatchildrenwithanalphaangleintherangeof50°likelyhadcam-typefemoroacetabularimpingement(FAI)[31–34].OverthelastdecadetherehasbeenincreasingawarenessthatsomepreviouslydefinedcamlesionsinpeoplewithFAImightbepresentinasymptomaticpopulationswithnohipdisease[35–38].Moreoverapositiveimpingementtest,oftenassociatedwiththepresenceofanteriorFAI,hasbeendemonstratedinhealthyyoungadultswhomightnothaveFAI[39],makingthisanunreliableindicatorofdiseaseinisolationofotherevidence.RadiographictechniqueGiventhatourinterestinidentifyingandtreatingpainfulanddebilitatingdiseaseinchildrenmightoutpaceourunderstandingofnormalanatomicalvariation,radiologistsneedguidelinesforinterpretingradiographsthatrevealanuncertaindegreeoffemoralheadcoverage.Acautiousapproachwouldbetosuggestthepossibilityofborderlinehipdysplasiaandrecommendreferraltoahipspecialist.Thisrecommendationshouldbeperformedwhentheimagingfindingshavebeendeemedreliable,whichrequiresstrictadherencetoproperimagingtechnique.ThefollowingshouldbeassessedoneveryAPradiographofthepelvis:(1)Isthepelvistiltedorrotated?Asaguideline,thedistancebetweenthesuperioredgeofthepubicsymphysisandthecoccyxshouldbe1–3cm[40].(2)Howwelldefinedarethemeasurementlandmarks?Ifthereisdoubtastowherethelandmarksarelocated,themeasurementsarelikelytobeinaccurate.(3)Aremeasurementsperformedusingelectroniccalipersorwithavalidatedcomputer-assistedprogram?Ifperformedbyhand,havetheinitialmeasurementsbeenvalidatedwitharepeatattempt?(4)Isthepatientolderthan15years,andifnotisthemodifiedlateralCEAstandardbeingemployedratherthantheclassiclateralCEA?Theanswerstothesequestionshaveagreatimpactonthereportedmeasures.Iftheimagingtechniqueisadequateandthechildstillfallsintoanindeterminatecategoryoftheborderlinedysplastic(alateralCEAthatfallsbetween18°and24°),thisisstillonlythefirststepinacomplexdiagnosticprocess.Ourunderstandingofhipdiseasehasevolvedconsiderablyoverthelastdecade.Itisimpossibletoaccuratelycharacterizeallofthedifferentpatternsofinstabilityandunder-coveragewith2-Dradiographicviews.RelyingsolelyonthelateralCEAtodeterminenormalversusdeficientcoverageassumesalldysplasiaisglobal,orprimarilyinvolvesthesuperioracetabulum.Wenowknowthatatleastthreedistinctpatternsofacetabulardeficiencyexist:anterosuperior,global,andposterosuperiorinsufficiency[41],andAPradiographsarenotdesignedtodetectafocalanteriororposteriordeficiency.Thepresenceofborderlinedysplasiaonradiographsalsodoesnotconfirmthepresenceofinstability,whichisultimatelywhatleadstosymptomsandjointdamage.Thepresenceorabsenceofinstabilityorimpingementmustbedeterminedthroughcarefulhistoryandphysicalexam,aswellasfromstaticandpossiblydynamicimaging.Thefemoroepiphysealacetabularroof(FEAR)indexhasbeenproposedasausefulradiographicmarkerofinstability(Fig.5)[42].Anotherhelpfulradiographiccluetothepresenceofinstabilityistheupslopinglateralsourcilmargin[43].Alloftheseobservations,however,requirefurthervalidationbeforetheycanbeconsideredreliablemarkersofdisease.Wiberg[5]laidtheimportantgroundworkwithhisseminalarticledescribingthe“normal”lateralcoverageofthefemoralhead,andformanydecadesthoseassertionshavenotbeendisproved;subsequentinvestigationshaveonlysubstantiatedhisoriginalfindings[44–46],thoughthelowerendofthenormalthresholdhasshiftedmoretowardthedysplasticendofthespectrum.Largerpopulation-basedstudieshaverecentlysuggestedthattheserangesaregender-specificandthatmaleandfemalepatientsshouldnotbemeasuredagainstthesamestandard.UpdatedreferencestandardsproposedbyLaborieetal.[39]suggestedthatcutoffvaluesformalepatientsshouldbe21°comparedto20°infemalepatients.Updatedupperthresholdvaluesforacetabularindexaccordingtothisstudywere15°formalesand16°forfemales,comparedtopreviouspublishedthresholdof10°forbothgroups.Accordingtothesenewcriteria,manypatientswhohadpreviouslybeencharacterizedasmildlyorborderlinedysplasticmightnowbeconsiderednormal.Additionally,age,gender,heightandbodymassindex(BMI)havebeenfoundtobefactorsinwhatareconsideredtobenormalrangesofacetabularcoverage,shiftingthelowerrangeofnormalcoveragefurtherintothedysplasticrangeforcertainpopulations[47].?
北大人民醫(yī)院科普號(hào)2024年08月02日467
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髖關(guān)節(jié)發(fā)育不良保髖手術(shù)常見問題
問：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)前問題的最佳方式。?問：保髖術(shù)后我的關(guān)節(jié)能用多少年？答：這個(gè)問題很難回答。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。總體上講，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：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：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，具體需要詢問當(dāng)?shù)蒯t(yī)保部門；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：髖臼周圍截骨手術(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)的入門門檻很高，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：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：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)月后門診復(fù)查，評(píng)估骨頭生長(zhǎng)情況。?問：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836
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發(fā)育性髖關(guān)節(jié)發(fā)育不良伯爾尼髖臼周圍截骨術(shù):從其在當(dāng)?shù)氐拈_始到在世界范圍內(nèi)的采用（2023）
發(fā)育性髖關(guān)節(jié)發(fā)育不良(DDH)伯爾尼髖臼周圍截骨術(shù)(PAO):從其在當(dāng)?shù)氐拈_始到在世界范圍內(nèi)的采用（2023）Berneseperiacetabularosteotomy(PAO):fromitslocalinceptiontoitsworldwideadoption?GanzR,LeunigM.Berneseperiacetabularosteotomy(PAO):fromitslocalinceptiontoitsworldwideadoption[J].JOrthopTraumatol,2023,24(1):55..?轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/37917385/?轉(zhuǎn)載文章的原鏈接2：https://jorthoptraumatol.springeropen.com/articles/10.1186/s10195-023-00734-2?AbstractThedevelopmentoftheBerneseperiacetabularosteotomy(PAO)isbasedonastructuredapproachstartingwithananalysisofthepreexistingprocedurestoimprovethecoverageofthefemoralheadandwasfollowedbyalistofadditionalgoalsandimprovements.Cadavericdissectionswithadetaileddescriptionofthevascularsupplyofacetabulumandperiacetabularbonesetthestageforanintrapelvicapproach,whichofferedthelargestacetabularcorrectionpossiblecombinedwithsafeintracapsularaccess.Thefinalcompositionofosteotomiesrequiredthedevelopmentofseveralinstrumentsandcuttingdevicesbeforethefeasibilitycouldbetestedonaseriesofcadaverichips.伯爾尼髖臼周圍截骨術(shù)（PAO）的發(fā)展基于一種結(jié)構(gòu)化的方法，首先對(duì)現(xiàn)有的手術(shù)方法進(jìn)行分析，以改善股骨頭的覆蓋范圍，然后列出了其他目標(biāo)和改進(jìn)措施。通過(guò)對(duì)髖臼和周圍骨的血管供應(yīng)進(jìn)行詳細(xì)描述的Cadaveric解剖，為內(nèi)盆入路奠定了基礎(chǔ)，這種入路可提供最大的髖臼矯正范圍，同時(shí)確保安全的關(guān)節(jié)囊內(nèi)入路。在對(duì)一系列cadaveric髖關(guān)節(jié)進(jìn)行可行性測(cè)試之前，需要開發(fā)幾種器械和切割裝置來(lái)完成所需的截骨。Whilethesequenceoftheosteotomiesremainedlargelyunchangedovertime(exceptforthepubicandischialosteotomies),severalpropositionsforaneasier/lessinvasiveapproachhavebeendiscussed;somemadeitintostandardpractice.Effortswereundertakentooptimizethelearningcurveandminimizefailuresusingvideo-clips,hands-oncourses,fellowships,publications,andongoingmentoringprograms.Inretrospect,withalmost40yearsofexperience,sucheffortshavepromotedaworldwideadoptionoftheBerneseperiacetabularosteotomy.雖然骨盆截骨的順序在長(zhǎng)期內(nèi)變化不大（除了恥骨和坐骨截骨），但人們還是討論了一些更簡(jiǎn)單、更微創(chuàng)的方法。其中一些方法已納入了常規(guī)實(shí)踐。人們還通過(guò)視頻剪輯、動(dòng)手課程、研討會(huì)、出版物和持續(xù)的導(dǎo)師項(xiàng)目等方式，努力優(yōu)化學(xué)習(xí)曲線，減少失敗?；仡欉^(guò)去，在近40年的經(jīng)驗(yàn)基礎(chǔ)上，這些努力促進(jìn)了伯爾尼髖臼周圍截骨術(shù)在全球范圍內(nèi)的采用。?KeywordsHipjointpreservationsurgery,Periacetabularosteotomy,PAO,BernesePAO,Pelvicosteotomyhistory?SimilarcontentbeingviewedbyothersResultsofPeriacetabularOsteotomy(PAO)Chapter?2017BerneseperiacetabularosteotomythroughadoubleapproachArticle10August2018Mini-IncisionPeriacetabularOsteotomyChapter?2017?IntroductionAttemptstoimprovecoverageofthefemoralheaddatebacktothebeginningoflastcentury,whenAlessandroCodivilla,directorofthefamousRizzoliOrthopedicInstituteinBologna,Italy,proposedamethodtotreattheestablisheddislocationofthehip[1,2].Hesuggestedtocoverthefemoralheadcompletelybythejointcapsuleandtointroduceitintoadeepenedacetabulumattheanatomiclevel.Thetechniquewaspopularized30yearslaterbyColonnaandremainsknownunderhisname[3].Theprocedurewasexecuteduntilthelate1990s,whenBoardmanandMoseleyintheirfollow-uppaperconcluded:“wedonotsupportrevivalofthisnowobscureprocedure”[4].Nevertheless,betterunderstandingofthebloodsupplytothehipregionfavoredarevivalofamodifiedversion,nowcalledcapsulararthroplasty[5].?AcetabularaugmentationClassicaugmentationproceduresofthedeficientacetabulumaretheshelf-arthroplasty[6,7]andtheChiariosteotomy[8].Likethecapsulararthroplasty,theyrelyontransformationoftheinterposedcapsulartissuetofibrocartilage.Comparedwithhyalinecartilagethemechanicalqualityoffibrocartilageisinferior,nevertheless,thesurvivalofsucha“neo-joint”canlastuptoseveraldecades.Theexecutionoftheacetabularshelfaugmentationiscomparativelyeasy.Overtimethistechniqueunderwentseveralminormodifications;itisstillinuseinFranceandincountrieswithFrenchorthopedicinfluence[9].ThetransversejuxtaarticulariliacosteotomyofChiariistechnicallysomewhatmoredemanding.Itwasfirstdescribedintheearly1950s[8]andgainedinternationalacceptancefordecades.Despitemultiplearticlesreportinggoodlong-termresults[10,11,12,13],theprocedurelostpopularitywiththeextensionoftotalhipreplacement(THR)indicationtoyoungerpatientsandwiththeemergenceofreorientationprocedures.?AcetabularreorientationIntheseprocedurestheentireacetabularboneandhyalinecartilageisredirectedoverthefemoralhead;theglidingsurfaceofthenewarticularrelationwiththefemoralheadremainsallhyalinecartilage.Experiencehasproventhatthereisnearlyalwayssufficientacetabularcartilageavailabletoallowcorrectreorientation.LeCoeurwasthefirsttoexecutesuchanosteotomyin1939,butdidnotpublishitbefore1965[14].Today,severalareofhistoricalvalue,themajorityisusedinthecountryoftheinventor,andfewhavereachedinternationalacceptance.?SingleosteotomiesTheSalterosteotomyistheonlyonewherewithatransverseandcompletesingleosteotomyofthesupraacetabulariliumisusedtoreorienttheacetabulum[14].Itispreferredbypediatricorthopedicsurgeonsforitsrathereasyexecution.However,withitspivotpointnearthepubicsymphysis,correctionislimitedandinterlinkedwithsidecorrectionssuchaslateral,anterior,andcaudadshiftofthejoint.Thehighestclinicalrelevance,however,hasthetendencytocreateretroversionoftheacetabulum,whichinhipswithlowornoanteversionmaycreateimpingementproblemsinearlyadulthood.ThePemberton[15]andDega[16]osteotomiesareincompletesupraacetabularosteotomiescorrectingtheroofonly.ThecutissimilarasforaSalterosteotomy[14]butdoesnotseparatetheiliumcompletely.WhilethePembertoncutisstraight,theDegacutiscurvedfollowingtheacetabularroof.Thedeeperthecutpenetrates,theeasiertheacetabularpartofthebonecanbebenddownwards,decreasingtheenlargedacetabularradius.Bothtechniquesareusedalmostexclusivelyinprematurehipswithashallowacetabulum.BotharetechnicallymoredemandingcomparedwiththeSalterosteotomy[17].Comparinglong-termresults,thePembertonosteotomyseemstocreateslightlybetterresultscomparedwiththeDegaandSalterosteotomies[18,19].?DoubleosteotomiesTwodoubleosteotomiesforacetabularcorrectionwithdifferentestimateshavebeendescribedfromSutherlandandGreenfield[20]andfromHopf[21].Thefirstiscuttingthroughthebonenearthesymphysis,thesecondiscuttingthroughtheemptydistalpartofthepaleo-acetabulumincasesofseveresubluxationandsecondaryacetabulum.?TripleosteotomiesTheycanbedividedintodifferenttypes:thoseexecutedatadistancefromthejoint,whichimpliesthatthesacrospinalandsacrotuberalligamentsinsertattheacetabularfragmentandthereforelimitthecorrection,andthoseexecutedclosetothejoint,whichimpliestheligamentsarenotattachedtotheacetabularfragmentandthereforeallowahigherspatialcorrection[14,22,23,24].?SphericalosteotomiesTheseareperformedveryclosetothejoint,allowingextensivecorrectionexceptformedialshiftingoftheacetabularfragment.Theexecutionisratherdemanding,andduetotheacetabularvicinityoftheosseouscuts,thefragmentperfusionislimitedtotheobturatorandcapsularvessels.Simultaneousarthrotomyisthereforelimited[25,26,27].?TheBerneseperiacetabularosteotomy(PAO)ThemostrecentlyintroducedreorientationprocedureisthePAO[28].Incontrasttopreviousosteotomies,itisexecutedfromanteriorandfromtheinsideofthepelvis.Theprocedureistheresultofaresearchprojectwithanalysisofthelimitationsoftheexistingprocedures,followedbyextensivecadavericdissectionsofthevascularsupplyandbytrialosteotomiesforbestdirectionoftheosteotomycuts.Finally,thedefinitiveversionoftheprocedurewastestedon25cadaverhipswiththefocustotestasetofnewinstruments.Traditionally,pelvicsurgeryperformedbyorthopedicsurgeonsapproachedtheacetabularareaalmostexclusivelyfromthelateralside.Withtheprogressinsurgicaltreatmentoftraumatotheacetabulumandpelvisinthelate1970sandearly1980sbyLetournel[29],aswellaswithbetterunderstandingofthevascularsupplyofthepelvis,theinnersideofthepelvisbecameaninterestingnewsurgicalapproacharea.Additionally,knownlimitationsofthepreexistingaugmentationandreorientationprocedures(Table1[14,15,20,21,22,23,24,25,26,27,28])raisedtheambitionforamoreversatileprocedureofacetabularreorientationthatshouldfulfillseveralgoals(Table2).??Table1Characteristicsofacetabularreorientationprocedures??Table2Criteriatomeetforanewreorientationprocedure??Thefirststepoftheprojectwasacadavericstudyofthevasculartopographytothepelvisrelevanttoperiacetabularosteotomies.Hereitbecameobviousthatthemostcrucialaspectwasthepreservationofthefragmentvascularityduringtheosteotomiesandduringwideningthegapsrequiredforcorrection.Itwasbestachievedifosteotomieswereperformedfromtheinnersideofthepelvis[28](Fig.1).AfterfirstclinicalintroductionofthePAO,intraoperativelaserDopplerflowmetryoftheacetabularfragmentwasusedanddemonstratedthatthesignalsdropduringthereorientationbutreturntonormalvaluesafterseveralminutes[30].Overall,theseteststookup1year,mainlyduetolimitedavailabilityofsuitablecadavers.Forthefinalsequenceandorientationofthefivenecessaryosteotomysteps,JeffreyMast,aclinicalfellowfromtheUSAatthetime,wasaningeniouscontributortothedevelopmentofthePAO(Figs.2,3).Finally,wepracticedonseveralcadaverhipstobecomefamiliarwithtechniqueandanewsetofinstruments,whichlaterbecamecommerciallyavailable(Fig.4)fromseveralproviders.??Fig.1Periacetabularvascularsupplycadaverstudyonvascularsupplyoftheperiacetabularbone.Righthip,osteotomiesfrompelvicinside.Thebranchesfromsuperiorandinferiorglutealarterycanbepreservedduringosteotomy(left)andfragmentcorrection(right)??Fig.2PAOosteotomycutsarrangementofthefiveosteotomycuts,visibleontheleftlateralview,inthemiddleanteriorview,andontherightmedialviewofarighthemipelvis,namelyincompleteischialcut(first),pubiscut(second),supraacetabularcut(third),retroacetabularcut(fourth),andinfraacetabularcutcompletingtheischialcut(fifth)??Fig.3Pelvisplasticmodel:plasticmodelshowingseparationoftheacetabularfragmentfromposteriorcolumnincludingsacrospinalandsacrotuberalligaments.Top:anteriorview;bottom:posteriorview??Fig.4PAOinstrumentationsetofinstrumentswithspecialosteotomesandretractors??Thefirsthipwasoperatedonon13March1984.Wewerewaitingseveralweeksforan“easy”case,butDrMastcouldnolongerpostponehisflightbacktotheUSA;thiswasthereasonwhywedecidedtotreatthemosturgentcaseonthelist,whichwasaproximalfemoralfocaldeficiency(PFFD)hipwithcomplexdeformity.Thesurgeryofthis13-year-oldgirltook4hand10minandincludedafemoralvalgusosteotomytocompensateforanearliervarusosteotomy.Atotalof3monthsaftersurgery,thehipdislocatedposteriorly,acomplicationthatwassuccessfullytreatedwithaposteriorshelf.Atthattime,wedidnotknowthatPFFDhipshavesevereacetabularretroversionasacharacteristicpartofthemalformation.Thehipfunctionedwellduring33yearsbeforeTHRbecamenecessary(Fig.5).Theresultsofthefirst75hipswithratherheterogeneousformsofdysplasia,multipleprecedentsurgeries,andosteoarthrosisstageincludingT?nnisgrade2werepublished4yearslater[28];thesuccessrateofthisgroupdroppedfrom80%after10yearsto60%after20yearsandto30%after30years[31,32].Meanwhile,morehomogeneousgroupsofhipdysplasia,youngerageatsurgery,exclusionofadvancedosteoarthritis,aswellasaconcurrentarthrotomyforfemoralhead–neckshaping,haveledtofurtherincreaseofsurvival[33,34].??Fig.51984:firstoperatedcase—13-year-oldfemalewithPFFDofthelefthip.aVarusproximalfemurafterintertrochantericosteotomy3yearsearlier.bPeriacetabularosteotomyfollowedbyintertrochantericrevalgisationforbetterjointcongruity.Goodlateralcoverageofthehead.Increasedretroversionoftheacetabulumledtoposteriorsubluxation3monthsaftersurgery,whichwastreatedwithaposteriorshelf.cProgressivejointdegenerationafter36years.Plateforshelffixationstillinplace.dFollow-upradiographyofTHR2yearslater.Thepatientregainedanormalgaitpattern??TechniqueThepatientisinsupineposition,thelegtobeoperatedonisdrapedmobile.Generalanesthesiaisstandardasisbloodsalvage(cellsaver).TheapproachisamodificationofSmithPetersen’sprimarydescription[35].Thesequenceofthefivepartialcutsisdescribedelsewhereindetail[28].Someperformthepubiccutpriortothefirstischialcut,especiallywhenarectussparingapproachisused.Theclassicexposurestartswithosteotomyoftheinsertionofthesartoriusoriginattheanteriorsuperioriliacspine(ASIS).Mainlyinyoungerpatients,thesartoriusinsertionincludingtheinguinalligamentarereleasedfromtheASISwithoutanosteotomy.Byincisingthefasciaofthetensorfasciaelataeandmovingawaythemuscletothelateralside,thejointcapsuleisreached.Bydissectingtheiliacussubperiosteally,themedialflapcanbemobilized.Intheclassicapproachthereflectedandthedirectheadoftherectusfemorismusclearedividedandtheiliocapsularismuscleisdissectedfromthecapsule.Followingtheanteroinferiorcapsuletotheinferior,thegapbetweencapsuleandpsoastendonfurtherdowntotheobturatorexternusmuscleiswidenedtoreachtheischium.Thedeepbranchofthemedialfemoralcircumflexartery(MFCA)runsonthecaudadsurfaceofthismuscle,whichneedstoberespected.Initially,foranincompletecutoftheischiumattheinfracotyloidaxilla,aspeciallyangulatedosteotomeisused.Positionandpropagationcanbecontrolledwithfluoroscopy.Intherectussparingapproach,theischiumisapproachedmedialtotherectusfemoris,whichisnotreleased.Thedeepfasciaisincised,andtheischialosteotomyisperformedquitesimilartotheclassictechnique.Incomparisonwiththeclassictechniquetakingdowntheinsertionoftherectus,therectussparingapproachisnotreallyinternervous,becausethefirstbranchofthefemoralnerveiscrossingtheapproachdistally.Thepubiccut,intheclassicversionsecond,isacompleteseparationofthepubisaftersubperiostealdissection;theobturatorneurovascularbundleisprotectedusingtwobluntretractors.Thethirdcutisasupraacetabularhorizontalseparationoftheiliacbone,startingjustdistaltothesartoriusmuscleorigin.Thecutisperformedfromtheanteriorandinnersideoftheiliumwithanoscillatingsaw.Duringthisosteotomytheabductormusculatureisprotectedwithabluntretractor.Thecutstopsabout10mmbeforethepelvicbrim.Forthefourthcut,aretroacetabularcutstartsfromthereandisdirecteddownwardsatanangleof110–120°posteriortothesupraacetabularcut.Again,fluoroscopyhelpstocorrectlypropagatethiscutusinga10mmosteotome.Attheangulationbetweenthethirdandfourthcut,acurvedosteotomeisusedtocuttheoutsidecortex.Atthispointabonespreaderisinsertedjustdistaltotheangulationtoopenupthegap.Witharetractorheldagainstthequadrilateralsurfaceneartheischialspine,theareaforthefifthosteotomycanbeopened.Thecutisexecutedwithaspecialosteotomeandcutsthefinalosseousbridgebetweenthefourthandthefirstcut.Itseparatesthesacropelvicligamentsfromtheacetabularfragment(Fig.3).Whenallcutsareproperlyaccomplished,theacetabularfragmentcanbeseparatedwithacounter-rotatingmoveofthespreaderandaSchanzscrewinsertedintotheiliacpartoftheacetabularfragment.Thedesiredcorrectionistemporarilyfixedwithtwo(?3)Kirschnerwiresandiscontrolledwithfluoroscopyorastandardanteroposteriorradiographoftheentirepelvis.Thelatterispreferredbecauseitalsoguaranteesthenecessaryorthogradepositionofthepelvis.?ModificationsoftheapproachovertimeSoonaftertheinitialexperiencewith75PAOs,thedissectionoftheabductormusculaturewasabandonedandsufficientprotectionofthesemusclesduringthethirdcutcouldberealizedwithtunnelingandplacementofabluntretractor[36].Animportantinsightcamefromfollow-upstudies,showingthatsomehipsdevelopedimpingementsymptomsafteracorrectlyorientedacetabulum.Acloserlookrevealedthatconcomitantfemoralhead–neckdeformityisrelativelyfrequentandwasnotproducingsymptomsbeforethePAO-improvedanteriorcoverage.Theproblemcanbedetectedbyassessinginternalrotationinhipflexionduringsurgeryandsolvedwithadditionalarthrotomyforosteochondroplastyoftheanteriorhead–neckjunction.SomeauthorsrecommendarthroscopybeforePAO[34],whichmaycompensateformissingorinadequateMRIandmayeveninfluencetheindicationforPAO.IncomplexdeformitiesnecessitatingthecombinationofaPAOwithafemoralprocedureweareinclinedtostartwiththefemoralprocedureandapproachtheinfracotyloidaxillabetweenmuscles.gemellusinferiorandobturatorexternus.Forbetterdiscriminationitisadvantageoustoexposethisgapbeforethefemoralprocedure;itallowstoperformthefirstischialcutunderdirectviewwiththesciaticnervebeingheldaside[37](Fig.6).??Fig.6Ischialcutviafemoralapproachinhipswithcombinedacetabularandfemoralsurgery.Ontop,accesstotheinfracotyloidgroovebetweenobturatorinternusandgemellusinferiormuscles.Bottom:itallowsoptimalprotectionoftheischialnerveduringexecutionofthecut??Amorerecentmodificationoftheoriginaltechniqueistherectussparingapproach,whichallowsthefirstcuttobeperformedbyapproachingtheischiummedialtotheintactrectustendons.Acadavericstudydescribesthefeasibilityofthismodification;however,intraarticularinspectionandrevisionoftheanteriorinferioriliacspine(AIIS)mightbesomewhatrestrictedandthemostproximalbranchofthefemoralnervecanbeoverstretched[38].Anumberofproposalsdealwithmodificationsoftheapproachwithoutchangingsequenceandconfigurationoftheosteotomy.TheattemptstoexecutethePAOusingmini-invasivetechniques,includingthetranssartoriousapproach[39,40],maybeapplicableforminimalcorrectionsbuthavelimitationswithcomplexdeformities;consequentlythewidespreaduseremainslimited.AnotherpropositionistheuseofamodifiedStoppaorapararectusapproaches;bothhavebeensuccessfullyperformedforanterioracetabularfractures[41];however,theusefulnessfortheexecutionofaPAOhasnotyetbeendemonstrated.Aninguinalextensionoftheapproachmayincreasetheviewonthepubicosteotomyarea,butwasnearlycompletelyabandonedafterseveralcaseshadpostoperativedeepveinthromboses(DVTs)ofthefemoralvein.Fewareusingatwo-incisiontechnique[42],similartotheT?nnistripleosteotomy[24].Aprimaryconceptionoftheoriginaltechniquewastoavoidfluoroscopyanduseonlylocallandmarksfortheexecution.However,mostsurgeonstodayusestandardizedfluoroscopycontrolforsomeorevenallosteotomies.Computerassistancehasbeenproposedseveraltimes,butlikeforTHR,sofarithasnotfounditswayintogeneralpractice.Amostrecentversion[43]confirmsthatitmaybehelpfulforthelessexperiencedsurgeon,aconclusionwegainedalreadymorethan25yearsagousingasimilarapproach;itwasgivenupafterashortclinicaltestingperiod[44].?SpectrumoftheprocedureThefollowingselectedcasesmaydemonstratethespectrumofindicationandthereforeversatilityofthePAO.Whiletheprocedurewasoriginallyintendedasamethodforprimaryacetabulardysplasiafromdevelopmentaldislocation(DDH),itbecameusefulsoonafterasanadditionalsurgeryforothercomplexdeformitieswithacetabularparticipation,mainlyPerthesorPerthes-likedisease,butalsoincaseswithfemoralexostosisorsepticarthritiswithfemoralheadnecrosisintherareepiphysealdysplasiaandoccasionallyinearlystageofprotrusionandposttraumaticperiacetabulardeformities.Specialchallengewasconstitutedincasesafterprevioussurgery,suchasretroversionafterSalterosteotomyorwhenare-PAOwasnecessary.?Case1A16-year-oldfemalesufferingfromseverebilateralacetabulardysplasiaandcoxavalgawithhighfoveacapitishadmorepainontherightside.Therewasbilateralsubluxationwithfatiguefractureofthelateralacetabularrimontherightside(Fig.7).Thelateralviewoftherighthipshowedsubstantialintraosseousganglionformationintheroof,whiletheabductionviewfeaturedrecenteringofthefemoralheadandsomereductionoftheacetabularfragment.ThecomplexdeformityonbothhipsmadeitnecessarytocombineaPAOwithafemoralvarusosteotomy.Surgerystartedonthefemorallevelinlateraldecubitus.Beforeexecutingtheintertrochantericosteotomy,thefirstischialcutofthePAOwasperformedthroughthisapproachunderdirectview.FortheremainingPAOcuts,thepatientwasturnedintosupineposition.Theacetabularrimfracturereducedspontaneouslyanddidnotneedadditionalfixation.Thelefthipwasoperatedon6monthslater.Healingoftheosteotomies,includingtherimfracture,wasuneventful.Painofbothhipsdisappearedshortlyaftersurgery,allowingforunrestrictedage-appropriateactivities.Theprominentbendofthefemoralimplantcreatedsomediscomfort,andthiswasthereasonwhypartialmetalremovalwasexecuted2yearsaftersurgery.Afollow-upradiographyat5-yearfollow-upshowedaperfectlyreducedandhealedrimfragmentanddisappearingacetabularcysts.??Fig.7Bilateralsevereacetabulardysplasiaof16-year-oldfemale;morepainontherightside.aSeveralsubchondralbonecysts,bestvisibleinalateralview(blackarrow).Displacedrimfracturewithsomereductioninabduction(whitearrow).bPAOcombinedwithfemoralvarusosteotomy.A6-monthintervalbetweensurgeryofthehipswasobserved(rightsidefirst).SlightovercorrectionofthePAOontherightsideforbetterunloadingofthedamagedrimareawasperformed.Partialmetalremovalafter2yearswasperformed.Radiologicalresultobservedafter5years.cCloserlooktothecriticaljointareaoftherighthipbeforesurgeryandaftersugery(d)showingreducedandhealedrimfragment(doublearrow)??Case2A13-year-oldmalewithPerthesdisease(Fig.8).AfterSalterosteotomypaindidnotsubsideandlimpingincreased;bothcouldbeexplainedwithpersistentsubluxation,widenedacetabulum,followedbyadductioncontracture.Computersimulationshowedreasonablereductionofthesubluxatedfemoralheadwithintracapitalosteotomy[45]andPAO.Thepreciseexecutionofthefemoralheadosteotomywasfacilitatedbyacuttingtemplateprefabricatedonthebasisofthecomputersimulationdata.Healingoftheosteotomieswasuneventful.Painsubsidedcompletely;abductortraininghelpedtoregainawalkingpatternwithoutlimping.At1yearaftersurgery,partialmetalremovalhelpedtosettlepainfromprojectingscrewheads.At2yearsaftersurgerytheconfigurationofthehipwasclosetonormal,rangeofmotion(ROM)wasslightlylesscomparedwiththeoppositesideandfunctionwasunrestricted.??Fig.8Perthesdiseaseintherighthipofa13-year-oldmale,operatedonwithSalterosteotomy.aPersistentsubluxationandadductionwithextrusionofthehealthylateralpillarandloadingofthenecroticarea.Adaptivewideningoftheacetabularcavity.Ontheright,computersimulationshowingrelocatedheadafterresectionofthenecroticarea(redportion)andoptimalcoveragewithPAO.bIntraoperativepicturesshowingtheresectionofthenecroticcentralpartoftheheadwiththetemplateinplaceandthefinalsizeoftheheadafterscrewfixationofthemobilelateralpartoftheheadwithtwoscrews.cPostoperativesequenceswiththenewheadhealedwithoutnecrosis??Case3A21-year-oldverygracilefemalewithmultipleexostosesaroundbothhipsandconcomitantacetabulardysplasia(Fig.9).Sheonlyhadpainontheleftsideanddescribeditassudden,happeningfrequentlyduringexternalrotationinfullextension.Thephenomenoncouldbedemonstratedbyultrasoundasimpingementbetweenaposteromedialneckexostosisandtheinfracotyloidischium;thecontactwasfollowedbyfemoralheadsubluxation.Ultrasoundalsorevealedthatthecausativetumorwasbiggerthanitsradiographicappearance.Bothhipsshowedahighcoxavalgaandacetabulardysplasia.Thesurgicalplanwastoremovethenecktumor,correctthehighneckvalguswithavarusosteotomy,andtoimproveacetabularcoveragewithaPAO.Preoperativeplanningbroughtoutthatintertrochantericosteotomywouldnotsufficientlyincreasethepelvifemoralclearance.Ontheotherside,theriskofdamagetothefemoralheadvascularsupplywasestimatedtobehighduringanattempttoexcisethebigtumorviaanteriorand/orposteriorretinaculardissection.Basedontheknowledgethattheposteriorneckisfreefrombloodvessels,itwasdecidedtoexecutetheresectionthroughtheneckosteotomy,whichcouldalsobeusedtoperformtheplannedvarusosteotomy.Again,surgerystartedwithdislocationofthehip.Subperiostealanteriorandposteriordissectionoftheneck,containingthevesselstothehead,wasperformedtowardthebaseoftheexostosis.Itwasfollowedbyamediocervicalosteotomyandwideningofthegapusingaspreader.Theviewwassufficienttoallowsubperiostealpiecemillresectionofthetumorunderconstantobservationofbleedingofthehead–neckfragment.Varuspositionoftheneckwasstabilizedwithtwoscrews.PAOwasexecutedasdescribedearlier.Subluxationofthehipdisappearedimmediatelyaftersurgery.The10-yearresultshowsareasonablehipjointwithawidejointspace.ThepatientispainfreeandthehiphasanormalROM.Sheisseenregularlybyherlocaldoctorwhoconfirmedthattheotherhipisstillfunctioningwell.??Fig.9Acetabulardysplasia,multipleexostoses,andsubluxationmultipleexostosesnearbothhipswithacetabulardysplasiainaverygracile21-year-oldfemale.aPainanddiscomfortofthelefthipduringsubluxation,palpablewithrotationinfullextension.Lateralview(right)showingthecausativeexostosisattheposteriorneck.bPostoperativeresultaftersurgicaldislocation,femoralneckvarusosteotomy,andremovaloftheexostosisthroughtheneckosteotomy,followedbyPAO.cThe10-year-result.Removalofthefemoralscrewsforlocalpainsoonaftersurgery.Bothhipsarepain-free??Case4A19-year-oldrugbyplayerwithpainoftherighthip,renderinghimunabletoparticipateinhisfavoredsport(Fig.10).Historyrevealedthathewasrunoverbyatruckwhenhewas3yearsold.Hesurvivedmultiplefracturesincludingacrushinjurytothepelvicring,alltreatedconservatively.Afterfullrecoveryhehadnofurthercontroluntilrecentlywhenheexperiencedincreasingpainintherighthipduringhissportiveactivities.Radiographyrevealedatypicalposttraumaticdysplasia,apparentlyaconsequenceofthecrushinjuringthetriradiatecartilage.Thisraretypeofdysplasiaischaracterizedbythickeningoftheinnerwall,deformityofthehemipelvis,andretrotorsionoftheacetabulum.Lateralandcaudadgrowthofthephysisleadstolengtheningoftheleg.Thelargeacetabularfragmentinthiscaseisaconsequenceofchronicoverloadoftherimarea.Thesurgicalplanwastocombinetheacetabularreorientationwithexceptionalmedialshiftingofthelateralizedacetabularfragment.Concernsaboutsufficientunloadingofthefragmentinfluencedthedecisiontofixitseparatelywithtwoscrews.Thesupra-andretroacetabularosteotomycutswerelaboriousduetotheunusuallylargediameterofthesupra-andretroacetabularbone.Optimalmedializationoftheacetabulumledtominimalbonycontactbetweenacetabulumandhemipelvis,whichwasthereasonwhythecorrectionofversionwaslessthandesired.Nevertheless,consolidationwasuneventful.Thepatientresumedhisrugbyactivitiesafter9months,butalthoughpainfree,didnotregainthenecessaryaggressivityforthistypeofsportandthereforegaveitup.The2-yearresultshowedperfectconsolidationofosteotomyandrimfragmentwithalargeandcongruentjointspace.??Fig.10Posttraumaticdysplasiaina19-year-oldmale.aTypicalposttraumaticdysplasiaoftherighthipafteracaraccidentatage3.Largeacetabularrimfragment.Laboriousexecutionoftheosteotomyduetothethicksupra-andretroacetabularbone.Screwfixationofthelargerimfragment.PAOwithmaximalpossiblemedialdisplacementoftheacetabularfragment.bRadiologicalresultafter2yearswithhealedfractureandosteotomies??Case527-year-oldfemalewithosteogenesisimperfectaandbilateralprotrusio(Fig.11).Shehadincreasingandconstantpainfromglobalpincerimpingementintherighthip,whiletheleftsideremainednearlypainfree.Radiographicallythejointspaceontherightsidewasgloballynarrowed.ThepatientfavoredjointpreservationaftershehadlearnedthatthelifetimeofTHRwithsuchbonequalityislimited.Finally,sheunderstoodthatjointpreservationforherhipwouldbeelaborateandthatagoodandlastingresultcannotbeguaranteed.Thedirectionofreorientationbeingreversedtotheclassiccorrectionwouldrequirealargerimtrimmingtostartwith.Surgicaldislocationconfirmedareasonablecartilagelayerofthefemoralheadwithsomeosteophytes.Circumferentialtrimming,especiallyattheposteroinferiorrimwascombinedwithsomeosteochondroplastyattheheadneckjunction.WhileexecutionofthePAOcutswaseasy,valguscorrectionoftheacetabulumwasratherdifficult,mainlyduetotheosteoporoticbone.Tobridgethelargesupraacetabularstepasaresultofthefinalposition,astaircase-shapedplatehadtobeused.Healingoftheosteotomywasuneventful;consolidationofthefatiguefracturecouldbeobservedatthe6-weekcontrol.At2yearsaftersurgery,thepatientwaspleasedwiththeimprovedandpain-freeROM.Radiographicwideningofthejointspacewasinterpretedassignofongoingimprovement.??Fig.11Acetabularprotrusiowasobserved,withabilateralprotrusionina21-year-oldladywithosteogenesisimperfecta.Constantpainontherightsidewhiletheleftsidewaspain-freeduringmostdailyactivities.PatientrefusedtogetTHR.Onthetop,preoperativeradiographyshowingfatiguefracturethroughthebottomofthejoint(whitearrow).bResult1yearafterexcessiverimtrimmingandPAOdecoveringthehead.Fatiguefracturehealed(blackarrow)withsubstantiallyreducedpain??Case6A23-year-oldfemalewithsevereunilateralnarrowingofthepelviccavityafteraconservativelytreatedcomplexperiacetabularfractureinchildhood(Fig.12).Thejointlookedrathernormalandhippainorrestrictedmotionwereminimal;herproblemwasconnectedtothedesperatedesiretogetpregnantandastatementofhergynecologistwhoexpressedconcernswhethertheasymmetricnarrowingcouldleadtoadeviationoftheincreasinguteruswithincreasdriskofabortion.Athree-dimensional(3D)modelofthepelvisdidnotgiveaconclusiveanswertothepossibilityofuterusdeviation,butshowedthatthebirthcanalwassomewhatnarrowforanaturaldelivery.Fromanearliercasewithpelvicdeformationandsuccessfuluseofadistractor,itseemedpossibletousesuchasystemforthenecessarylateralanddistalshiftingofthemedializedjointcomplex.TestsurgeryonaplasticmodelofthedeformedpelvisrevealedthatamodifiedPAO,separatingtheposteriorcolumnproximally,wouldallowtolateralizetheacetabularfragmentsufficientlyandrecreateanormalcurvatureoftheinnerpelviccontour.Fortheverticalizedpubicramusanadditionalosteotomynearthesymphysiswasnecessary.ThebestplacefortheSchanz’screwsofthedistractorweretheoppositeiliacbonenearthesacroiliacjointandattheipsilateralfemoralhead.Bestfixationwaspossiblewithareconstructionplateplacedalongthepelvicbrim.Anilio-inguinalapproachwouldallowexposureoftheentirehemipelvis.FortheSchanz’screwneartheoppositesacroiliacjoint,ashortincisionattheiliaccrestwouldbesufficient.Thethreecutsaroundthejointandtheadditionalcutofthepubisnearthesymphysiswereexecutedastestedonthemodel.Manualtractiondidnotdispalcetheacetabularfragmentmuch.Instrumenteddistraction,however,allowedslowbutconstantdisplacementwhilealignmentcouldbeassistedwithinstruments.Theprebendedplatewasfirstfixednearthesymphysisandonthemobilepubissegment.Proximaloff-standingoftheplatecouldbesteadilyconvergedtothestableiliacbonebyalternatedrivinginthescrews.Thistechniqueallowedanoptimalfinalpositioningoftheacetabularfragment.Osteotomyhealingwasuneventful;shortlyaftershebecamepregnant.Shefinallyhadanaturaldeliveryanddidso2yearsaftersurgerywithasecondchild.Atotalof16yearsaftersurgery,thepatient,nowamotherof5children,ispainfreeandlikesoutdooractivitiesverymuch.??Fig.12Posttraumaticprotrusioobservedinpatient.aPosttraumaticprotrusioanddeformationofthehemipelvisina23-year-oldfemale.Hergynecologistdiscussedtheriskofabortionduetodeviationoftheuterus,whichwasthereasonwhyshewasaskingforcorrection.AmodifiedPAOwasfirsttestedonaplasticmodel.Correctionofprotrusioundpelvicdeformationwasassistedbyadistractor.bThenewpositionwasstabilizedwithalongrecoplateplacedalongthepelvicbrim.Ultrasoundwasperformedjustbeforenaturaldelivery.cAt16yearsaftersurgery,sheisnowthemotheroffivechildrenandisveryactiveinoutdooractivities.Thestraightlegistheoperatedone??Case7Thiscase(Fig.13)wasoperatedbyProfessorPauloRego,aformerfellow.Itispresentedtoshowthatthetechniquesarelearnablebyothers.??Fig.13Severedeformity(courtesyProf.P.Rego,HospitaldaLuz,Lisbon,Portugal)oftherighthipina16-year-oldmaleafteropenreductionattheageof1.5years,followedbyavascularnecrosis.aVarusosteotomyattheageof14years,whichdidnotimprovelimpingandpain.bPostoperativeradiographyaftercomplexsurgerywithrelativelengtheningoftheneck,intracapitalosteotomytoreducethesizeofthehead,andsubtrochantericderotationosteotomyfollowedbyPAO.cThe4-yearfollow-upresultwithgoodandpain-freefunction??Complexdeformityoftherighthipina16-year-oldmalewasobserved.HehadopenreductionforDDHattheageof1year,whichwasfollowedbyincompletenecrosisoftheepiphysis.Togetherwithongoingsubluxation,theacetabulumbecameshallowoveraPerthes-likedeformedfemoralhead.Painandlimpingdidnotimproveafterintertrochantericvarusosteotomyattheageof14years.MRIshowedareasonableconditionofthejointcartilageandcomputersimulationrevealedanimprovedheadsphericitywithintracapitalosteotomy[45].Thepreoperativeevaluationalsoexposedahighfemoralneckanteversion.Surgerywasstartedwiththefemoralside:thefirstischialcutofthePAOwasfollowedbyrelativenecklengtheningandintracapitalosteotomyandfinallysubtrochantericderotation.ThePAOwascompletedafterturningthepatientintosupineposition.Thesurgeoncommentedthattheentiresurgerywasdemandingandtimeconsuming;however,theradiographicresultwasconvincing.The6-yearfollow-upradiographyshowedaresultofcorrectionclosetoanormalhip.Thepatientispain-free,hasanormalwalkingpatternandanearlysymmetricalROM(courtesyProf.P.Rego,HospitaldaLuz,Lisbon,Portugal).?ComplicationsTechnicalcomplicationsdevelopedfirstandforemostduringthelearningcurve,whichinturnisdependentonthecaseloadovertime.Inaliteraturereviewfrom2006,inabout13publications,theincidenceofmajorcomplicationsrangedfrom6%to37%[46].Inourfirstseriesof500cases,themostfrequentcomplicationwassevereunder-,over-,andintraarticularcorrectioncountingfornearly2%ofcomplications[47].Injurytooneofthemainnerves(femoral,sciatic,orobturator)follows,makinguplessthan1%ofcomplications[48],anumberthatmayhavebeeninfluencedbystrictobservationofrecommendationsfromacadaverstudyaboutsurgicalcircumstancesleadingtosuchinjury[48].In1760casesoftheANCHORgroup,complicationincidencewas2.1%,50%(17outof36)ofwhichweretransient[49].NeuromonitoringduringPAOcanidentifythesurgicalmaneuverendangeringtraumatoanerve,butcannotpersepreventdamagewhentheblowisheavyenoughtocausealaceration[50].?InternationaladoptionoftheBernesePAOThisisprimarilytheresultofmultiplepublicationscomingfromdifferentcentersovernearly40yearssinceitsintroduction.Furtherpromotioncamefromaseriesofinstructionalcoursesindifferentcountriesandfromfellowships,mainlyorganizedinSwitzerlandandtheUSA.Also,theongoingmentorshipforcolleaguesduringtheirlearningperiodshouldberemembered[51].SwitzerlandhasprobablythehighestconcentrationoforthopedicdepartmentsperformingtheBerneseperiacetabularosteotomy,withmostoftherelevantpublicationscomingfromtheBerneseGroup[52].NextaretheUSAandCanada,whereseveralinstitutionsworktogetherintheANCHORgrouptostudyallaspectsofsurgerypreservingthenativehipjoint[53].Oneormorecentersarepracticing,andsomedoreportabouttheirresultswiththeBerneseperiacetabularosteotomyinGermany,England,Denmark,Italy,Spain,Portugal,Chile,Iran,andfinallyChina,fromwherethemostrecentreportwaspublished[54].?FutureopportunitiesandchallengesTheindicationfor(oragainst)PAOisstilloneofthemostdifficultdecisionstobemade.Thereisatendencytoperformthesurgeryevenwhenthetriradiategrowthplateisstillopen,butlittleisknownabouthowfaronecangowithoutriskingsurgery-relatedmalformationafterinjuringthegrowthplate.Interestinglyenough,deepeningoftheimmatureacetabulumforcapsulararthroplastydoesnotseemtoproduceamalformation.Maybemolecularstudiesofthetriradiatecartilagecangivesomeideasaboutitsgrowthbalance.TheindicationlimitforoldercandidatesisindirectlydefinedbytherecognitionthatPAOresultsaftertheageof40yearsarestatisticallylessfavorable.However,maybethedirectreasoncouldbetheincreaseofcartilagedegenerationwithage.However,tousedetailedinformationaboutthestatusofthejointcartilageasoftwarewouldberequiredtoquantifyandlocatethecartilagedamageoffemoralheadandacetabulumseenonanMRI.Inanycase,todaytheT?nnisclassificationofhipjointarthrosisaloneisnotagoodparameterfordecision-makingandfollow-upconclusions.WhilethegeometryofthePAOcutsdidnotchange,theapproachalreadywentthroughsomemodifications.Somerepresentaclearadvantage;oneshowedabenefittogetherwithonlyoneminorhandicapduringcadavertesting.Itwouldbehelpfultohavesuchorsimilarstudiesofcomparison,includingthepreoperativeexpenditurefortheminimallyinvasivetechniques.Furtherpropositionsofcomputerassistanceshouldbeanalyzedforexpenditureversusimpact.Progresscanbeexpectedwhenthisdemandingsurgeryisconcentratedinfewcenterswithahighcaseloadandwhenseveralsuchcentersworktogetherandcollecttheirmaterialinacentralregistry.
北京潞河醫(yī)院骨關(guān)節(jié)科科普號(hào)2024年06月17日50
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中國(guó)最微創(chuàng)的兒童髖關(guān)節(jié)Salter骨盆截骨手術(shù)
兒童發(fā)育性髖關(guān)節(jié)發(fā)育不良（DDH）是小兒骨科最常見的髖關(guān)節(jié)畸形，嚴(yán)重影響兒童的健康成長(zhǎng)。18月齡以內(nèi)的DDH患兒由于重塑形的潛能大，通?？梢酝ㄟ^(guò)吊帶或閉合復(fù)位、石膏固定的方式有效治療。隨著年齡的增大，18月齡及以上的DDH患兒病理改變進(jìn)一步加重，通常需要更大矯正幅度的截骨手術(shù)。對(duì)于學(xué)齡前（小于5-6歲）的低齡兒童髖關(guān)節(jié)畸形，Salter骨盆截骨術(shù)(SalterInnominateOsteotomy,SIO)，仍是目前使用最為廣泛的手術(shù)方式。作為小兒骨科的關(guān)鍵手術(shù)技術(shù)之一，其對(duì)于兒童的各種復(fù)雜髖關(guān)節(jié)畸形，具有強(qiáng)大的矯正能力，可以實(shí)現(xiàn)髖臼對(duì)股骨頭的良好包容、穩(wěn)定髖關(guān)節(jié)。該類截骨手術(shù)被廣泛應(yīng)用于治療DDH等各種原因?qū)е碌膬和l(fā)育性髖關(guān)節(jié)發(fā)育不良，是目前全世界公認(rèn)的低齡兒童髖關(guān)節(jié)畸形最有效的手術(shù)方法之一。傳統(tǒng)Salter骨盆截骨術(shù)RobertSalter于1961年發(fā)明了Salter骨盆截骨術(shù)（salterinnominateosteotomy，SIO）治療發(fā)育性髖關(guān)節(jié)脫位。SIO以恥骨聯(lián)合為鉸鏈，可使髖臼向前、下、外恢復(fù)覆蓋，骨盆截骨處可通過(guò)骨塊和克氏針固定，從而得到一個(gè)穩(wěn)定復(fù)位的髖關(guān)節(jié)。SIO至今已經(jīng)沿用了50余年，治療了大量的發(fā)育性髖關(guān)節(jié)脫位病例，獲得了良好的效果！改良原創(chuàng)（Improveandoriginal）國(guó)內(nèi)著名兒童骨科專家李旭教授帶領(lǐng)汕頭大學(xué)廣州華新骨科醫(yī)院兒童骨科團(tuán)隊(duì)在傳統(tǒng)的Salter骨盆截骨術(shù)（SIO）基礎(chǔ)上做了進(jìn)一步的改良，并推廣應(yīng)用于臨床工作中，我們將此技術(shù)命名為Salter-Li骨盆截骨術(shù)（Salter-LiInnominateOsteotomy，SLIO)。區(qū)別于傳統(tǒng)SIO手術(shù)，優(yōu)勢(shì)明顯華新兒童骨科團(tuán)隊(duì)2015年開始，受瑞士TheddySlongo教授的Bernese骨盆截骨術(shù)影響，李旭教授帶領(lǐng)團(tuán)隊(duì)對(duì)小兒骨科的經(jīng)典手術(shù)—Salter骨盆截骨術(shù)進(jìn)行了大幅改良，具體改進(jìn)內(nèi)容包括：（1）無(wú)需劈開髂骨骨骺，避免了遠(yuǎn)期髂嵴的發(fā)育性畸形風(fēng)險(xiǎn)；（2）僅從髂骨內(nèi)板行骨膜外剝離，提前處理骶髂關(guān)節(jié)旁滋養(yǎng)血管，大大減少了術(shù)中失血；（3）?術(shù)中無(wú)需剝離髂骨外板的肌肉軟組織附著，避免了遠(yuǎn)期因臀肌損傷導(dǎo)致的步態(tài)異常，及髖臼緣出現(xiàn)缺血性改變的風(fēng)險(xiǎn)；（4）特殊的倒“L”形髂骨截骨設(shè)計(jì)，無(wú)需進(jìn)行髂骨取骨即可獲得較經(jīng)典手術(shù)更優(yōu)的截骨穩(wěn)定性；（5）特殊的髂骨截骨設(shè)計(jì)，可以使遠(yuǎn)端骨塊獲得更大旋轉(zhuǎn)幅度而不影響固定的穩(wěn)定性，從而獲得較經(jīng)典手術(shù)更大的髖臼指數(shù)的矯正和頭臼覆蓋改善；（6）由于手術(shù)操作大大簡(jiǎn)化，切口長(zhǎng)度、手術(shù)時(shí)間、術(shù)中失血量等均明顯優(yōu)于經(jīng)典Salter手術(shù)，手術(shù)更加微創(chuàng)，學(xué)習(xí)曲線亦顯著縮短。SLIO相比于傳統(tǒng)SIO更加微創(chuàng)，該術(shù)式不需要劈開髂骨骨骺，不需要植骨，不需要?jiǎng)冸x髂骨外板的肌肉組織，不會(huì)破壞臀肌以及損傷髖臼周圍的血供。實(shí)現(xiàn)在截骨端近端和遠(yuǎn)端之間的兩點(diǎn)接觸，對(duì)髖臼畸形有更強(qiáng)大的矯正能力。更重要的是術(shù)中切口非常微創(chuàng)，不超過(guò)3cm，這也是迄今為止同類手術(shù)中文獻(xiàn)所報(bào)道使用的最小切口?。?！顛覆你的想象：中國(guó)最微創(chuàng)的兒童髖關(guān)節(jié)開放復(fù)位、Salter骨盆截骨術(shù)——李旭教授改良Salter骨盆截骨術(shù)（SLIO）臨床病例Case1:馮2歲，女，右側(cè)發(fā)育性髖關(guān)節(jié)脫位，雙下肢不等長(zhǎng)手術(shù)方式：右側(cè)髖關(guān)節(jié)開放復(fù)位、Salter骨盆截骨矯形內(nèi)固定、髖人字石膏固定術(shù)、右側(cè)闊筋膜張肌、內(nèi)收肌、腰肌松解手術(shù)時(shí)間：1.5小時(shí)手術(shù)出血量：小于100mlCase2:陸2歲，女，左側(cè)發(fā)育性髖關(guān)節(jié)脫位，雙下肢不等長(zhǎng)手術(shù)方式：左側(cè)髖關(guān)節(jié)切開復(fù)位關(guān)節(jié)腔清理、Salter骨盆截骨矯形內(nèi)固定、左側(cè)內(nèi)收肌經(jīng)皮松解、髂腰肌松解、石膏固定手術(shù)時(shí)間：1.5小時(shí)手術(shù)出血量：80ml中國(guó)最微創(chuàng)的兒童髖關(guān)節(jié)開放復(fù)位、Salter骨盆截骨手術(shù)李旭兒童骨科團(tuán)隊(duì)近年來(lái)開展改良原創(chuàng)的（微創(chuàng)）骨盆截骨術(shù)——Salter-Li骨盆截骨術(shù)并大力推廣應(yīng)用于臨床，充分體現(xiàn)了團(tuán)隊(duì)不斷探索、創(chuàng)新的發(fā)展理念。上面兩個(gè)病例在手術(shù)中都使用了團(tuán)隊(duì)原創(chuàng)改良的Salter-Li骨盆截骨術(shù)，手術(shù)時(shí)間短，術(shù)中出血量小，手術(shù)切口小于3cm，這也是迄今為止同類手術(shù)中文獻(xiàn)所報(bào)道使用的最小切口，術(shù)后患者恢復(fù)快，臨床癥狀改善明顯，滿意率高！“Salter骨盆截骨術(shù)”作為小兒骨科的關(guān)鍵手術(shù)技術(shù)之一，對(duì)于兒童的復(fù)雜髖關(guān)節(jié)畸形，具有強(qiáng)大的矯正能力，但由于手術(shù)難度大、學(xué)習(xí)曲線長(zhǎng)，目前在國(guó)內(nèi)尚只在具有兒童骨科?？频尼t(yī)院能夠獨(dú)立開展，大多數(shù)骨科醫(yī)師尚未能完全掌握和理解這一手術(shù)技術(shù)。這些年我們賦能提質(zhì)，髖關(guān)節(jié)手術(shù)逐步向微創(chuàng)化、創(chuàng)新化、精準(zhǔn)化高質(zhì)量發(fā)展，團(tuán)隊(duì)對(duì)該手術(shù)技術(shù)已經(jīng)處于國(guó)際領(lǐng)先水平。不再“大刀闊斧”，我院骨科手術(shù)邁入微創(chuàng)化時(shí)代工欲善其事，必先利其器。華新李旭兒童骨科團(tuán)隊(duì)在李旭教授的帶領(lǐng)下，始終秉持“復(fù)雜手術(shù)簡(jiǎn)單化、常規(guī)手術(shù)微創(chuàng)化、疑難手術(shù)個(gè)性化”的創(chuàng)新發(fā)展理念，一路披荊斬棘、技術(shù)革新，科室醫(yī)療技術(shù)得到全新的突破，從“大刀闊斧”到“精雕細(xì)琢”，華新李旭兒童骨科手術(shù)邁入微創(chuàng)化時(shí)代，為中國(guó)患兒提供更有質(zhì)量的醫(yī)療。迎難而上的勇氣，是源于團(tuán)隊(duì)加強(qiáng)技術(shù)積累和敢于業(yè)務(wù)攻關(guān)的實(shí)力和底氣。上述技術(shù)的開展，只是我們?cè)谖?chuàng)化道路上的縮影，為了更好的服務(wù)廣大患者，我們將繼續(xù)迎難而上，往高精尖技術(shù)的道路上大步邁進(jìn)！汕頭大學(xué)廣州華新骨科醫(yī)院兒童骨科，前身為原南方醫(yī)科大學(xué)第三附屬醫(yī)院兒童骨科團(tuán)隊(duì)，由李旭博士于2011年7月份創(chuàng)建成立。2018年12月，李旭博士帶領(lǐng)兒童骨科團(tuán)隊(duì)遷移至廣州華新骨科醫(yī)院，學(xué)科建設(shè)邁上新臺(tái)階，與國(guó)際間的學(xué)術(shù)交流合作日益增多。2020年5月，美國(guó)哥倫比亞大學(xué)終身名譽(yù)教授——紐約摩根斯坦利兒童醫(yī)院前小兒骨科主任DavidP.RoyeJr.教授加盟華新兒童骨科團(tuán)隊(duì)，以謀求為中國(guó)患兒提供更有質(zhì)量的醫(yī)療，和培訓(xùn)中國(guó)兒童骨科醫(yī)生加速走向國(guó)際化。廣州華新骨科醫(yī)院李旭兒童骨科團(tuán)隊(duì)，為中國(guó)醫(yī)師協(xié)會(huì)骨科分會(huì)兒童骨科學(xué)組副主任委員單位，和廣東省醫(yī)師協(xié)會(huì)骨科分會(huì)兒童骨科學(xué)組主任委員單位。學(xué)科技術(shù)實(shí)力雄厚、特色鮮明；除常見的兒童創(chuàng)傷和畸形診治外，李旭兒骨團(tuán)隊(duì)對(duì)傳統(tǒng)國(guó)內(nèi)骨科界鮮少涉足的領(lǐng)域，如腦癱等神經(jīng)肌肉型疾病所涉及的四肢、脊柱畸形和運(yùn)動(dòng)功能障礙的治療，可提供世界級(jí)水平的高質(zhì)量服務(wù)；2020年9月，國(guó)內(nèi)一流的3D步態(tài)實(shí)驗(yàn)室也于我院正式落成。醫(yī)學(xué)博士后，主任醫(yī)師，碩士研究生導(dǎo)師；汕頭大學(xué)廣州華新骨科醫(yī)院院長(zhǎng)；中國(guó)著名兒童骨科專家。學(xué)術(shù)任職：亞太小兒骨科學(xué)會(huì)（APPOS）理事會(huì)中國(guó)執(zhí)委；華裔小兒骨科學(xué)會(huì)首任主席；中國(guó)骨科醫(yī)師協(xié)會(huì)第一、二屆小兒骨科專委會(huì)副主任委員；中華醫(yī)學(xué)會(huì)骨科分會(huì)小兒創(chuàng)傷與矯形學(xué)組委員；廣東省骨科醫(yī)師協(xié)會(huì)常務(wù)委員暨小兒骨科學(xué)組主任委員；SICOT中國(guó)部小兒骨科專委會(huì)副主任委員；中國(guó)康復(fù)醫(yī)學(xué)會(huì)修復(fù)重建外科專委會(huì)四肢先天畸形學(xué)組副組長(zhǎng)；Depuy-Synthes南方小兒骨科培訓(xùn)中心主任；AO中國(guó)小兒骨科講師。專業(yè)擅長(zhǎng)：兒童骨關(guān)節(jié)系統(tǒng)各種嚴(yán)重復(fù)雜創(chuàng)傷和后遺癥的手術(shù)治療；兒童先天性髖關(guān)節(jié)脫位(DDH)、腦癱、馬蹄內(nèi)翻足、多并指（趾）等各種兒童先天及后天性復(fù)雜肢體畸形；各種骨病后遺癥、兒童股骨頭壞死(Perthes病)、肌性斜頸、骨與軟組織腫瘤、各種肢體少見病及疑難雜重癥。關(guān)注我?了解更多兒童骨科相關(guān)知識(shí)！
李旭醫(yī)生的科普號(hào)
2024年06月06日441
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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)沿著正常“軌道”發(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)專業(yè)醫(yī)生，共466份有效問卷的調(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)等多方面的問題亟待解決?？祻?fù)醫(yī)學(xué)會(huì)修復(fù)重建外科專委會(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409
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6
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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417
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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 77票
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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)育疾病（骨纖維異常增殖癥、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 -
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擅長(zhǎng)：小兒骨科各種先天畸形(先天性髖脫位，馬蹄足畸形，股骨頭缺血性壞死，膝關(guān)節(jié)內(nèi)外翻，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，先天性狹窄性腱鞘炎，多指手術(shù) -
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