中國醫(yī)學科學院北京協(xié)和醫(yī)院

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保髖截骨治療髖關(guān)節(jié)發(fā)育不良(8)：單臺同時進行無(會陰)柱髖關(guān)節(jié)鏡檢查聯(lián)合髖臼周圍截骨術(shù)治療DDH保髖截骨治療髖關(guān)節(jié)發(fā)育不良(8)：單臺同時進行無(會陰)柱髖關(guān)節(jié)鏡檢查聯(lián)合髖臼周圍截骨術(shù)治療髖關(guān)節(jié)發(fā)育不良作者：DustinWoyski,SteveOlson,BrianLewis.作者單位:DepartmentofOrthopaedicSurgery,DukeUniversity,Durham,NorthCarolina,U.S.A.譯者：陶可（北京大學人民醫(yī)院骨關(guān)節(jié)科）摘要已經(jīng)證實，關(guān)節(jié)鏡和開放式髖關(guān)節(jié)保留技術(shù)都可以改善患者的預(yù)后并阻斷髖關(guān)節(jié)疾病的自然病程。傳統(tǒng)上，髖關(guān)節(jié)鏡檢查用于治療由盂唇撕裂、髖關(guān)節(jié)撞擊畸形和軟骨病變組成的髖關(guān)節(jié)疾病。髖臼周圍截骨術(shù)是治療因股骨頭對髖臼覆蓋不足或發(fā)育不良引起的髖關(guān)節(jié)不穩(wěn)定的最常用方法。由于髖臼周圍截骨術(shù)失敗與術(shù)后撞擊有關(guān)，且發(fā)育不良髖關(guān)節(jié)的關(guān)節(jié)內(nèi)病變發(fā)生率高，人們對將髖關(guān)節(jié)鏡檢查與髖臼周圍截骨術(shù)相結(jié)合產(chǎn)生了濃厚的興趣。在這里，我們描述了一種單臺、單鋪巾、無(會陰)柱聯(lián)合髖關(guān)節(jié)鏡檢查和髖臼周圍截骨術(shù)的技術(shù)。討論據(jù)報道，通過開放或關(guān)節(jié)鏡檢查發(fā)現(xiàn)髖關(guān)節(jié)發(fā)育不良患者的關(guān)節(jié)內(nèi)病變發(fā)生率很高。我們的絕大多數(shù)患者也符合Warwick髖關(guān)節(jié)鏡治療標準，這體現(xiàn)在影像學、體格檢查和病史方面。由于這些因素，自2013年以來，我們一直在我們機構(gòu)的幾乎每例PAO患者身上同時進行關(guān)節(jié)鏡檢查，并且自2018年3月以來一直采用當前的無(會陰)柱技術(shù)。多年來，我們的髖關(guān)節(jié)鏡和PAO聯(lián)合技術(shù)已發(fā)展到本技術(shù)說明中所述的使用1張手術(shù)臺且無需會陰柱的技術(shù)。這位資深外科醫(yī)生已經(jīng)進行了500多例PAO手術(shù)，并發(fā)現(xiàn)同時進行的關(guān)節(jié)鏡檢查不會增加PAO的手術(shù)時間，而且，如果有的話，由于關(guān)節(jié)鏡檢查液的水分離，使暴露更容易，出血更少，組織平面更清晰。過去20年來，PAO的長期結(jié)果已得到充分描述，伯爾尼原始隊列的三分之一患者的髖關(guān)節(jié)在30年后得以保存。PAO失敗的一個已知原因是未解決股骨髖臼撞擊或通過PAO矯正造成撞擊。然而，在PAO時解決中央和外周間室病理是否會影響短期和長期結(jié)果仍有待觀察。迄今為止的報告很少，并且與治療關(guān)節(jié)內(nèi)病理的選擇偏差不一致，這些選擇偏差針對的是那些有撞擊體征和癥狀或MRI發(fā)現(xiàn)盂唇病理的患者。我們堅信，由于關(guān)節(jié)內(nèi)病理與發(fā)育不良患者的凸輪形態(tài)高度相關(guān)，因此在PAO之前對所有髖關(guān)節(jié)進行關(guān)節(jié)鏡評估和治療是必要的。我們發(fā)現(xiàn)關(guān)節(jié)內(nèi)病變的患病率非常高，幾乎所有髖關(guān)節(jié)均出現(xiàn)PAO且需要進行盂唇修復(fù)，超過一半的髖關(guān)節(jié)出現(xiàn)一定程度的髖臼軟骨軟化。使用一張手術(shù)臺和鋪巾使我們能夠完成高效的髖關(guān)節(jié)鏡和PAO聯(lián)合手術(shù)。在我們機構(gòu)，關(guān)節(jié)鏡和PAO均由一位外科醫(yī)生進行。缺乏經(jīng)驗的外科醫(yī)生不應(yīng)單獨進行這兩種手術(shù)，因為PAO和關(guān)節(jié)鏡髖關(guān)節(jié)手術(shù)的學習曲線都很陡峭。任何涉及多種復(fù)雜、困難手術(shù)和新設(shè)備組合的新技術(shù)都可能帶來潛在的缺點和風險。但是，如果由經(jīng)驗豐富的外科醫(yī)生進行，在PAO之前增加關(guān)節(jié)鏡檢查是安全的，并且不會增加并發(fā)癥發(fā)生率。?Fig1ViewofstandardHanatablesetupwithPinkHipKitandpatientdrawsheetfoldedinhalffromthe(A)sideand(B)above.(C)Viewfromaboveoftheidealpatientplacementwithperineumapproximately4to6cmfromthepostpositioninghole.圖1?標準Hana桌設(shè)置視圖，配有粉色髖關(guān)節(jié)套件和患者抽紙，從(A)側(cè)面和(B)上方折疊成兩半。(C)從上方查看理想的患者放置位置，會陰距離定位孔約4至6厘米。Fig2(A)Patientissupinewiththelefthipsterilelypreppedanddrapedandinferiormarginofiliaccrestoutlined.TheASISandGTaremarkedaswell.TheincisionoftheperiacetabularosteotomyismadefromtheGTandisconnectedtotheMAP.(B)IncisionforthePAOismadefromtheGTtotheMAP.(C)ExposureoftheEOFisimportantbeforemasking.(D)FleckosteotomyoftheASISoffoftheICusingaone-half-inchstraightosteotome.(AL,anterolateralportal;ASIS,anterosuperioriliacspine;DALA,distalanterolateralaccessoryportal;EOF,externalabdominalobliquemuscleandfascia;GT,glutealtubercle;IC,iliaccrest;MAP,mid-anteriorportal;PAO,periacetabularosteotomy.)圖2?(A)患者仰臥，左側(cè)髖關(guān)節(jié)無菌準備并鋪上布，髂嵴下緣輪廓清晰。ASIS和GT也已標記。髖臼周圍截骨術(shù)的切口從GT開始，并與MAP相連。(B)PAO的切口從GT到MAP。(C)在遮蓋之前，暴露EOF非常重要。(D)使用半英寸直骨刀對IC上的ASIS進行斑點截骨術(shù)。（AL，前外側(cè)入口；ASIS，髂前上棘；DALA，遠端前外側(cè)副入口；EOF，腹外斜肌和筋膜；GT，髂結(jié)節(jié)；IC，髂嵴；MAP，中前入口；PAO，髖臼周圍截骨術(shù)。）Fig3Magneticresonanceimagingbased3-dimensionalrenderingofalefthipjointviewedanteriorlyisusedforpreoperativeplanning.Thisdemonstratestypicalfindingsoffocalfemoroacetabularimpingementfoundinthedysplastichipwithaminimalcamandpincer(),whicharelabeled.(PS,pubicsymphysis;SS,subspine.)圖3?基于磁共振成像的左側(cè)髖關(guān)節(jié)前方三維渲染圖用于術(shù)前規(guī)劃。這顯示了髖關(guān)節(jié)發(fā)育不良中發(fā)現(xiàn)的典型局灶性股骨髖臼撞擊，輕度凸輪和鉗夾畸形（），已標記。（PS，恥骨聯(lián)合；SS，髂前下棘。）Fig4Intraoperativefluoroscopicimagesofalefthipperiacetabularosteotomy.(A)Anteroposteriorviewdemonstratingthenarrowcurvedosteotomeagainstthemedialaspectoftheanteriorischiumpriortoosteotomy.(B)Iliacobliqueviewwiththeacetabulumoutlinedinblueandposteriorcolumnincludingischialspineoutlinedingreenshowingthe(C)appropriatedepthofthecurvedosteotomeoftheincompleteischialosteotomy.(D)Anteroposteriorviewshowingthecurvedosteotome’sidealpositionbehindtheacetabulum.圖4?左側(cè)髖臼周圍截骨術(shù)術(shù)中透視圖像。（A）前后視圖，顯示截骨術(shù)前狹窄彎曲骨鑿抵靠前坐骨內(nèi)側(cè)。(B)髂骨斜視圖，髖臼以藍色勾勒，包括坐骨棘在內(nèi)的后柱以綠色勾勒，(C)顯示不完全坐骨截骨術(shù)的彎曲骨鑿的適當深度。(D)前后視圖顯示彎曲骨鑿在髖臼后方的理想位置。Fig5Fluoroscopicimagesofthelefthip.(A)Widestraightosteotomeincorrectpositionontheanteroposteriorviewoverlyingtheacetabularteardrop.(B)Iliacobliqueviewwiththeiliacosteotomymadeusingtheoscillatingsawoutlinedinblue.(C)Iliacobliqueviewofthestraightosteotomecomingbehindtheacetabulumand(D)connectingwiththepreviousincompleteischialosteotomy,whichisoutlinedinblue.圖5?左髖的透視圖像。(A)寬直骨鑿在前后視圖上處于正確位置，覆蓋髖臼淚滴。(B)髂骨斜視圖，使用擺鋸進行的髂骨截骨術(shù)以藍色勾勒。(C)髂骨斜視圖，直骨鑿位于髖臼后方，(D)與之前的不完全坐骨截骨術(shù)相連，后者以藍色勾勒。Fig6Lefthipfluoroscopiciliacobliqueviewsoftheacetabularfragment(A)beforecorrectionwiththeacetabulumoutlinedinblueand(B)postcorrectionwithprovisionalfixationusing3.2-mmdrillbits.(C)Iliacobliqueand(D)anteroposteriorfluoroscopicviewsshowingfinalpositionofacetabularfragmentfollowingperiacetabularosteotomywith4.5-mmscrewsinplace.圖6左髖關(guān)節(jié)透視髂骨斜視圖顯示髖臼塊（A）矯正前，髖臼用藍色勾勒，（B）矯正后，使用3.2毫米鉆頭進行臨時固定。（C）髂骨斜視圖和（D）前后透視視圖顯示髖臼塊的最終位置，髖臼周圍截骨術(shù)后，4.5毫米螺釘固定。Fig7Anteroposteriorviewsofthepelvisshowingthelefthip(A)preoperativelyand(B)postoperatively.Increasedlateralcoverageofthefemoralheadanddecreasedinclinationoftheacetabularsourcilarenoted.圖7?骨盆前后視圖顯示左髖關(guān)節(jié)（A）術(shù)前和（B）術(shù)后。注意到股骨頭的側(cè)向覆蓋增加，髖臼底部傾斜度減小。?SingleTableConcomitantPost-LessHipArthroscopyCombinedwithPeriacetabularOsteotomyforHipDysplasiaAbstractIthasbeenwellestablishedthatbotharthroscopicandopenhippreservationtechniquescanresultinimprovedpatientoutcomesandinterruptthenaturalhistoryofhipdisease.Traditionally,hiparthroscopyhasbeenusedtoaddresscentralandperipheralcompartmentdiseaseconsistingoflabraltears,impingementmorphologyandcartilagepathology.Theperiacetabularosteotomyhasbeenthemostusedtreatmentforhipinstabilitycausedbyinadequateacetabularcoverageofthefemoralheadordysplasia.Withfailuresofperiacetabularosteotomylinkedtopostoperativeimpingementandthehighincidenceofintra-articularpathologyinthedysplastichip,therehasbeenagreatinterestincombinghiparthroscopywiththeperiacetabularosteotomy.Here,wedescribeatechniqueforasingletable,singledrape,postlesscombinedhiparthroscopy,andperiacetabularosteotomy.DiscussionAhighincidenceintra-articularpathologyinpatientswithhipdysplasiawhenidentifiedbyopenorarthroscopicmeanshasbeenreported.5ThevastmajorityofourpatientsalsosatisfytheWarwickcriteriaforacceptabilityforhiparthroscopyfromtheirimaging,physicalexamination,andhistory.6Becauseofthesefactors,wehavebeenperformingconcomitantarthroscopyonnearlyeveryPAOatourinstitutionsince2013andhavebeenperformingthecurrentpostlesstechniquesinceMarch2018.OurtechniqueofcombinedhiparthroscopyandPAOhasevolvedovertheyearstowhatisdescribedinthisTechnicalNotewiththeuseof1tableandwithoutaperinealpost.Theseniorsurgeonhasperformedmorethan500PAOproceduresandhasfoundthatconcomitantarthroscopydoesnotincreasetheoperativetimeofthePAOand,ifanything,hasmadetheexposureeasierwithlessbleedingandbetter-definedtissueplanesbecauseofhydro-dissectionfromthearthroscopyfluid.TheeaseofexposurealongwithothertechnicalpearlsandbenefitsareoutlinedinTable1.Thelong-termoutcomesofPAOhavebeenwelldescribedoverthepast2decades,withone-thirdoftheoriginalBernesecohorthavingbeenpreservedat30years.7AknowncauseoffailureofthePAOisnotaddressingfemoroacetabularimpingementorcreatingimpingementwiththePAOcorrection.8However,itremainstobeseenifaddressingcentralandperipheralcompartmentpathologyatthetimeofPAOcanaffectshort-andlong-termoutcomes.Reportsthusfarhavebeensparseandinconsistentwithselectionbiasoftreatingintra-articularpathologytothosewithsignsandsymptomsofimpingementorMRIfindingsoflabralpathology.Wefirmlybelievethatwiththehighassociationofintra-articularpathologyandcammorphology9inpatientswithdysplasiathatanarthroscopicevaluationandtreatmentofthecentralandperipheralcompartmentsofthehipiswarrantedinallhipsbeforePAO.Wehavefoundaveryhighprevalenceofintra-articularpathologywithnearlyallhipspresentingforPAOrequiringalabralrepairandmorethanone-halfwithsomedegreeofchondromalaciaoftheacetabulum.TheuseofasingletableanddrapinghasallowedustocompleteanefficientcombinedhiparthroscopyandPAO(Table1).Atourinstitution,boththearthroscopyandPAOareperformedbyasinglesurgeon.NeitheroftheseproceduresaloneshouldbetakenonbytheinexperiencedsurgeonbecauseboththePAOandarthroscopichipsurgeryhaveasteeplearningcurve.10,11Anynewtechniqueinvolvingthecombinationofmultiplecomplex,difficultproceduresandnewequipmentcancarrypotentialdisadvantagesandrisks(Table2).Whenperformedbyanexperiencedsurgeon,however,theadditionofarthroscopybeforePAOcanbedonesafelyanddoesnotincreasethecomplicationrate.12文獻出處：DustinWoyski,SteveOlson,BrianLewis.SingleTableConcomitantPost-LessHipArthroscopyCombinedwithPeriacetabularOsteotomyforHipDysplasia.ArthroscTech.2019Nov25;8(12):e1569-e1578.doi:10.1016/j.eats.2019.08.015.eCollection2019Dec.
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（北京大學人民醫(yī)院骨關(guān)節(jié)科）摘要在過去的幾十年里，影像技術(shù)的改進和手術(shù)技術(shù)的進步使得保髖手術(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議。在這篇評論中，我們將確定相關(guān)問題并描述患者評估和治療方案。我們將提供自己的建議，并確定未來的研究領(lǐng)域。簡介在過去的幾十年里，髖關(guān)節(jié)生物力學知識的提高和手術(shù)技術(shù)的進步使得保髖手術(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，但人們同樣認為，必須減小過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，有一個過渡區(qū)，很難區(qū)分不穩(wěn)定性和股骨髖臼撞擊(FAI)。過去，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，因為它是一個放射學定義，只涉及描述髖關(guān)節(jié)穩(wěn)定性的幾個重要參數(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?shù)闹委?。最近的研究表明，對患有臨界發(fā)育不良(LCEA?>?20°)的患者進行關(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)）可能會在短期內(nèi)帶來適當?shù)母纳芠3,4]。然而，有證據(jù)表明，之前錯誤的髖關(guān)節(jié)鏡檢查會對此類髖關(guān)節(jié)的治療結(jié)果產(chǎn)生負面影響[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極具爭議的問題。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。定義第一個問題在于定義。在前后位骨盆X線片[9](LCEA)上測量的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中差異很大[3,10]。然而，使用外側(cè)中心邊緣角(LCEA)存在兩個問題。首先是測量方法。為了測量外側(cè)中心邊緣角(LCEA)，首先通過與股骨頭輪廓相符的圓來定義股骨頭的中心。角度的第一個分支垂直穿過旋轉(zhuǎn)中心。第二個分支由股骨頭的中心和股骨最外側(cè)點定義（圖1a）。重要的是不要使用髖臼的最外側(cè)點（圖1b），因為這不符合Wiberg的定義，并且會給出錯誤的高值(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)測量不正確。使用此值會錯誤地將此髖關(guān)節(jié)歸類為臨界。其次，實際術(shù)語“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)是一種放射學測量，本身無法預(yù)測臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性，也無法完全描述股骨頭覆蓋范圍。因此，外側(cè)中心邊緣角(LCEA)無法指導(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估髖關(guān)節(jié)的穩(wěn)定性[15]。另一方面，股骨前傾過度可能會加劇髖關(guān)節(jié)前部不穩(wěn)定[16]。根本問題是什么？對于疼痛的臨界髖關(guān)節(jié)發(fā)育不良，很難僅通過二維射線測量將病理機制表征為撞擊（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量。髖關(guān)節(jié)穩(wěn)定性的功能表征對于指導(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)病理學的了解有多少？應(yīng)該如何評估這些患者？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導(dǎo)致病理性髖關(guān)節(jié)生物力學，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[18]。一旦軟組織約束失效，髖關(guān)節(jié)就會變得不穩(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，并且必然會導(dǎo)致關(guān)節(jié)退化[5]。惡化速度與半脫位嚴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，就會出現(xiàn)嚴重的退行性變化[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。最近的一項研究強調(diào)了髖臼覆蓋的重要性。在一項為期20年的大型女性隊列研究中，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OA風險就會增加13%[20]。因此，除了短期緩解癥狀外，還必須考慮長期可能的發(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、體格檢查和放射學評估對于正確診斷這些患者至關(guān)重要。病史重點記錄病史。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)療護理，包括物理治療、藥物、其他意見和手術(shù)。檢查隨后應(yīng)進行髖關(guān)節(jié)的合理臨床檢查，包括恐懼試驗和撞擊測試。患者通常會表現(xiàn)出“膝內(nèi)翻”步態(tài)，同時伴有髖關(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，可能存在前凸過度。應(yīng)確定大轉(zhuǎn)子處有無壓痛[22]。務(wù)必記住檢查患者的旋轉(zhuǎn)輪廓、進行神經(jīng)血管檢查以及檢查全身關(guān)節(jié)松弛的跡象，并使用Beighton評分對此進行量化。具體關(guān)鍵目標包括排除(i)晚期退化過程的存在，例如表現(xiàn)為固定屈曲畸形和運動范圍減少，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)從骨盆的標準化AP平片和股骨頸側(cè)位片（穿桌側(cè)位、Dunn位、假斜位）[23]開始。仔細檢查這些圖像以測量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等級以及是否存在凸輪形態(tài)。應(yīng)仔細檢查不穩(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識別，髖關(guān)節(jié)處于外展狀態(tài)，使用MR關(guān)節(jié)造影時后關(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）。必須精確測量和記錄各種參數(shù)。有必要使用三維計算機斷層掃描(CT)進行橫斷面成像，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)包括股骨前傾的評估，如果前傾過大，可能會加劇髖關(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。其他測量包括盂唇大小[13,28]和髂關(guān)節(jié)囊體積[29]。對于這些患者，我們還提倡進行非牽引性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)定的細微征兆[30]。這些測量值的價值是什么？在平片上，那些直接表明不穩(wěn)定的測量值是股骨頭移位，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)測不穩(wěn)定性[30]（表1）。表1.用于評估髖關(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)，似乎對預(yù)測髖關(guān)節(jié)穩(wěn)定性具有很高的價值[27]。它是由髖臼頂與股骨生長板中央1/3處之間的角度形成的（圖2）。其依據(jù)是：在生長過程中，股骨的骨骺生長板會垂直于髖關(guān)節(jié)的關(guān)節(jié)反作用力。股骨頸的生長和方向受股骨頸下生長板的控制[31]。Pauwels和Maquet[32]提出理論，合力作用于骨骺軟骨的中心，在生長過程中，根據(jù)Heuter-Volkman原理，骨骺板會垂直于關(guān)節(jié)反作用力。Pauwels和Maquet的理論后來得到了Carter等人[33]的證實，他們通過二維有限元分析研究了髖關(guān)節(jié)負荷的影響。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)力在過去的作用方式。因此，它是一個功能參數(shù)，反映了髖關(guān)節(jié)在生長過程中長期的關(guān)節(jié)反作用力。如果FEAR<0°，則認為髖關(guān)節(jié)穩(wěn)定。統(tǒng)計分析表明，5°的臨界值預(yù)測穩(wěn)定性的概率為80°。最近的研究表明，2°的臨界值預(yù)測穩(wěn)定性的概率為90%（Batailler等人，正在準備發(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)。測量連接股骨最內(nèi)側(cè)和外側(cè)點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（通過髖關(guān)節(jié)鏡或髖關(guān)節(jié)外科脫位進行的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、活動調(diào)整、簡單的止痛藥、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)生正在使用它來治療臨界髖關(guān)節(jié)發(fā)育不良，尤其是因為人們認為髖臼周圍截骨術(shù)等替代技術(shù)的風險更高，術(shù)后恢復(fù)時間更長。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行更大規(guī)模手術(shù)時的表現(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項研究報告了主觀和/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，只有兩項研究使用了Byrd和Jones的定義[36]。三項研究報告了髖關(guān)節(jié)鏡作為輔助工具，三項研究報告了髖關(guān)節(jié)鏡作為獨立治療。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，其中只有一項描述了患者報告的結(jié)果測量。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)育不良的放射學證據(jù)的結(jié)果。對臨界髖關(guān)節(jié)發(fā)育不良進行髖關(guān)節(jié)鏡檢查有什么危險？臨界髖關(guān)節(jié)發(fā)育不良患者進行關(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]。沒有確鑿的文獻支持在這些情況下進行關(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)定性可能由次級軟組織結(jié)構(gòu)來確保。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)就會變得不穩(wěn)定。恢復(fù)軟組織穩(wěn)定性可能只會在短時間內(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，才能取得良好的長期效果。最近的一份報告顯示，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，對這組患者單獨進行髖關(guān)節(jié)鏡檢查應(yīng)謹慎處理。但是，對于那些由于髖關(guān)節(jié)狀況不佳（即AI和股骨前傾正常）或高齡（即>40歲）而不適合進行PAO的患者，它可能有用。重新定向髖臼周圍截骨術(shù)對這組患者有何影響？通過髖臼周圍截骨術(shù)進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)報道術(shù)后20多年效果良好。傳統(tǒng)上，PAO時關(guān)節(jié)內(nèi)病變的處理方法是進行前關(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)時間[45]。最近的一項研究表明，一些可改變的因素，例如較高的體力活動量和較高的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)年齡的獨立預(yù)測因素，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°，這涵蓋了我們對臨界髖關(guān)節(jié)發(fā)育不良的定義。最近的一項多中心前瞻性隊列研究檢查了患者報告的PAO結(jié)果指標，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，這可能導(dǎo)致過度矯正和醫(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)。如果接受這個概念，治療就會變得相對簡單。不穩(wěn)定可能與其他病癥（如FAI或超負荷/過度使用和軟骨疾?。┫嘟Y(jié)合，需要同時治療。如果髖關(guān)節(jié)不穩(wěn)定，則需要髖臼重新定位。僅解決磨損的二級穩(wěn)定器并不能解決潛在的生物力學問題，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期結(jié)果的機會，我們主張進行髖臼重新定向PAO截骨手術(shù)。重要的是要確定我們?nèi)狈χR的領(lǐng)域，以指導(dǎo)進一步的研究。將對這些患者進行長期隨訪研究，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評分。此外，還應(yīng)獲得患者報告的結(jié)果測量和恢復(fù)時間，以及包括運動在內(nèi)的活動恢復(fù)時間。?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.文獻出處：MichaelCWyatt,MartinBeck.Themanagementofthepainfulborderlinedysplastichip.ReviewJHipPreservSurg.2018Apr5;5(2):105-112.doi:10.1093/jhps/hny012.
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，保守治療無非控制活動量、控制體重、吃止疼藥、加強肌肉鍛煉，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，保守治療只能一定程度延緩病情進展，無法解決根本問題。手術(shù)的目的是為了緩解疼痛、延長自身關(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，通過手術(shù)糾正畸形可以讓關(guān)節(jié)的使用壽命盡可能延長，最好的效果就是用一輩子，當然，少術(shù)患者也有術(shù)后幾年、十幾年后出現(xiàn)關(guān)節(jié)磨損嚴重，進而換關(guān)節(jié)的?？傮w上講，找一個靠譜的醫(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)負重會走極端，比如坐輪椅，甚至少穿衣服，其實大可不必，該干嘛干嘛。如果可以的話，適當避免長時間重體力勞動或者劇烈運動。當然，如果你覺得運動是生命中不可缺少的一部分，那也不用刻意壓抑，這一點國外是比較積極的，很多患者手術(shù)就是為了后續(xù)運動時不疼。當然，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)該做哪些準備？答：1、異地就醫(yī)，提前進行醫(yī)保備案，具體需要詢問當?shù)蒯t(yī)保部門；2、準備一副拐杖，肘拐腋拐都可以，調(diào)整拐杖高度，練習拄拐單腿走路；3、術(shù)前可以按醫(yī)生的建議進行功能鍛煉，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、酌情準備個人生活物品。?問：髖臼周圍截骨手術(shù)風險高不高？答：這個手術(shù)確實難度很大，被譽為骨科的珠穆朗瑪，手術(shù)的入門門檻很高，學習曲線很長，目前全國只有為數(shù)不多的醫(yī)生可以做這類手術(shù)。記得我在美國學習的時候，看過兩個醫(yī)生做這個手術(shù)，一個醫(yī)生平均需要三四個小時，另一個醫(yī)生需要6-8個小時。對于我們來說，絕大多術(shù)的手術(shù)可以在1小時出頭的時間完成，手術(shù)不但做得快，質(zhì)量也是絕對有保證。?問：手術(shù)需要輸血嗎？答：這個手術(shù)的出血確實偏多，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斷，調(diào)整好位置后進行固定，截斷的骨頭長好需要大概3個月的時間。所以，術(shù)后3個月內(nèi)需要小心保護自己的髖關(guān)節(jié)，不要摔，一定要拄雙拐，拄雙拐，拄雙拐！一般我會讓患者術(shù)后6-8周內(nèi)術(shù)腿不負重，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個月的時候可以負重身體重量1/3-1/2，具體以醫(yī)生通知為準。過早扔拐，過早過多負重可能導(dǎo)致骨頭移位，影響手術(shù)效果。3個月后門診復(fù)查，評估骨頭生長情況。?問：術(shù)后如何進行康復(fù)鍛煉？答：康復(fù)鍛煉很重要，鍛煉不好，走路十有八九會瘸。我的患者我一般會給每人一個康復(fù)計劃，由于每個人的手術(shù)不一樣，畸形不一樣，骨頭質(zhì)量不一樣，所以方案不會完全一樣，大家按照自己的方案去做鍛煉即可。大家認真閱讀鍛煉資料，保證動作做對，一旦動作做錯，就可能練錯肌肉。3個月復(fù)查時人要過來，很重要，我會根據(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