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臨界髖關(guān)節(jié)發(fā)育不良Borderline DDH (3)：股骨骨骺髖臼頂指數(shù)(FEAR)臨界髖關(guān)節(jié)發(fā)育不良BorderlineDDH(3)：股骨骨骺髖臼頂指數(shù)（TheFemoro-EpiphysealAcetabularRoof(FEAR)index）：一個預(yù)測髖關(guān)節(jié)穩(wěn)定性具有很高價值的功能參數(shù)作者：MichaelWyatt,JanWeidner,DominikPfluger,MartinBeck.作者單位:ClinicforOrthopaedicandTraumaSurgery,LuzernerKantonsspital,Spitalstrasse4,6004,Lucerne,Switzerland.michaelcharleswyatt@icloud.com.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要TheFemoro-EpiphysealAcetabularRoof(FEAR)index:股骨骨骺髖臼頂指數(shù)FEAR指數(shù)是最近描述的一個預(yù)測髖關(guān)節(jié)穩(wěn)定性具有很高價值的參數(shù)。它是由髖臼頂與股骨生長板中央1/3處之間的夾角。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。Pauwels和Maquet等提出理論，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°(角開口向內(nèi))，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）。摘要背景：在放射學(xué)臨界髖關(guān)節(jié)發(fā)育不良中，骨性不穩(wěn)定性很難定義。因此，可靠的放射學(xué)工具（可幫助決策）——具體來說，可能與不穩(wěn)定性相關(guān)的工具——對這類患者非常有幫助。問題/目的：(1)比較一種新的放射學(xué)測量方法，我們稱之為股骨-骨骺髖臼頂(FEAR)指數(shù)，與側(cè)中心邊緣角(LCEA)和髖臼指數(shù)(AI)，以了解觀察者內(nèi)和觀察者間的可靠性；(2)將AI、頸干角、LCEA、髂關(guān)節(jié)囊體積、股骨前傾和FEAR指數(shù)與穩(wěn)定和不穩(wěn)定臨界髖關(guān)節(jié)發(fā)育不良接受的手術(shù)治療相關(guān)聯(lián)；以及(3)評估FEAR指數(shù)是否與臨界髖關(guān)節(jié)發(fā)育不良的臨床不穩(wěn)定性相關(guān)。方法：我們使用兩名盲法獨立觀察員在10張無癥狀對照的標準化X線片中定義和驗證了FEAR指數(shù)。計算了評分者間和評分者內(nèi)系數(shù)，并輔以Bland-Altman圖。我們將其可靠性與LCEA和AI進行了比較。我們進行了一項病例對照研究，使用39例經(jīng)手術(shù)治療的有癥狀的臨界放射學(xué)髖關(guān)節(jié)發(fā)育不良和20例年齡匹配的無癥狀髖關(guān)節(jié)對照者的標準化X線片（比例為2:1），后者是因與髖關(guān)節(jié)無關(guān)的創(chuàng)傷而到我們機構(gòu)就診的患者，但在2016年1月1日至2016年3月1日期間進行了標準化骨盆X線片檢查。使用單變量Wilcoxon雙樣本檢驗評估患者的人口統(tǒng)計數(shù)據(jù)。各研究組的平均年齡沒有差異（總體：31.5±11.8歲[95%CI,27.7-35.4歲]；穩(wěn)定臨界DDH組：平均32.1±13.3歲[95%CI,25.5-38.7歲]；不穩(wěn)定臨界DDH組：平均31.1±10.7歲[95%CI,26.2-35.9歲]；p=0.96）。接受的治療是髖臼周圍截骨術(shù)（如果髖關(guān)節(jié)不穩(wěn)定），或者對于股骨髖臼撞擊患者，接受開放式或關(guān)節(jié)鏡下股骨髖臼撞擊手術(shù)。首先使用Wilcoxon雙樣本檢驗（雙側(cè)）評估所接受的治療類別與變量AI、頸干角、LCEA、髂關(guān)節(jié)囊體積、股骨前傾和FEAR指數(shù)之間的關(guān)聯(lián)，然后進行逐步多元邏輯回歸分析，以確定組合環(huán)境中的潛在相關(guān)變量。計算了敏感性、特異性和受試者工作曲線。主要終點是FEAR指數(shù)與不穩(wěn)定性之間的關(guān)聯(lián)，我們將其定義為股骨頭移位（在常規(guī)X線片上已經(jīng)可見）或在AP外展視圖上重新集中、Shenton線斷裂或MR關(guān)節(jié)造影時在后下關(guān)節(jié)間隙出現(xiàn)新月形釓積聚。結(jié)果：FEAR指數(shù)顯示出出色的觀察者內(nèi)和觀察者間可靠性，優(yōu)于AI和LCEA。與不穩(wěn)定臨界DDH組（平均值，13.3±15.2；95%CI，6.2-20.4）相比，穩(wěn)定臨界DDH組的FEAR指數(shù)較低（平均值，-2.1±8.4；95%CI，-6.3至2.0）（p<0.001），并且與所接受的治療的相關(guān)性最高。FEAR指數(shù)小于5°時，將髖關(guān)節(jié)正確分為穩(wěn)定和不穩(wěn)定的概率分別為79%（敏感性78%；特異性80%）。結(jié)論：LCEA為25°或更小且FEAR指數(shù)小于5°的疼痛髖關(guān)節(jié)很可能是穩(wěn)定的，在這種情況下，診斷重點可能更有效地集中在股骨髖臼撞擊上，因為股骨髖臼撞擊是患者疼痛的潛在原因，而不是髖關(guān)節(jié)不穩(wěn)定。?討論臨界發(fā)育不良是一種放射學(xué)定義，由LCEA量化[19]。不幸的是，這種放射學(xué)發(fā)現(xiàn)并不能說明髖關(guān)節(jié)的臨床穩(wěn)定性。其他因素也會導(dǎo)致不穩(wěn)定；這些因素包括前傾、髖臼頂傾角和頸干角。雖然將臨界髖關(guān)節(jié)分類為穩(wěn)定或不穩(wěn)定對于成功治療這些髖關(guān)節(jié)是必要的，但在實踐中很難做到這一點，可能會導(dǎo)致治療不當。特別是，如果錯誤地推測問題是FAI而不是不穩(wěn)定，并進行髖關(guān)節(jié)鏡檢查來治療，這可能會導(dǎo)致不穩(wěn)定癥狀持續(xù)存在。必須解決的問題不是髖關(guān)節(jié)是發(fā)育不良還是臨界發(fā)育不良，而是髖關(guān)節(jié)是穩(wěn)定還是不穩(wěn)定。因此，關(guān)鍵是準確地將髖關(guān)節(jié)歸類為其中一種，然后進行相應(yīng)的治療。傳統(tǒng)上，LCEA用于將髖關(guān)節(jié)分為正常、邊緣或發(fā)育不良。然而，LCEA并不總是能預(yù)測髖關(guān)節(jié)的穩(wěn)定性。為了幫助決策，我們提出了一種新的放射學(xué)參數(shù)，該參數(shù)可以在標準化AP骨盆X線片上可靠地測量。本研究的目的是評估這個FEAR指數(shù)，看看它是否與臨界不穩(wěn)定髖關(guān)節(jié)的病理行為有關(guān)。這項研究是有限的，因為納入的患者數(shù)量很少，無法進行精確的患者匹配。更詳盡的參數(shù)匹配，如全身韌帶松弛的跡象、BMI和肌肉調(diào)節(jié)將是有利的。此外，回顧性研究使我們能夠顯示關(guān)聯(lián)，但不能做出預(yù)測。因此，有必要進行未來的前瞻性研究，以顯示FEAR指數(shù)是否預(yù)測進行性不穩(wěn)定。我們還通過各種參數(shù)來定義不穩(wěn)定性，包括MR關(guān)節(jié)造影上后下方釓的聚集、股骨頭的旋轉(zhuǎn)中心重新定位或Shenton線的斷裂，而不是純粹基于放射學(xué)；這導(dǎo)致了對不穩(wěn)定性的功能性定義。我們嘗試通過讓兩名對患者所接受的治療不知情的人員進行測量來解決評估者偏見的問題。我們的研究結(jié)果表明，我們的新指數(shù)表現(xiàn)出極好的觀察者間和觀察者內(nèi)信度，優(yōu)于LCEA和AI。這種優(yōu)越性可能是因為難以定義髖臼底部的邊緣，正如所提到的[16]。已發(fā)表了幾項研究專門關(guān)注臨界髖關(guān)節(jié)發(fā)育不良的手術(shù)治療結(jié)果，其中一項研究顯示邊緣性髖關(guān)節(jié)的失敗率高于具有足夠髖臼覆蓋的髖關(guān)節(jié)[10]，另一項研究顯示結(jié)果基本一致[15]。目前髖關(guān)節(jié)的穩(wěn)定性通過LCEA進行評估。意識到LCEA的局限性，有人嘗試使用臨界髖關(guān)節(jié)的其他參數(shù)作為髖關(guān)節(jié)不穩(wěn)定的替代指標，例如盂唇大小或髂關(guān)節(jié)囊體積，已知這兩個結(jié)構(gòu)在髖關(guān)節(jié)發(fā)育不良時通常會肥大[1,8,11]。引入FEAR指數(shù)是評估髖關(guān)節(jié)功能穩(wěn)定性的新嘗試，其基于生長板在生長過程中垂直于關(guān)節(jié)反作用力的生物力學(xué)概念[5,6,8,9]。在對照組和穩(wěn)定臨界DDH組中，F(xiàn)EAR指數(shù)具有向內(nèi)張開的角度，即向內(nèi)指向的向量，表示向內(nèi)指向的關(guān)節(jié)反作用力和穩(wěn)定性。在發(fā)育不良組(13°)中，角度向外側(cè)張開，表示關(guān)節(jié)反作用力有利于關(guān)節(jié)的橫向移位和不穩(wěn)定。我們的研究不支持髂關(guān)節(jié)囊體積作為邊緣發(fā)育不良髖關(guān)節(jié)的鑒別因素。這與Babst等人的研究相反[1]。這可能歸因于患者的選擇。Babst等[1]將髖關(guān)節(jié)發(fā)育不良與鉗狀FAI髖關(guān)節(jié)進行了比較，我們將不穩(wěn)定髖關(guān)節(jié)與穩(wěn)定性臨界髖關(guān)節(jié)進行了比較，解剖學(xué)差異很小。我們建議進一步研究以檢驗這一點，因為我們的研究表明髂關(guān)節(jié)囊體積與股骨前傾之間存在相關(guān)性。FEAR指數(shù)的統(tǒng)計建模表明，這可能成為識別可能表現(xiàn)為穩(wěn)定的臨界髖關(guān)節(jié)的有用工具。這可能有利于識別適合髖關(guān)節(jié)鏡檢查的髖關(guān)節(jié)。79%的髖關(guān)節(jié)被正確識別為穩(wěn)定的臨界髖關(guān)節(jié)，靈敏度為80%，特異性為78%，F(xiàn)EAR指數(shù)似乎適合識別穩(wěn)定的髖關(guān)節(jié)。FEAR指數(shù)識別不穩(wěn)定的能力不太令人鼓舞，這可能反映了其他因素，例如韌帶松弛與決策過程有關(guān)。有趣的是，有癥狀的FAI患者中，關(guān)節(jié)過度活動更為普遍[10,14]。我們認為FEAR指數(shù)可能適用于包括標準射線照相在內(nèi)的全面臨床和放射學(xué)檢查，最好將MR關(guān)節(jié)造影術(shù)作為標準的第一步。MR關(guān)節(jié)造影術(shù)在檢測髖關(guān)節(jié)不穩(wěn)定方面優(yōu)于MRI，因為可以觀察到新月征。必須尋找不穩(wěn)定的跡象，例如標準X線片上的股骨頭移位和MR關(guān)節(jié)造影上的新月征。如果存在，則必須通過髖臼周圍截骨術(shù)來穩(wěn)定髖關(guān)節(jié)。如果仍不確定髖關(guān)節(jié)是否穩(wěn)定，可以使用FEAR指數(shù)來評估穩(wěn)定性的可能性。我們發(fā)現(xiàn)，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LCEA20°至25°），F(xiàn)EAR指數(shù)小于5°表示髖關(guān)節(jié)穩(wěn)定的可能性為80%，如果FEAR指數(shù)增加1°，發(fā)生撞擊的幾率會降低24%。在這種情況下，F(xiàn)AI似乎比發(fā)育不良更有可能；然而，在確定FAI診斷之前，應(yīng)考慮并排除其他原因。如有指征，應(yīng)相應(yīng)選擇手術(shù)治療。需要進一步研究以前瞻性驗證FEAR指數(shù)。?Fig.1A–COurmeasurements,usingthepicturearchivingandcommunicationsystem(PACS)measurementdevice,of(A)theFEARindex;(B)LCEA;and(C)AIareshown.StandardizedAPpelvicradiographsof10asymptomaticcontrolpatientstreatedforunrelatedtraumaatourinstitutionduringJanuary2016wereselectedforthemeasurements.Nopatientshadpriorhipproblems.UsingthedigitalmeasurementtoolsontheMerlinpicturearchivingandcommunicationsystem(PACS)(Ph?nixMerlinSoftware5.0;Ph?nixPACSGmbH,Freiburg,Germany),twoindependentreviewers(MCWandJW)measuredtheFEARindex,LCEA,andAI,whichwedefinedastheangleofthesourcilversusthehorizontal(Fig.1).圖1A–C?我們使用圖片存檔和通信系統(tǒng)(PACS)測量設(shè)備測量了(A)FEAR指數(shù)；(B)LCEA；和(C)AI。選擇了2016年1月在我們機構(gòu)接受無關(guān)創(chuàng)傷治療的10名無癥狀對照患者的標準化AP骨盆X線片進行測量。沒有患者之前有髖關(guān)節(jié)問題。使用Merlin圖片存檔和通信系統(tǒng)(PACS)上的數(shù)字測量工具（Ph?nixMerlinSoftware5.0；Ph?nixPACSGmbH，德國弗萊堡），兩名獨立審查員（MCW和JW）測量了FEAR指數(shù)、LCEA和AI（我們將其定義為髖臼眉弓與水平線之間的夾角）（圖1）。Fig.2A–BBland-AltmanplotsareshownfortheFEARindexforthe(A)firstand(B)secondmeasurements.Theinter-andintraobserverreliabilitywasfairtogoodfortheLCEA,whereastheAIwasexcellentforbothyetinferiortotheFEARindex.TheFEARindexdidnotvarysubstantiallybetweenassessorsforeachreplication(Fig.2).圖2A–B?顯示了(A)第一次和(B)第二次測量的FEAR指數(shù)的Bland-Altman圖。對于LCEA來說，觀察者間和觀察者內(nèi)信度為中等至良好，而AI對兩者而言都非常好，但不如FEAR指數(shù)。評估者之間的FEAR指數(shù)在每次重復(fù)中沒有顯著差異（圖2）。Fig.3AboxplotoftheFEARindexversustreatmentgroupisshown.Therewasnodifferenceinmeanage(overall:31.5±11.8years[95%CI,27.7–35.4years];stableborderlinegroup:mean,32.1±13.3years[95%CI,25.5–38.7years];unstableborderlinegroup:mean,31.1±10.7years[95%CI,26.2–35.9years])betweenstudygroups..TheFEARindexwashigheramongthegroupswithFAIandunstabletreatmentcomparedwiththeasymptomaticcontrolgroup(mean?2.1±8.4and13.3±15.2respectivelyversus?7.7±7.1forcontrols;p<0.001)(Fig.3).圖3?顯示了FEAR指數(shù)與治療組的箱線圖。各研究組間平均年齡無差異（總體：31.5±11.8歲[95%CI,27.7–35.4歲]；穩(wěn)定臨界DDH組：平均32.1±13.3歲[95%CI,25.5–38.7歲]；不穩(wěn)定臨界DDH組：平均31.1±10.7歲[95%CI,26.2–35.9歲]）。FAI組和不穩(wěn)定治療組的FEAR指數(shù)高于無癥狀對照組（平均-2.1±8.4和13.3±15.2，對照組為-7.7±7.1；p<0.001）（圖3）。Fig.4Athree-dimensionalscattergraphshowstheLCEA,AI,andFEARindex.Inaddition,theFEARindexyieldedthegreatestdistinctionwithrespecttotreatmentstatus(impingementborderlinegroupmean?2.1±8.4versusunstableborderlinegroupmean13.3±15.2;p<0.001)comparedwiththeLCEA(impingementborderlinegroup20±3.1versusunstableborderlinegroupmean13.7±8.3;p<0.001)andAI(impingementborderlinegroup13.6±3.6versusunstableborderlinegroupmean19.2±6.8;p=0.006),respectively(Fig.4).Iliocapsularisvolume,neck-shaftangle,andfemoralantetorsiondidnotdiscriminatebetweentreatmentgroups.However,inourstudy,iliocapsularisvolumehadapositiveassociationwithfemoralantetorsion,thatis,alargeriliocapsularisvolumewasassociatedwithgreaterantetorsion.圖4?三維散點圖顯示LCEA、AI和FEAR指數(shù)。此外，與LCEA（撞擊臨界DDH組20±3.1對比不穩(wěn)定臨界DDH組平均值13.7±8.3；p<0.001）和AI（撞擊臨界DDH組13.6±3.6對比不穩(wěn)定臨界DDH組平均值19.2±6.8；p=0.006）相比，F(xiàn)EAR指數(shù)在治療狀態(tài)方面產(chǎn)生了最大的區(qū)別（撞擊臨界DDH組平均值-2.1±8.4對比不穩(wěn)定臨界DDH組平均值13.3±15.2；p<0.001）（圖4）。髂關(guān)節(jié)囊體積、頸干角和股骨前傾在治療組之間沒有區(qū)別。然而，在我們的研究中，髂關(guān)節(jié)囊體積與股骨前傾呈正相關(guān)，也就是說，髂關(guān)節(jié)囊體積越大，前傾越大。Fig.5TheROCforFEARindexmodelisshown(areaunderthecurve=0.8944).Thisisshowngraphically(Fig.5).ThevalueofareaunderthecurveinthisROCcurvebeingclosetotheupperleftcornerindicatesthattheFEARindexhasaveryhighassociationwithinstability.圖5?顯示了FEAR指數(shù)模型的ROC（曲線下面積=0.8944）。這以圖形方式顯示（圖5）。此ROC曲線中曲線下面積的值接近左上角，表明FEAR指數(shù)與不穩(wěn)定性有非常高的關(guān)聯(lián)性。?DiscussionBorderlinedysplasticisaradiographicdefinitionthatisquantifiedbytheLCEA[19].Unfortunatelythisradiographicfindingdoesnotgiveanyindicationregardingtheclinicalstabilityofthehip.Additionalfactorscontributetoinstability;theseincludeantetorsion,acetabularroofinclination,andneckshaftangle.Althoughthecategorizationofborderlinehipsasstableorunstableisnecessaryforsuccessfultreatmentofthesehips,thiscanbedifficulttodoinpracticeandmayleadtoincorrecttreatment.Inparticular,ifonemistakenlysurmisestheproblemisFAIratherthaninstabilityandperformshiparthroscopytotreatit,thislikelywillresultinpersistentsymptomsfrominstability.Thequestionthathastobeaddressedisnotwhetherahipisdysplasticorborderlinedysplastic,butwhetherthehipisstableorunstable.Thekeythereforeistoclassifythehipaccuratelyasoneortheotherandthentreatitaccordingly.Traditionally,theLCEAwasusedtocategorizehipsasnormal,borderline,ordysplastic.However,theLCEAdoesnotalwayspredictstabilityofthehip.Toaiddecision-making,wehaveproposedanewradiographicparameterthatcanbemeasuredreliablyonstandardizedAPpelvicradiographs.ThepurposeofthisstudywastoevaluatethisFEARindextoseewhetheritisassociatedwithpathologicbehaviorintheborderline-unstablehip.Thestudyislimitedbecausewiththesmallnumberofpatientsincluded,precisepatientmatchingcouldnotbeperformed.More-exhaustivematchingforparameterslikesignsofgeneralizedligamentouslaxity,BMI,andmuscularconditioningwouldbeadvantageous.Furthermore,aretrospectivestudyallowsustoshowassociationsbutnottomakepredictions.ThereforefutureprospectivestudiestoshowwhethertheFEARindexpredictsprogressiveinstabilityarewarranted.Wealsodefinedinstabilitybyvariousparameters,includingpoolingofgadoliniumposteroinferiorlyonMRarthrography,recenteringofthefemoralheadorabreakinShenton’slineandratherthanonapurelyradiographicbasis;thisresultsinafunctionaldefinitionofinstability.Weattemptedtoaddresstheissueofassessorbiasbyhavingtwoindividualsblindedtothetreatmentspatientsreceivedperformthemeasurements.Thefindingsfromourstudyshowthatournewindexshowsexcellentinter-andintraobserverreliabilityandwassuperiortotheLCEAandAI.Thissuperioritymaybebecauseofdifficultyindefiningtheedgeoftheacetabularsourcilashasbeenalludedto[16].?Acoupleofstudieshavebeenpublishedlookingspecificallyattheresultsofsurgicaltreatmentofborderlinedysplastichips,withonestudyshowinghigherratesoffailureintheborderlinehipsthaninthosewithadequateacetabularcover[10],andtheotherstudyshowingcomparableoutcomes[15].CurrentlystabilityofthehipisassessedwiththeLCEA.RealizingthelimitationsoftheLCEA,therehavebeenattemptstouseotherparametersinborderlinehipsassurrogatemarkersforhipinstability,suchasthesizeofthelabrumorthevolumeoftheiliocapsularis,bothstructuresknownoftentobehypertrophicinhipdysplasia[1,8,11].IntroducingtheFEARindexisanewattempttoassessfunctionalstabilityofthehip,basedonthebiomechanicalconceptthatthegrowthplateorientsitselfperpendicularlytothejointreactingforcesduringgrowth[5,6,8,9].Inthecontrolgroupandthestableborderlinegroup,theFEARindexhadamediallyopenangle,thatis,amediallydirectedvector,indicatingmedial-directedjoint-reactionforcesandstability.Inthedysplasticgroup(13°),theangleopenedlaterally,indicatingjoint-reactionforcesfavoringlateralmigrationandinstabilityofthejoint.Ourstudydidnotsupporttheiliocapsularisvolumeasadiscriminatorinborderlinedysplastichips.ThisiscontrarytothestudybyBabstetal.[1].Thisprobablyisattributabletopatientselection.Babstetal.[1]compareddysplastichipswithhipswithpincerFAIandwecomparedunstablewithstableborderlinehips,theanatomicdifferencebeingonlyminimal.Werecommendfurtherresearchtoexaminethis,becauseourstudyshowedacorrelationbetweeniliocapsularisvolumewithfemoralantetorsion.StatisticalmodelingoftheFEARindexsuggeststhatthiscouldbecomeausefultoolinidentifyingborderlinehipsthatlikelywillbehaveasstable.Thiscouldproveadvantageousinidentifyinghipsthatwouldbeappropriateforhiparthroscopy.With79%correctlyidentifiedasstableborderlinehipswithasensitivityof80%andspecificityof78%,theFEARindexseemssuitabletoidentifystablehips.TheabilityoftheFEARindextoidentifyinstabilitywaslessencouragingandthismayreflectotherfactorssuchasligamentouslaxitybeingpertinentinthedecision-makingprocess.Interestingly,hypermobilityhasbeennotedtobemoreprevalentinsymptomaticpatientswithFAI[10,14].WebelievetheFEARindexmightbeappliedinthecontextofathoroughclinicalandradiographicworkupincludingstandardradiographs,andpreferablyMRarthrographyremainsthestandardfirststep.MRarthrographyissuperiortoMRIfordetectionofhipinstabilitybecausethecrescentsigncanbeobserved.Signsofinstability,likemigrationofthefemoralheadonstandardradiographsandthecrescentsignonMRarthrography,havetobelookedfor.Ifpresent,thehiphastobestabilizedwithaperiacetabularosteotomy.Ifoneisstillundecidedwhetherthehipisstable,theFEARindexcanbeusedtoassessthelikelihoodofstability.Wefoundthatifapatientpresentswithhippainandborderlinedysplasia(definedasaLCEA20°to25°),aFEARindexlessthan5°indicatesan80%probabilitythatthehipisstable,andiftheFEARindexincreasesby1°,theoddsofhavingimpingementdecreasesby24%.Inthatsituation,FAIseemsmorelikelythandysplasia;however,othercausesshouldbeconsideredandexcludedbeforedeterminingadiagnosisofFAI.Surgicaltreatment,ifindicated,shouldbeselectedaccordingly.FurtherstudiesareneededtovalidatetheFEARindexprospectively.?TheFemoro-EpiphysealAcetabularRoof(FEAR)Index:ANewMeasurementAssociatedWithInstabilityinBorderlineHipDysplasia?AbstractBackground:Thedefinitionofosseousinstabilityinradiographicborderlinedysplastichipsisdifficult.Areliableradiographictoolthataidsdecision-making-specifically,atoolthatmightbeassociatedwithinstability-thereforewouldbeveryhelpfulforthisgroupofpatients.Questions/purposes:(1)Tocompareanewradiographicmeasurement,whichwecalltheFemoro-EpiphysealAcetabularRoof(FEAR)index,withthelateralcenter-edgeangle(LCEA)andacetabularindex(AI),withrespecttointra-andinterobserverreliability;(2)tocorrelateAI,neck-shaftangle,LCEA,iliocapsularisvolume,femoralantetorsion,andFEARindexwiththesurgicaltreatmentreceivedinstableandunstableborderlinedysplastichips;and(3)toassesswhethertheFEARindexisassociatedclinicalinstabilityinborderlinedysplastichips.Methods:WedefinedandvalidatedtheFEARindexin10standardizedradiographsofasymptomaticcontrolsusingtwoblindedindependentobservers.Interraterandintraratercoefficientswerecalculated,supplementedbyBland-Altmanplots.WecompareditsreliabilitywithLCEAandAI.Weperformedacase-controlstudyusingstandardizedradiographsof39surgicallytreatedsymptomaticborderlineradiographicallydysplastichipsand20age-matchedcontrolswithasymptomatichips(a2:1ratio),thelatterwerepatientsattendingourinstitutionfortraumaunrelatedtotheirhipsbutwhohadstandardizedpelvicradiographsbetweenJanuary1,2016andMarch1,2016.PatientdemographicswereassessedusingunivariateWilcoxontwo-sampletests.Therewasnodifferenceinmeanage(overall:31.5±11.8years[95%CI,27.7-35.4years];stableborderlinegroup:mean,32.1±13.3years[95%CI,25.5-38.7years];unstableborderlinegroup:mean,31.1±10.7years[95%CI,26.2-35.9years];p=0.96)amongstudygroups.Treatmentreceivedwaseitheraperiacetabularosteotomy(ifthehipwasunstable)or,forpatientswithfemoroacetabularimpingement,eitheranopenorarthroscopicfemoroacetabularimpingementprocedure.TheassociationofreceivedtreatmentcategorieswiththevariablesAI,neck-shaftangle,LCEA,iliocapsularisvolume,femoralantetorsion,andFEARindexwereevaluatedfirstusingWilcoxontwo-sampletests(two-sided)followedbystepwisemultiplelogisticregressionanalysistoidentifythepotentialassociatedvariablesinacombinedsetting.Sensitivity,specificity,andreceiveroperatorcurveswerecalculated.TheprimaryendpointwastheassociationbetweentheFEARindexandinstability,whichwedefinedasmigrationofthefemoralheadeitheralreadyvisibleonconventionalradiographsorrecenteringoftheheadonAPabductionviews,abreakofShenton'sline,ortheappearanceofacrescent-shapedaccumulationofgadoliniumintheposteroinferiorjointspaceatMRarthrography.Results:TheFEARindexshowedexcellentintra-andinterobserverreliability,superiortotheAIandLCEA.TheFEARindexwaslowerinthestableborderlinegroup(mean,-2.1±8.4;95%CI,-6.3to2.0)comparedwiththeunstableborderlinegroup(mean,13.3±15.2;95%CI,6.2-20.4)(p<0.001)andhadthehighestassociationwithtreatmentreceived.AFEARindexlessthan5°hada79%probabilityofcorrectlyassigninghipsasstableandunstable,respectively(sensitivity78%;specificity80%).Conclusions:ApainfulhipwithaLCEAof25°orlessandFEARindexlessthan5°islikelytobestable,andinsuchasituation,thediagnosticfocusmightmoreproductivelybedirectedtowardfemoroacetabularimpingementasapotentialcauseofapatient'spain,ratherthaninstability.文獻出處：MichaelWyatt,JanWeidner,DominikPfluger,MartinBeck.TheFemoro-EpiphysealAcetabularRoof(FEAR)Index:ANewMeasurementAssociatedWithInstabilityinBorderlineHipDysplasia?ComparativeStudy,ClinOrthopRelatRes.2017Mar;475(3):861-869.doi:10.1007/s11999-016-5137-0.
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(xué)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(xué)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)闹委煛Ｗ罱难芯勘砻?，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(xué)。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(xué)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(xué)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(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[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(xué)OA風(fēng)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(xué)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。可以區(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(fēng)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(xué)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(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.